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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:
___
|
10001884-DS-32 | 10,001,884 | 29,678,536 | DS | 32 | 2130-10-12 00:00:00 | 2130-10-13 22:19:00 |
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:
Dyspnea, Atrial Fibrillation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with pmhx of COPD (nighttime O2), htn, afib who presents
with dyspnea, currently being treated for COPD and admitted for
Afib with RVR.
The patient went to the ED on ___ and was diagnosed with a
COPD flare. She was discharged with a prednisone taper
(currently on 60mg) and azithromycin. This AM she initially felt
well, then developed dyspnea at rest, worsening with exertion.
Her inhalers improved her SOB. She felt that these symptoms were
consistent with her COPD. She saw her PCP ___ today in
clinic where she was found to be in Afib w/ RVR, rate around
110-120. She has a history of afib. He referred her to the ED
for persistent SOB and afib with RVR. She states she been
compliant with nebs and steroid/azithro regimen. She denies any
___ edema, orthopnea. She denies recent travel, surgeries. She
had an episode of chest tightness this AM that felt like her
COPD flares. Denies fevers or coughing or production of sputum,
hemomptysis.
Past Medical History:
ASTHMA/COPD
ATYPICAL CHEST PAIN
CERVICAL RADICULITIS
CERVICAL SPONDYLOSIS
CORONARY ARTERY DISEASE
HEADACHE
HIP REPLACEMENT
HYPERLIPIDEMIA
HYPERTENSION
OSTEOARTHRITIS
HERPES ZOSTER
ATRIAL FIBRILLATION
ANXIETY
GASTROINTESTINAL BLEEDING
OSTEOARTHRITIS
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
PERIPHERAL VASCULAR DISEASE
Social History:
___
Family History:
Mother: ___, HTN
Father: ___ CA
Brother: CA?
Brother: ___
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: 98.14 154/74 71 24 98% 2L
GENERAL: Well appearing, NAD, no accessory muscle use.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: No JVD
CARDIAC: Irregular rhythm, normal rate. Normal S1, S2. No
murmurs/rubs/gallops.
LUNGS: Moving air well bilaterally. Trace inspiratory wheezing
and louder expiratory wheezing in all lung fields. No
crackles/rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.8 Tc 98.4 ___ RA
GENERAL: NAD
HEENT: NCAT. Sclera anicteric. Conjunctivae noninjected. OM
clear.
NECK: No JVD
CARDIAC: RRR. Normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Mildly reduced air movement, significant wheezing
bilaterally, +rhonchi, no crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
Pertinent Results:
ADMISSION LABS:
___ 03:38PM BLOOD WBC-7.2 RBC-4.06 Hgb-9.4* Hct-31.4*
MCV-77* MCH-23.2* MCHC-29.9* RDW-16.9* RDWSD-47.2* Plt ___
___ 03:38PM BLOOD Neuts-93.8* Lymphs-4.2* Monos-1.3*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-6.74*# AbsLymp-0.30*
AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 03:38PM BLOOD ___ PTT-30.3 ___
___ 03:38PM BLOOD Glucose-141* UreaN-20 Creat-1.0 Na-133
K-3.8 Cl-93* HCO3-30 AnGap-14
___ 03:38PM BLOOD Calcium-9.9 Phos-2.8 Mg-2.1
PERTINENT LABS:
___ 03:58PM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:50AM BLOOD calTIBC-398 Ferritn-16 TRF-306
___ 06:50AM BLOOD TSH-4.5*
___ 09:31AM BLOOD ___ pO2-73* pCO2-58* pH-7.35
calTCO2-33* Base XS-3
___ 07:15AM BLOOD T4, FREE, DIRECT DIALYSIS-Test
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-13.2* RBC-3.97 Hgb-9.0* Hct-31.1*
MCV-78* MCH-22.7* MCHC-28.9* RDW-17.4* RDWSD-48.7* Plt ___
___ 05:30AM BLOOD Glucose-85 UreaN-23* Creat-0.9 Na-136
K-3.9 Cl-95* HCO3-30 AnGap-15
___ 06:30AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0
IMAGING:
___ Chest X ray: Relative increase in opacity over the lung
bases bilaterally felt due to overlying soft tissue rather than
consolidation. Lateral view may be helpful for confirmation.
___ Chest X ray: There is hyperinflation. There is no
pneumothorax, effusion, consolidation or CHF. There is probable
osteopenia.
Brief Hospital Course:
___ is a ___ with a history of CAD, PVD, and
COPD and history of recurrent chest pain who presented with afib
with RVR and COPD exacerbation.
ACUTE PROBLEMS:
#COPD exacerbation: Ms. ___ had had two recent ED visits
for COPD exacerbation, most recently ___ when she was started
on prednisone 60 mg. She presented to her PCP's office with
worsening dyspnea despite this therapy and was also complaining
of nasal congestion, suggesting a viral URI trigger. In clinic
she was also noted to be in afib with RVR so was referred to the
ED where she was admitted after control of her heart rate (see
below). On admission to the floor, she was noted to have
wheezing, increased work of breathing, and poor air movement.
She was treated with 125 mg solumedrol and maintained on 60 mg
PO prednisone daily. Her home theophylline was decreased from
400 mg BID to ___ mg BID due to concerns it was contributing to
her tachyarrhythmia. She was placed on ipratropium nebs q6h,
albuterol nebs q2h, and fluticasone-salmeterol. Pulmonary was
consulted and recommended a trial of diuresis so she received 10
mg IV Lasix as well. Azithromycin was not given due to concerns
for QT prolongation with theophylline and amiodarone (QTc was
460). She was started on a 5 day course of ceftriaxone instead,
and discharged to finish the course with cefpodoxime. She was
discharged with a prednisone taper (10 mg decrease q3d until at
10 mg, then stay at 10 mg until pulm follow up) as well as
follow up with pulmonary rehab and a pulmonologist she
previously followed with, Dr. ___. She was also discharged on
2L supplemental O2 to be worn at all times.
#Atrial fibrillation: Ms. ___ has known atrial
fibrillation for which she was on amiodarone and apixaban but
was found to have HR in the 120s in her PCP's office, prompting
her referral to the ED. Her COPD exacerbation was the likely
precipitant, with medications also possibly contributing,
particularly theophylline. She was started on a diltiazem gtt in
the ED to control her rates than transitioned to diltiazem 90 mg
q6h. After arrival to the floor, her rates remained controlled.
Her amiodarone and apixaban were continued. Her theophylline was
decreased to 200 mg BID from 400 mg BID.
#Iron deficiency anemia. Patient was found to have microcytic
anemia with low iron and ferritin. She was started on IV iron
125 mg ferric gluconate x4 doses and wasdischarged on PO iron
with a bowel regimen. Her H/H was stable throughout the
hospitalized; there was no evidence of bleeding.
Transitional issues:
- patient discharged on prednisone taper: decrease by 10 mg
every 3 days until at 10 mg, then keep at 10 mg until seen by
pulmonology
- patient discharged with plan to follow up with pulmonology and
pulmonary rehab. Can call ___ to schedule appointment
with pulmonary rehab.
- patient discharged on with 2 days of cefpodoxime to complete 5
day course of antibiotics for severe COPD exacerbation
- patient discharged with O2 concentrator for continuous home O2
- patient's theophylline decreased from 300 mg BID to ___ mg BID
due to her afib with RVR; may want to consider further
theophylline wean, and addition of azithromycin (if QTc is
decreased as patient also on amiodarone), and/or roflumilast
therapy
- patient found to be iron deficient, started on IV iron
repletion, discharged on PO iron
- patient found to have elevated TSH, please follow up free T4
which was pending on discharge
- Code: full
- Emergency Contact ___ (Husband) ___
Daughter ___: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Apixaban 5 mg PO BID
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Amiodarone 200 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Artificial Tears ___ DROP BOTH EYES PRN irritation
7. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
8. Diltiazem Extended-Release 180 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Hydrochlorothiazide 50 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
13. Lorazepam 0.5 mg PO QHS:PRN insomnia
14. Theophylline ER 300 mg PO BID
15. Ranitidine 300 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Aspirin 81 mg PO DAILY
19. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
Discharge Medications:
1. Home O2
2 Liters continuous nasal cannula with exertion
Diagnosis: chronic obstructive pulmonary disease (J44.9)
Length of Needs: ongoing (years)
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Amiodarone 200 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath
6. Artificial Tears ___ DROP BOTH EYES PRN irritation
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. Diltiazem Extended-Release 180 mg PO BID
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Hydrochlorothiazide 50 mg PO DAILY
14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
16. Lorazepam 0.5 mg PO QHS:PRN insomnia
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Ranitidine 300 mg PO DAILY
19. Tiotropium Bromide 1 CAP IH DAILY
20. Theophylline SR 200 mg PO BID
RX *theophylline 200 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
22. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
23. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
24. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
25. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea, wheezing
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb INH Every six
hours Disp #*30 Nebule Refills:*0
26. PredniSONE 10 mg PO ASDIR
50 mg ___, then
40 mg ___, then
30 mg ___, then
20 mg ___, then
10 mg ongoing
Tapered dose - DOWN
RX *prednisone 10 mg 1 to 5 tablet(s) by mouth As directed Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Chronic obstructive pulmonary disease
Atrial fibrillation with rapid ventricular response
Secondary diagnoses:
Hypertension
Coronary artery disease
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___
because you were having difficulty breathing and were found in
clinic to have a fast heart rate. Your difficulty breathing was
due to your COPD flaring. Your fast heart rate was due to your
atrial fibrillation, which is an irregular heart rate that can
sometimes cause the heart to beat very quickly. Medications that
you were taking, such as theophylline, were likely contributing.
Your heart rate was lowered using the same medication that you
take at home, diltiazem, given through your IV.
Your COPD was likely worsened because of a cold. However, your
flare was very serious requiring IV steroids and many inhaled
treatments. You should follow up with the lung doctors as ___
as with pulmonary rehab to make sure your lung disease is being
treated as well as possible to prevent you from coming into the
hospital as often. Please call ___ to schedule an
appointment with them.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10001884-DS-34 | 10,001,884 | 28,664,981 | DS | 34 | 2130-11-30 00:00:00 | 2130-12-01 21:56:00 |
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:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with a PMH notable for COPD on
home O2(hospitalized ___, multiple recent ED visits), Afib on
apixaban, HTN, CAD, and HLD who presents with several days of
worsening dyspnea.
Patient has had several ED visits for dyspnea and a recent
hospitalization for a COPD exacerbation in ___. She has
been on steroid therapy with several attempts to taper over the
last several months. After her most recent ED visit on ___
she was on placed on 60 mg PO prednisone with a taper down by 10
mg each day. Her SOB worsened with the taper and she was seen on
___ by her PCP who started her on a course of prednisone 30 mg
PO to be tapered down by 5 mg every 3 days. With the taper she
is currently on prednisone 25 mg QD.
She reports that her SOB improved slightly after starting the
steroids on ___. However, last night it acutely worsened and she
was unable to sleep. She usually uses 3 pillows to sleep but was
only comfortable seated upright last night. This morning she
increased her oxygen to 3L and felt better. She is usually on 2L
NC at home. She reports that for the last several months she has
been using two different albuterol inhalers each every ___
hours. She knows that this is more than they are prescribed for
but it makes her comfortable. She mostly stays put on the second
floor of her home. She states that she can walk to the bathroom
without being short of breath, but does not use the stairs
unless she has to leave the house because it worsens her
breathing. She endorses a cough occasionally productive of ___
sputum. This is consistent with her baseline. She endorses one
episode of non-exertional chest pain today that spontaneously
resolved. She denies fever, chills, recent sick contacts, and
lower extremity edema.
In the ED, initial vital signs were: T 98.5 P 80 BP 154/97 R 20
O2 sat 97% NC.
- Exam notable for: Diffuse expiratory wheezing, prolonged
expiratory phase, left inspiratory crackles, irregularly
irregular rhthym, minimal pedal edema
- Labs were notable for CBC wnl, proBNP 235, Trop 0.02, chem
notable for bicarb 31, AG 13, UA notable for 40 RBCs
- Studies performed include CXR with stable mild/moderate
cardiomegaly, atelectasis at bases, otherwise clear lung fields
- Patient was given Albuterol neb x 1, ipratropium neb x 1,
Azithromycin 500 mg PO, Prednisone 25 mg PO
Upon arrival to the floor, the patient states that she is doing
well. She says that her SOB has improved since this morning and
is better than last night when she could not sleep.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
ASTHMA/COPD
ATYPICAL CHEST PAIN
CERVICAL RADICULITIS
CERVICAL SPONDYLOSIS
CORONARY ARTERY DISEASE
HEADACHE
HIP REPLACEMENT
HYPERLIPIDEMIA
HYPERTENSION
OSTEOARTHRITIS
HERPES ZOSTER
ATRIAL FIBRILLATION
ANXIETY
GASTROINTESTINAL BLEEDING
OSTEOARTHRITIS
PERIPHERAL VASCULAR DISEASE (s/p bilateral iliac stents)
Social History:
___
Family History:
Mother: ___, HTN
Father: ___ CA
Brother: CA?
Brother: ___
Physical ___:
=================
ADMISSION EXAM:
=================
Vitals- T 98.0 BP 148/70 HR 70 RR 24 O2Sat 96% on 2L NC
GENERAL: AOx3, NAD, sitting up in bed
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is clear.
NECK: Supple. JVD not visualized.
CARDIAC: Irregularly irregular, ___ systolic murmur best at the
LSB, no rubs or gallops.
LUNGS: Poor air movement throughout. Mild diffuse inspiratory
and expiratory wheezes. No use of accessory muscles of
breathing. No rhonchi or rales.
BACK: No CVA tenderness
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing or cyanosis. Bilateral pitting edema to
the mid shin. Pulses DP/Radial 2+ bilaterally.
SKIN: No rash or ulcers
NEUROLOGIC: CN2-12 intact. Moves all extremities spontaneously.
Normal sensation.
=================
DISCHARGE EXAM:
=================
Vitals- T 98.7 BP 154/85 HR 77 RR 18 O2Sat 99% on 3L NC
GENERAL: AOx3, NAD, sitting up in bed
HEENT: NCAT. PERRL. EOMI. Sclera anicteric and not injected.
MMM. Oropharynx is clear.
NECK: Supple. No LAD. JVP not appreciated at 45 degrees.
CARDIAC: Irregularly irregular, normal rate. ___ systolic murmur
at the RUSB. No rubs or gallops.
LUNGS: Poor air movement throughout all zones of the lungs. No
wheezes. No prolonged expiratory phase. No rhonchi or rales.
Does typically sit cross legged in the bed with forearms on her
legs in a tripod position.
BACK: No CVA tenderness.
ABDOMEN: +BS, soft, nontender, nondistended
EXTREMITIES: Trace pitting edema to the mid shin. 2+ DP pulses
bilaterally. No TTP.
SKIN: No rash or ulcers.
NEUROLOGIC: CN2-12 intact. Moves all extremities spontaneously.
Normal sensation.
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 02:27PM BLOOD WBC-7.4 RBC-4.57 Hgb-12.3 Hct-39.3 MCV-86
MCH-26.9 MCHC-31.3* RDW-23.6* RDWSD-70.9* Plt ___
___ 02:27PM BLOOD Neuts-86.5* Lymphs-6.1* Monos-6.6
Eos-0.0* Baso-0.0 Im ___ AbsNeut-6.38* AbsLymp-0.45*
AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*
___ 02:27PM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-137
K-3.7 Cl-93* HCO3-31 AnGap-17
==================
PERTINENT RESULTS:
==================
LABS:
==================
___ 12:15AM BLOOD ___ pO2-103 pCO2-49* pH-7.42
calTCO2-33* Base XS-5
===
___ 02:27PM BLOOD cTropnT-0.02* proBNP-235
___ 09:05PM BLOOD CK-MB-6 cTropnT-<0.01
___ 07:45AM BLOOD CK-MB-6 cTropnT-0.02*
===
___ 07:45AM BLOOD THEOPHYLLINE-17.3 (10.0-20.0)
==================
IMAGING:
==================
CXR (___): PA and lateral views the chest provided. Biapical
pleural parenchymal scarring noted. No focal consolidation
concerning for pneumonia. No effusion or pneumothorax. No signs
of congestion or edema. Cardiomediastinal silhouette is stable
with an unfolded thoracic aorta and top-normal heart size. Bony
structures are intact.
===
CT Chest (___):
1. Moderate upper lobe predominant centrilobular and paraseptal
emphysema.
2. New left lower lobe nodule, potentially measuring as large
as 6 x 8 mm, warrants close follow-up. Stable to slightly
smaller 4 mm right middle lobe nodule.
3. Severe coronary artery calcifications. Aortic valve
calcifications.
4. Enlargement of the main and right pulmonary arteries is
suggestive of chronic pulmonary arterial hypertension.
5. Fusiform aneurysmal dilatation of the abdominal aorta
measuring up to 3.7 cm has progressed compared to prior
examination.
==================
DISCHARGE LABS:
==================
___ 07:45AM BLOOD WBC-7.8 RBC-4.74 Hgb-12.7 Hct-41.0 MCV-87
MCH-26.8 MCHC-31.0* RDW-23.7* RDWSD-71.7* Plt ___
___ 07:45AM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-135
K-3.3 Cl-93* HCO3-31 AnGap-14
___ 07:45AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with a PMH notable for COPD on
home O2 (hospitalized ___, multiple recent ED visits), Afib
on apixaban, HTN, CAD, and HLD who presented with dyspnea and
orthopnea in the setting of a steroid taper for recent COPD
exacerbation. Her dyspnea was thought to be multifactorial due
to her severe COPD and with a component of anxiety. The patient
was not thought to be having an acute COPD exacerbation.
================
ACTIVE ISSUES:
================
# Dyspnea: Patient was admitted after one night of worsened
orthopnea and dyspnea in the setting of a steroid taper from 30
mg to 25 mg. Her dyspnea was thought to be multifactorial due to
her severe COPD and with a component of anxiety. The patient was
not thought to be having an acute COPD exacerbation. The patient
was treated with occasional duonebs and lorazepam 0.5 mg PRN
that helped relieve her dyspnea. Pulmonology was consulted. The
patient underwent CT that showed emphysema but no evidence of
infection such as ___. The patient was initiated on a steroid
taper on ___ of prednisone 30 mg for 3 days, then 20 mg for 3
days, then 10 mg until outpatient follow-up. Pulmonology
recommended increasing her Advair dose to 500/50, which was
done. They also recommended switching from theophylline to
roflumilast and initiation of long-term azithromycin therapy
provided the patient's QTc was not prolonged; this was deferred
to the outpatient setting. Throughout her admission she had O2
sats greater than 95% on 2L NC. She did not desaturate on
ambulation.
# Anxiety/Insomnia: Patient with a history of anxiety and
insomnia, thought to be contributing to her experience of
dyspnea. The patient was discharged with lorazepam Q8H as needed
for anxiety. The patient would likely benefit from therapy with
an SSRI.
# Demand Ischemia: Patient with troponin 0.02, <0.01, then 0.02.
ECG without acute ischemic changes.
# Microscopic hematuria: On admission the patient had a UA with
40 RBCs. Occasional UAs over the last year in OMR with
microscopic hematuria. Would recommend repeat UA as an
outpatient or work-up for microscopic hematuria.
================
CHRONIC ISSUES:
================
# Smoking: Patient recently quit smoking one month ago. Patient
was provided with a nicotine patch 7 mg while in house; could
consider continuing as an outpatient if patient endorses
cravings.
# Atrial fibrillation: Patient continued on diltiazem 240 mg PO
BID and apixaban 5 mg BID.
# HTN: Patient with a history of hypertension. Blood pressure
well-controlled. Continued on isosorbide mononitrate ER 240 mg
PO daily and hydrochlorothiazide 50 mg PO daily.
# CAD: Cardiac catheterization in ___ without evidence of
significant stenosis of coronaries. ECHO on ___ with EF>55%
and no regional or global wall motion abnormalities. The patient
was continued on aspirin 81 mg daily and atorvastatin 10 mg QPM.
===================
TRANSITIONAL ISSUES:
===================
#New Medications:
-Prednisone 30 mg PO QD through ___, then on ___ mg for 3
days, then on ___ mg until outpatient follow-up
-Increased Advair (Fluticasone-Salmeterol) to 500/50 dose
-Lorazepam 0.5 mg PO Q8H PRN for anxiety
#Follow-up:
-Appointment arranged with PCP, ___ ___
-Appointment arranged with Pulmonologist, Dr. ___, ___
#COPD: Patient was seen by pulmonology during admission who had
the following recommendations to consider as an outpatient.
-Switch to roflumilast from theophylline
-Daily azithromycin for treatment of chronic inflammation
provided QTc within normal limits.
-Patient may benefit from treatment of anxiety with an SSRI, as
her anxiety is likely contributing to her experience of dyspnea.
-In the future, palliative care consult for consideration of
opioid treatment of dyspnea
#Microscopic hematuria: Patient had a UA with 40 RBCs on
admission
-Recommend repeat UA as an outpatient or work-up for microscopic
hematuria
#Lung nodule: New left lower lobe nodule, potentially measuring
as large as 6 x 8 mm, warrants close follow-up. Stable to
slightly smaller 4 mm right middle lobe nodule. Follow-up CT in
___ months as per ___ guidelines for evaluation
of new left lower lobe pulmonary nodule.
#Code Status: Full code
#Emergency Contact/HCP: ___ (HUSBAND) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
2. Acetaminophen 325 mg PO Q4H:PRN Pain
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
4. Tiotropium Bromide 1 CAP IH DAILY
5. Guaifenesin 1 teaspoon PO Q3H:PRN cough
6. Lorazepam 0.5 mg PO QHS vertigo/insomnia
7. Diltiazem Extended-Release 240 mg PO BID
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
11. Apixaban 5 mg PO BID
12. Ranitidine 300 mg PO DAILY
13. Atorvastatin 10 mg PO QPM
14. Ferrous Sulfate 325 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
18. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
19. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
20. Theophylline SR 300 mg PO BID
21. Aspirin 81 mg PO DAILY
22. albuterol sulfate 90 mcg/actuation inhalation Q4H
23. Hydrochlorothiazide 50 mg PO DAILY
24. cod liver oil 1 capsule oral BID
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN Pain
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Diltiazem Extended-Release 240 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
10. Hydrochlorothiazide 50 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Multivitamins 1 TAB PO DAILY
14. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
15. Ranitidine 300 mg PO DAILY
16. Theophylline SR 300 mg PO BID
17. Tiotropium Bromide 1 CAP IH DAILY
18. Guaifenesin 1 teaspoon PO Q3H:PRN cough
19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
20. cod liver oil 1 capsule oral BID
21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
22. albuterol sulfate 90 mcg/actuation inhalation Q4H
23. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1
dose Inhaled Twice a day Disp #*1 Disk Refills:*1
24. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth Every 8
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Chronic obstruction pulmonary disease exacerbation
Secondary Diagnoses:
Tobacco use disorder
Atrial fibrillation
Hypertension
Anxiety
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you during your admission to
___. You were admitted to the hospital for
shortness of breath and concern that you were having a flare of
your COPD.
While in the hospital we increased your dose of steroids to help
your breathing. You also received several nebulizer treatments
that helped your breathing. You were also expressing some
anxiety that may have been contributing to your shortness of
breath. You were given a medication called Ativan for your
anxiety that also seemed to help your breathing.
During your admission you were seen by the pulmonary
specialists. They recommended a CT scan that showed that you
have extensive COPD but did not show any infection. They also
suggested increasing the dose of your Advair inhaler, which we
did.
If you feel short of breath, first please check your oxygen
level. If it is less than 90, you can use oxygen and your
inhaler. If not, try to wait a few minutes, take a few deep
breaths and see if your shortness of breath improves. You can
use the medication called Ativan(lorazepam) to help with the
shortness of breath(no more than three times a day). If still
not improved, you can use one of the inhalers/oxygen.
Please follow-up with all your appointments as listed below and
continue to take all of your medications as prescribed. If you
experience any of the danger signs listed you should call your
doctor immediately or go to the Emergency Room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10001884-DS-36 | 10,001,884 | 27,507,515 | DS | 36 | 2130-12-24 00:00:00 | 2130-12-26 17:14:00 |
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:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with hx COPD on home O2, atrial
fibrillation on apixaban, hypertension, CAD, and hyperlipidemia
who presented with dyspnea.
She has had multiple prior admissions for dyspnea. She was
recently discharged on ___ after 3 day inpatient admission for
COPD exacerbation. She was discharged on extended prednisone
taper with plan for 5d 40mg Prednisone (to finish ___ followed
by 10mg taper every 5 days (35mg from ___, 30mg ___,
etc...). She initially went to rehab and subsequently went home
2 days prior to admission.
Upon arrival at home she subsequently had recrudescence of
fatigue, wheezing, dyspnea. She also had increased O2
requirements (up to 3L, using oxygen 24hr instead of during day
only). Also with new cough, non-productive. Denies f/c, CP. No
n/v, no myalgias. Decreased hearing in right ear with fullness
for past 4 days. She was seen by PCP ___ noted to have
inspiratory/expiratory wheezes, as well as decreased hearing and
bulging TM right ear. She was referred to the ___ ED for
further management.
In the ED, initial vital signs were: 98.4 74 142/69 16 100%(2L
NC)
- Labs were notable for:
136 95 17 140
3.5 29 1.0
BNP 254
CBC within normal limits, but with neutrophil predominance
UA with 30 protein
VBG: pH 7.45, pCO2 43, pO2 59, HCO3 31
Flu PCR negative
- Imaging:
CXR notable for no acute cardiopulmonary process.
- The patient was given:
___ 16:03 IH Albuterol 0.083% Neb Soln 1 NEB
___ 16:03 IH Ipratropium Bromide Neb 1 NEB
___ 17:12 IH Albuterol 0.083% Neb Soln 1 NEB
___ 17:12 IH Ipratropium Bromide Neb 1 NEB
___ 18:12 IH Albuterol 0.083% Neb Soln 1 NEB
___ 18:12 IH Ipratropium Bromide Neb 1 NEB
___ 21:05 IH Albuterol 0.083% Neb Soln 1 NEB
___ 21:05 PO PredniSONE 60 mg
___ 21:05 IV Magnesium Sulfate 2 gm
___ 21:33 IH Albuterol 0.083% Neb Soln 1 NEB
Vitals prior to transfer were:
98.8 87 131/83 16 97% (2L)
Upon arrival to the floor, she complained of wheezing and SOB,
and persistent decreased hearing with fullness in right ear.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
- COPD/Asthma on home 2L O2
- Atypical Chest Pain
- Hypertension
- Hyperlipidemia
- Osteroarthritis
- Atrial Fibrillation on Apixaban
- Anxiety
- Cervical Radiculitis
- Cervical Spondylosis
- Coronary Artery Disease
- Headache
- Herpes Zoster
- GI Bleeding
- Peripheral Vascular Disease s/p bilateral iliac stents
- s/p hip replacement
Social History:
___
Family History:
Mother with asthma and hypertension. Father with colon cancer.
Brother with leukemia.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
VITALS: 98.1 139/79 78 22 98RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: Normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Inspiratory and expiratory wheezes in all lung fields
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
VITALS: 98.2 130-140/70'S 70-80's 20 98RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: Normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Decreased inspiratory and expiratory wheezes in all
lung fields
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:00PM BLOOD Neuts-92.1* Lymphs-4.5* Monos-2.7*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-5.51 AbsLymp-0.27*
AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00*
___ 04:00PM BLOOD Plt ___
___ 04:00PM BLOOD Glucose-140* UreaN-17 Creat-1.0 Na-136
K-3.5 Cl-95* HCO3-29 AnGap-16
___ 04:00PM BLOOD proBNP-254
___ 03:58PM BLOOD ___ pO2-59* pCO2-43 pH-7.45
calTCO2-31* Base XS-4
LABS ON DISCHARGE:
==================
___ 08:00AM BLOOD WBC-5.8 RBC-4.37 Hgb-11.9 Hct-38.2 MCV-87
MCH-27.2 MCHC-31.2* RDW-20.4* RDWSD-65.6* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-156* UreaN-21* Creat-0.9 Na-134
K-3.4 Cl-92* HCO3-30 AnGap-15
___ 08:00AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0
STUDIES:
========
CXR ___: No acute cardiopulmonary process
EKG: NSR rate 72, QTC 469, LBBB
Brief Hospital Course:
___ yo F with history of COPD on home O2, atrial fibrillation on
apixaban, hypertension, CAD, hyperlipidemia, and recurrent
hospitalization for COPD exacerbation over the last 4 months,
who presented with dyspnea consistent with COPD exacerbation,
possibly secondary to acute viral URI with concurrent sinusitis
/ Eustachian tube dysfunction
# COPD exacerbation:
Patient has been experiencing recurrent COPD exacerbations over
the last 4 months. She presented with dyspnea consistent with
COPD exacerbation, possibly secondary to acute viral URI with
concurrent sinusitis / Eustachian tube dysfunction. We continued
home spiriva, theophylline, and advair. We continued her steroid
therapy at 30mg prednisone daily with a slow taper (5mg every 2
weeks). We also treated her with levofloxacin (Day ___
with plan for 5-day course given COPD exacerbation with
concurrent concern for sinusitis / bulging right tympanic
membrane.
CHRONIC ISSUES:
==================
# Anxiety/Insomnia: We continued home lorazepam.
# Atrial Fibrillation: We continued diltiazem for rate control
and apixaban for anticoagulation.
# Hypertension: We continued home imdur, hydrochlorothiazide,
and diltiazem.
# CAD: Cardiac catheterization in ___ without evidence of
significant stenosis of coronaries. ECHO on ___ with EF >
55% and no regional or global wall motion abnormalities. We
continued home aspirin and atorvastatin.
# Anemia: We continued home iron supplements.
***TRANSITIONAL ISSUES:***
- Continue levofloxacin with plan for 5-day course (Day
___ end ___
- Patient was started Bactrim PPX (1 tab SS daily) given
extended courses of steroids, stop after discontinuation of
steroids
- Patient was discharged on prednisone 30 mg with plan for taper
by 5mg every 2 weeks:
Prednisone 30 mg for two weeks (Day 1= ___ end
___
Prednisone 25 mg for two weeks (Day 1= ___ end
___
Prednisone 20 mg for two weeks (Day 1= ___ end
___
etc...
# CONTACT: ___ (husband/HCP) ___
# CODE STATUS: Full confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q4H:PRN Pain
2. albuterol sulfate 90 mcg/actuation inhalation Q4H
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Diltiazem Extended-Release 240 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Guaifenesin ___ mL PO Q4H:PRN cough
13. Hydrochlorothiazide 50 mg PO DAILY
14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo
17. Multivitamins 1 TAB PO DAILY
18. Ranitidine 300 mg PO DAILY
19. Theophylline SR 300 mg PO BID
20. Tiotropium Bromide 1 CAP IH DAILY
21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
22. cod liver oil 1 capsule oral BID
23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
24. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN Pain
2. albuterol sulfate 90 mcg/actuation inhalation Q4H
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Diltiazem Extended-Release 240 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Guaifenesin ___ mL PO Q4H:PRN cough
13. Hydrochlorothiazide 50 mg PO DAILY
14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo
17. Multivitamins 1 TAB PO DAILY
18. PredniSONE 30 mg PO DAILY
Please decrease dose by 5mg every 2 weeks
Tapered dose - DOWN
RX *prednisone 10 mg 3 tablets(s) by mouth once a day Disp #*45
Dose Pack Refills:*0
19. Ranitidine 300 mg PO DAILY
20. Theophylline SR 300 mg PO BID
21. Tiotropium Bromide 1 CAP IH DAILY
22. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for
long term steroid use
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
24. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
25. cod liver oil 1 capsule oral BID
26. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
COPD exacerbation
SECONDARY DIAGNOSES:
CAD
Hypertension anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a great pleasure taking care of you at ___
___. You came here because you were
experiencing worsening shortness of breath as well as nasal
congestion and decreased hearing. Your symptoms are likely
related to an upper respiratory tract infection and exacerbation
of your COPD. We started you on antibiotics and continued your
prednisone.
The dose of prednisone will be decreased by 5 mg every two
weeks; please take your prednisone as follows:
- Prednisone 30 mg for two weeks (Day 1= ___ end
___
- Prednisone 25 mg for two weeks (Day 1= ___ end
___
- Prednisone 20 mg for two weeks (Day 1= ___ end
___
- Discuss with Dr. ___ further taper at f/u
Please take all your medications on time and follow up with your
doctors as ___.
Best regards,
Your ___ team
Followup Instructions:
___
|
10002013-DS-10 | 10,002,013 | 24,848,509 | DS | 10 | 2162-07-09 00:00:00 | 2162-07-11 07:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ y/o F with pMHx significant for HTN, GERD,
CAD s/p CABG and stenting, IDDM with periperal neuropathy who
presents with R flank pain.
Per patient, this pain has been going on for the past 3 weeks
but has worsened over the past 2 days. It is worsened with
coughing and moving. She otherwise denies any dysuria, urinary
frequency, abdominal pain, n/v, chest pain, shortness of breath
or dizziness. She endorses 4 episodes of diarrhea today.
In the ED initial vitals were: 10 98.2 106 167/84 16 99% RA. RR
later trended up to 20, HR down to 89. Labs were significant for
positive UA (WBC 19), lactate 3.0, WBC 9.4% (70% PMN), AST 53,
ALT 16, Lip 70, trop-T < 0.01, Chem hemolyzed but Cr 1.4
(baseline 1.0 in ___, repeat K 3.6. Hyperglycemic to 446, 340
on repeat. CXR showed no acute process. Patient was given 1L NS,
1g CTX, 14 units insulin. Unclear if she received her home
long-acting insulin. UCx and BCx's were sent after antibiotics
initiated. Vitals prior to transfer were: 3 98.4 89 152/80 20
100% RA.
Past Medical History:
COPD
CAD s/p CABG and stenting
Depression
DM
GERD
HTN
Migraines
Chronic shoulder pain on narcotics
OSA
Peripheral neuropathy
Restless leg
Social History:
___
Family History:
Mother Unknown ALCOHOL ABUSE pt was ward of state, doesn't know
full details of family hx
Father ___ ___ HODGKIN'S DISEASE per old records
Physical Exam:
Admission Physical Exam:
Vitals - 98.3 155/88 92 20 99% on RA
GENERAL: NAD
HEENT: NCAT
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
BACK: no tenderness to spinal processes, no pain the left side,
+CVA tenderness, tenderness to palpation of the R sided
paraspinal muscles along entire length of spinal cord
Discharge Physical Exam:
Vitals: 97.8 107/59 78 18 97/RA
General: awake, alert, NAD
HEENT: NCAT EOMI MMM grossly normal oropharynx
CV: RRR nl S1+S2 no g/r/m no JVD/HJR.
Lungs: CTAB no w/r/r, good movement in all fields
Abdomen: obese, soft nt/nd normoactive BS
Back: ttp along right paraspinal region from sacrum to shoulder.
+ CVA tenderness.
Ext: dry and WWP. no c/c/e
Neuro: AAOx3, moving all extrem with purpose, facial movements
symmetric, no focal deficits.
Skin: no rashes, lesions, excoriations
Pertinent Results:
CT ABD/PELVIS ___:
Noncontrast imaging of the abdomen and pelvis demonstrates a
punctate
nonobstructing calculus in the right collecting system (02:31).
There is no left renal calculus. There is no evidence of
ureteral or urinary bladder calculus. There is symmetric renal
enhancement and excretion of intravenous contrast. Subcentimeter
cortically based hypodensity in the left interpolar region
(06:30) is too small to accurately characterize but likely
represents renal cyst. There is no evidence of collecting system
filling defect. There are segments of the mid to distal ureters
are not well opacified, possibly secondary to peristalsis,
however there is no evidence of inflammatory change or mass
about the ureters. The adrenal glands are unremarkable.
Low hepatic attenuation on noncontrast imaging is consistent
with hepatic
steatosis. There is no evidence of focal hepatic mass. There is
no
intrahepatic or extrahepatic biliary ductal dilatation. There
are numerous gallstones within the gallbladder without evidence
of acute cholecystitis.
The spleen is not enlarged. There is no pancreatic ductal
dilatation or
evidence of pancreatic mass.
There are no dilated loops of bowel. There is no evidence of
bowel wall
thickening. There is no intraperitoneal free air or free fluid.
There are no enlarged inguinal, iliac chain, retrocrural, or
retroperitoneal lymph nodes. Abdominal aorta has a normal course
and caliber with moderate atherosclerotic calcification. There
is atherosclerotic calcification of the superior mesenteric
artery origin. There is no suspicious osseous lesion.
IMPRESSION:
1. Tiny nonobstructing right collecting system calculus.
2. Hepatic steatosis.
3. 3 nodular pulmonary densities in the left basilar region
measuring up to 8 x 8 mm. These findings may may represent areas
of rounded atelectasis, however short-term followup with
nonemergent CT chest is recommended.
ADMISSION LABS:
___ 08:30PM BLOOD WBC-9.4 RBC-3.95* Hgb-13.3 Hct-37.4
MCV-95 MCH-33.7* MCHC-35.5* RDW-13.5 Plt ___
___ 08:30PM BLOOD Neuts-70.1* ___ Monos-5.2 Eos-1.6
Baso-0.7
___ 08:30PM BLOOD Glucose-446* UreaN-18 Creat-1.4* Na-133
K-5.6* Cl-97 HCO3-21* AnGap-21*
___ 08:30PM BLOOD ALT-16 AST-54* AlkPhos-65 TotBili-0.4
___ 08:30PM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.9 Mg-1.8
___ 08:30PM BLOOD cTropnT-<0.01
___ 08:30PM BLOOD Lipase-70*
___ 10:53PM BLOOD ___ pO2-38* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
___ 10:53PM BLOOD Lactate-3.0* K-3.6
___ 10:53PM BLOOD O2 Sat-69
___ 10:40PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 10:40PM URINE RBC-3* WBC-19* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
___ 10:40PM URINE Color-Straw Appear-Clear Sp ___
DISHCARGE LABS:
___ 07:00AM BLOOD WBC-7.0 RBC-3.37* Hgb-11.2* Hct-31.8*
MCV-94 MCH-33.2* MCHC-35.2* RDW-12.9 Plt ___
___ 06:23AM BLOOD Neuts-53.5 ___ Monos-5.0 Eos-1.8
Baso-0.6
___ 07:00AM BLOOD Glucose-254* UreaN-13 Creat-1.0 Na-136
K-3.9 Cl-101 HCO3-24 AnGap-15
___ 07:00AM BLOOD ALT-14 AST-17 AlkPhos-50
___ 07:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.5*
Brief Hospital Course:
___ PMH with HTN, GERD, CAD s/p CABG and stenting, IDDM with R
flank pain presumed to musculoskeletal in nature due to negative
workup. Incidental UTI / asymptomatic bacturia.
ACUTE ISSUES:
# UTI / Bacturia: Patient presented without any history of
urinary or systemic symptoms, but was started on ceftriaxone in
the ED after U/A with ___ positive and 19 WBCs.
Antibiotics were taken prior to drawing urinary or blood
cultures, and there was no yield. Patient switched to
ciprofloxacin and received a three day total antibiotic course.
CT scan performed did not have any evidence of pyelonephritis.
Antibiotics were discontinued at time of discharge.
# Flank Pain:
Patient reported 3 weeks of back/flank pain, constant and achy
in nature and worsened by movement. Treated with
anti-inflammatories with minimal effect. CT scan demonstrated no
nephrolithiasis. CXR showed no bony abnormality, but could not
totally exclude multiple rib fractures. Patient's pain was well
controlled and tolerating PO medications, so she was discharged
with PCP following for further workup.
# Diabetes / Hyperglycemia:
Patient had persistently
# IDDM: Last A1C (___) 8.0. Serum glucose initially in the 400s
and Chem-7 with gap; however, this was likely ___ lactate and
unlikely to be DKA given normal pH on ABG. AM glucose 218.
- continue home dose lantus 90 units qPM
- per ___ records, is on a very aggressive ISS, will decrease
for now and uptitrate as necessary depending on ___
# ___ on CKD: Cr elevated at 1.4 from baseline 1.0. Most likely
pre-renal in the setting of infection. Now s/p 2L IVF in the ED
and creatinine has corrected to 1.0. Appears euvolemic, maybe
slightly up.
- consider further workup if no improvement (urine lytes,
spinning urine, renal u/s)
- renally dose medications for now
CHRONIC ISSUES:
# HF with pEF/CAD s/p CABG and stents: Was not an active issue
whil inpatient. Fluid use was judicious. Metoprolo converted to
short acting while in house, isosorbide, aspirin and
atorvastatin were continued. Losartan held as below.
# HTN: home metoprolol and isosorbide continued, losartan held
while inpt as pressures were soft and within normal range.
Discharged home off losartan.
# Restless leg syndrome: home ropinarole continued
# Shoulder pain: oxycodone and tylenol seperately dose while
inpatient
# COPD: home advair and PRN albuterol nebs were continued
# GERD: home pantoprazole continued
# Insomnia: home trazodone continued
TRANSITIONAL ISSUES:
- Losartan held inpatient and at discharge andpatient blood
pressures were low-normal. PCP to determine restart.
- Patient to follow up with PCP for resolution of UTI and back
pain symptoms
- Patient should have insulin regiment adjustments for optimal
glycemic control - no changes to regimen were made at discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 25 mg PO DAILY
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Atorvastatin 80 mg PO HS
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain
6. Ropinirole 0.5 mg PO QPM
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Pantoprazole 40 mg PO Q12H
10. Aspirin 325 mg PO DAILY
11. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing
12. TraZODone 150 mg PO HS
13. Vitamin D 1000 UNIT PO DAILY
14. Levemir Flexpen (insulin detemir) 90 units subcutaneous in
the evening
15. HumaLOG KwikPen (insulin lispro) per sliding scale
subcutaneous as directed
Discharge Medications:
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Levemir Flexpen (insulin detemir) 90 units subcutaneous in
the evening
5. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS DIRECTED
6. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*11 Tablet Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
9. TraZODone 150 mg PO HS
10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
11. Aspirin 325 mg PO DAILY
12. Atorvastatin 80 mg PO HS
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Pantoprazole 40 mg PO Q12H
15. Ropinirole 0.5 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
UTI
Secondary Diagnosis:
Back Pain
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were seen in the emergency department for back pain. ___
were admitted to the hospital where ___ were also diagnosed with
a urinary tract infection. ___ were treated with antibiotics, IV
fluids and pain medication. Due to the concern of your back
pain, a CT scan was as performed and it was determined that ___
did not have a kidney stone or an infection. Your diabetes was
controlled with an insulin scale while ___ were an inpatient.
___ will be discharged home on antibiotics and intent to follow
up with your primary care provider, Dr. ___. Please take all
medications as prescribed and keep all scheduled appointments.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of ___!
Your ___ Care Team
Followup Instructions:
___
|
10002013-DS-13 | 10,002,013 | 25,442,395 | DS | 13 | 2166-04-19 00:00:00 | 2166-04-19 20:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Left diabetic foot ulcer
Major Surgical or Invasive Procedure:
Left partial hallux amputation
History of Present Illness:
___ with poorly controlled diabetes (complicated by retinopathy,
neuropathy, PAD, foot ulcer L hallux), CAD with ___ s/p
CABG,
and narcotics agreement, presenting with 3 days subjective
fever,
chills, increased pain in L great toe. Pt recently had ulcer
debrided by podiatry on ___, ulcer had healed to the size of a
pin, but within the span of a week enlarged to size of a tennis
ball. Presented to ___ urgent care in ___, found to be
febrile to ___, given Tylenol, sent to ER and was afebrile and
normotensive upon arrival, though sustained tachycardia to low
100s. Podiatry consulted in ER, wound to left medial hallux
probes to bone w/ high c/f osteomyelitis. X-rays show bony
erosion but no subcutaneous gas. Plan for IV antibiotics and
partial amputation of left great toe tomorrow (___). ___ n/v,
abd pain, diarrhea, excessive urination, orthostasis, dyspnea,
chest pain.
In the ED:
Initial vital signs were notable for: afebrile, tachycardia to
118, normotensive
Exam notable for:
PE: warm, slightly diaphoretic
CV: RRR, +S1/S2
Resp :lungs clear b/l
MSK: erythema involving L big toe, tracking along inferior base.
Tenderness tracking along path of great saphenous on L calf.
Limited dorsiflexion and plantar flexion. Limited ROM of ankle
and toe.
Mental Status: A&ox4
Lines & Drains: 20g L hand
Labs were notable for:
136 98 26* AGap=20
------------<266*
4.2 18* 1.6*
Lactate elevated: 2.4
Whites elevated: 23.4, neut predominance
Studies performed include:
Xray Foot Ap,Lat & Obl Left (prelim read): Re-demonstration of
ulceration along the medial distal aspect of the great toe and
erosion along the medial base of the distal phalanx of the great
toe perhaps slightly progressed in the interval. Findings again
remain concerning
for osteomyelitis and MRI with contrast could be obtained for
further
assessment.
Patient was given:
Piperacillin-Tazobactam
Vancomycin
Consults: Podiatry
Vitals on transfer: T100.5, BP 154/80, HR117, RR18, 99 Ra
Upon arrival to the floor, patient resting comfortably in bed,
complains of chills, which resolve with blankets. Left foot
wrapped in gauze dressing, very tender up to midcalf.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative
Past Medical History:
-COPD
-CAD s/p BMS proximal-LAD ___, DES to mid LAD ___, DES to edge
ISR of mid LAD DES and stenosis distal to stent ___, DES to OM1
___, s/p 3 v CABG LIMA-LAD, SVG-OM1,
___
-HFpEF
-Depression
-DM
-GERD
-Hypertension
-Migraines
-Chronic shoulder pain on narcotics
-OSA
-Peripheral neuropathy
-Restless leg
Social History:
___
Family History:
Patient was ward of the ___, doesn't know full details of
family history. Mother with possible alcohol abuse. Father
deceased at ___ from Hodgkin's Disease per old records.
Physical Exam:
ADMISSION EXAM
==============
VITALS: T100.5, BP 154/80, HR117, RR18, 99 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. MMM.
CARDIAC: RRR, no MRG
LUNGS: Normal WOB, CTA B/L
ABDOMEN: Soft, nontender to deep palpation, nondistended,
normoactive bowel sounds.
EXTREMITIES: left foot wrapped in gauze dressing, mildly
erythematous and very tender up to lower calf, RLE no edema,
thready DP pulses
NEUROLOGIC: Sensory and motor function grossly intact.
DISCHARGE EXAM
==============
VS: 98.5, 134 / 75,75, 18, 97% RA
General Appearance: Well-groomed, in NAD.
HEENT: Atraumatic, normocephalic. Sclera anicteric b/l. MMM. No
oropharyngeal lesions. No LAD.
Lungs: Equal chest rise. Good air movement. No increased work of
breathing. Decreased breath sounds in LLL. Rales in left base.
No
wheezes or rhonchi.
CV: RRR. Normal S1, S2. No murmurs, gallops, or rubs. No carotid
bruits b/l. +2 carotid pulses b/l, +2 radial pulses b/l, +1
dorsalis pedis pulse on right, unable to palpate on left due to
surgical bandage.
Abdomen: Non-distended. Bowel sounds present. Soft, non-tender
to
palpation throughout.
Extremities: No clubbing or cyanosis. Left foot dressing clean
today. Erythema and edema around margin of surgical site is
improved today. Suture site is clean with no pus.
Skin: No rashes or lesions besides surgical site.
Neuro: A+O to person, place, and time. CN III-XII grossly
intact.
Pertinent Results:
ADMISSION LABS
==============
___ 05:50PM BLOOD WBC-23.4* RBC-4.01 Hgb-13.3 Hct-37.9
MCV-95 MCH-33.2* MCHC-35.1 RDW-12.0 RDWSD-42.1 Plt ___
___ 05:50PM BLOOD Neuts-81.4* Lymphs-10.5* Monos-7.1
Eos-0.0* Baso-0.3 Im ___ AbsNeut-19.09* AbsLymp-2.47
AbsMono-1.66* AbsEos-0.00* AbsBaso-0.06
___ 05:50PM BLOOD Glucose-266* UreaN-26* Creat-1.6* Na-136
K-4.2 Cl-98 HCO3-18* AnGap-20*
___ 05:50PM BLOOD CRP-180.1*
___ 07:45PM BLOOD ___ pO2-22* pCO2-44 pH-7.32*
calTCO2-24 Base XS--4
___ 05:50PM BLOOD Lactate-2.4*
___ 07:40PM URINE Color-Straw Appear-Clear Sp ___
___ 07:40PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-SM*
___ 07:40PM URINE RBC-4* WBC-7* Bacteri-FEW* Yeast-NONE
Epi-1 TransE-<1
___ 07:40PM URINE Mucous-RARE*
PERTINENT INTERVAL LABS
=======================
___ 09:48AM BLOOD ALT-25 AST-29 LD(LDH)-210 AlkPhos-130*
TotBili-0.8
DISCHARGE LABS
==============
___ 07:17AM BLOOD WBC-9.9 RBC-3.07* Hgb-9.8* Hct-30.4*
MCV-99* MCH-31.9 MCHC-32.2 RDW-12.3 RDWSD-44.2 Plt ___
___ 07:29AM BLOOD Glucose-109* UreaN-18 Creat-1.2* Na-140
K-4.0 Cl-100 HCO3-25 AnGap-15
___ 07:29AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8
___ 07:29AM BLOOD CRP-44.6*
IMAGING
=======
LEFT FOOT XRAY (___)
IMPRESSION:
Re-demonstration of ulceration along the medial distal aspect of
the great toe
and erosion along the medial base of the distal phalanx of the
great toe, the
latter of which is perhaps slightly progressed in the interval.
Findings again
remain concerning for osteomyelitis and MRI with contrast could
be obtained
for further assessment.
NIAS (___)
---------------
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the
right femoral,
popliteal, and dorsalis pedis arteries. Absent waveform in the
posterior
tibial artery.
The right ABI was 1.6, artifactually elevated due to
noncompressible vessels.
On the left side, triphasic Doppler waveforms are seen at the
left femoral and
popliteal arteries. Monophasic waveforms are seen in the
posterior tibial and
dorsalis pedis arteries.
The left ABI could not be calculated
Pulse volume recordings showed decreased amplitudes at the level
the right
calf, ankle and metatarsal.
IMPRESSION:
Significant bilateral tibial arterial insufficiency to the lower
extremities
at rest, more significant on the right side.
CXR (___)
--------------
IMPRESSION:
Comparison to ___. No relevant change is noted.
Alignment of the
sternal wires is unremarkable. Mild elongation of the
descending aorta.
Borderline size of the heart. No pleural effusions. No
pneumonia, no
pulmonary edema.
MRI LEFT FOOT (___)
IMPRESSION:
1. Nonenhancing stump soft tissue and the plantar fat pad under
the middle
phalanges, concerning for devitalized tissue. No evidence of
drainable
abscess.
2. 4 mm focus of low T1 signal with edema at the most distal
cortex of the
first metatarsal. This is nonspecific as there was no
comparison study and
focus of osteomyelitis cannot be excluded.
3. 2 sinus tracts medial to the head of the first metatarsal,
status post
amputation at the first MTP with postsurgical changes.
4. Dorsal swelling and diffuse skin edema.
CXR PICC PLACEMENT (___)
IMPRESSION:
New right PICC with tip projecting over the junction of the
superior vena cava
and right atrium. No pneumothorax. Clear lungs.
PATHOLOGY
==========
SURGICAL TISSUE (___)
- Bone with reparative changes, consistent with chronic
osteomyelitis.
- There is no evidence of acute osteomyelitis.
SURGICAL TISSUE (___)
1. LEFT GREAT TOE, EXCISION:
- Acute osteomyelitis, focal.
- Bone with reparative changes.
- Skin and subcutis with ulceration and acute inflammation.
- Atherosclerosis, severe.
2. PROXIMAL PHALANX BASE MARGIN, LEFT, EXCISION:
- Bone with reparative changes.
- There is no evidence of acute osteomyelitis.
3. PROXIMAL PHALANX, LEFT, EXCISION:
- Bone with reparative changes.
- There is no evidence of acute osteomyelitis.
MICROBIOLOGY
============
___ 10:00 am TISSUE PROXIMAL PHALYNX.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
Reported to and read back by ___ (___) ON
___ AT
1:20PM.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 7:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:38 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:34 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:18 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:53 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
=============
SUMMARY
=============
___ yo F with hx of DMII, HTN who presented with diabetic foot
ulcer on her left hallux complicated by osteomyelitis. She
underwent surgical debridement and partial tissue and bone
removal on ___. However the infection persisted, and she
underwent left hallux amputation on ___. She was started
on IV nafcillin for MSSA infection with plan to continue home
infusions of nafcillin until at least ___
ACTIVE ISSUES
=============
#Osteomyelitis of left hallux: Due to diabetic ulcer of left
hallux. Patient underwent partial left hallux amputation on ___
by podiatry. She was initially placed on IV Vancomycin, Flagyl,
and cefepime. Initial surgical cultures came back positive for
MSSA, so was changed to IV nafcillin. Patient continued to be
afebrile, but her left foot continued to have erythema, edema,
pain, and the ulcer was not healing well. There was concern for
poor arterial blood flow and therefore underwent noninvasive
arterial studies on bilateral lower extremities. The studies
showed mild atherosclerotic disease in her left leg and foot,
and severe atherosclerotic disease in her right leg and foot.
Vascular surgery was consulted for potential intervention, but
they felt that no further vascular intervention was warranted
prior to podiatric surgery. The patient was brought back to the
OR by podiatry on ___ for total left hallux amputation
given lack of clinical improvement. Her ___ blood cell count
continued to down trend. The pathology report showed clean
margins. However, patient was continuing to have pain, and there
was increased erythema and swelling around surgical site. An MRI
of the left foot was done, which showed devitalization of the
surgical flap, some edema, and a hyperintense focal spot at the
site of the surgery. There were no signs of abscess or fluid
collection. Podiatry team felt patient did not need any acute
surgical intervention and will have close follow-up on
___. A PICC line was placed in the right arm
___ with tentative plan to complete a two-week course of IV
nafcillin on ___. For the wound, podiatry recommends daily
dressing changes to left foot surgical site: Betadine moistened
gauze, 4x4 gauze, and kerlix.
#Cough: During her stay the patient developed cough that was
nonproductive. It was thought to be due to atelectasis after
surgery, especially since her rales on exam would clear with
coughing. A repeat chest x-ray was negative for any acute
cardiopulmonary processes and on comparison to previous chest
x-ray during this hospital stay there were no changes. Will
restart home Lasix at discharge.
#Hypertension: Patient's antihypertensives were held upon
admission given that her blood pressures were low with systolic
blood pressures in the ___ likely due to sepsis in the
setting of her osteomyelitis from her diabetic foot ulcer. After
her first debridement, patient's blood pressures increase to
160s-170s so we restarted her losartan and furosemide. However
her blood pressure dipped back down again to the ___ systolic
and her creatinine bumped up to 1.8 so we discontinued her
losartan and furosemide. Her metoprolol was continued with
holding parameters, and it was held when her systolic blood
pressure was less than 110. Her ___ resolved, and she became
hypertensive again, so we restarted her losartan while in the
hospital and instructed the patient to restart her Lasix upon
discharge from the hospital.
#Acute Kidney Injury: Her baseline creatinine is 1.0. It bumped
up to 1.8 in the setting of sepsis, restarting her losartan and
furosemide, and hypotension. We gave her IV fluids and stopped
her losartan and furosemide. Her creatinine continued to improve
with these measures and upon discharge it was 1.1-1.2, which is
around her baseline.
CHRONIC ISSUES
==============
#Diabetes Mellitus Type 2: Upon admission, patient was started
on 80% of home insulin doses. Her Lantus inpatient dose was 32
units, and her Humalog inpatient dose was 12 units 3 times
daily. Patient's blood sugars were hard to control while she was
inpatient. Working with the ___ diabetes consult team we
adjusted her insulin doses as needed. ___ recommended
discharging the patient on 48 units of Toujeo and 18 units of
Novolog with meals as well as resuming her Trajenta and
Jardiance.
#CODE STATUS: Full (presumed)
#CONTACT: ___ (grandson's girlfriend) ___
TRANSITIONAL ISSUES
===================
[ ] Patient is on oxycodone 5 mg Q8H for her foot pain from the
surgery. She was given enough to get her to her PCP appointment,
which is ___. Please re-assess pain management.
[ ] Osteomyelitis, infected diabetic foot ulcer: Surgical margin
from total left hallux amputation on ___ was negative for
osteomyelitis. Patient to complete a 2 week course of nafcillin
for ongoing soft tissue infection and will follow up with ID
prior to completion of antibiotics to ensure resolution. Will be
discharged on q4 hour nafcillin to be infused via a pump. Once
finished an antibiotic should also have right arm PICC line
removed. For the wound, podiatry recommends daily dressing
changes to left foot surgical site: Betadine moistened gauze,
4x4 gauze, and kerlix
[ ] Diabetes mellitus type 2: Patient's blood sugars were very
labile. Given that she came in with a diabetic foot ulcer
suggesting that her blood sugars are not well-controlled at
home, she needs close follow-up to optimize her diabetic
medication regimen. She is being discharged on reduced dose
Toujeo and regular home Novolog along with her usual Trajenta
and Jardiance with close follow-up with ___ provider on
___, ___ at 1 ___. Please reassess patient's need for
Jardiance given history of recurrent AKIs
[ ] Cough: Patient developed non-productive cough while in
hospital but afebrile, no leukocytosis, CXR no signs of pleural
effusion or consolidation. Suspect due to atelectasis in post-op
period after foot surgery. Will discharge on incentive
spirometer and restarting home Lasix as outpatient. If not
improved once back on outpatient Lasix, would consider further
workup.
[ ] Hypertension: Patient was discharged on her regular home
medications. While she was an inpatient, she became hypotensive
when we restarted her on all of her antihypertensives. Please
follow her blood pressure to ensure that she is on the right
regimen. If too low, might consider removing furosemide.
[ ] ___: Discharge creatinine 1.2 on ___. Suspect patient will
have a slight bump in creatinine after restarting losartan on
___. Patient had weekly labs checked with IV antibiotic
infusions. If continues to rise, may be due to nafcillin and
would consider switching antibiotic to cefazolin.
#CODE STATUS: Full (presumed)
#CONTACT: ___ (grandson's girlfriend) ___
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. canagliflozin 100 mg oral DAILY
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
3. rOPINIRole 0.5 mg PO QHS restless leg syndrome
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Pantoprazole 40 mg PO BID
6. Gabapentin 400 mg PO QHS:PRN Neuropathic pain
7. Atorvastatin 80 mg PO QPM
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. linaGLIPtin 5 mg oral DAILY
10. Losartan Potassium 25 mg PO DAILY
11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain -
Severe
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Furosemide 20 mg PO DAILY
14. Metoprolol Succinate XL 150 mg PO DAILY
15. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
16. Aspirin EC 325 mg PO DAILY
17. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY Rosacea
18. nystatin 100,000 unit/gram topical DAILY:PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours for
foot pain Disp #*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
RX *bisacodyl 5 mg 2 tablet(s) by mouth Once a day as needed for
constipation Disp #*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*30 Capsule Refills:*0
4. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV Every
four hours Disp #*84 Intravenous Bag Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth Once every 8 hours as
needed for severe foot pain. Disp #*15 Capsule Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day as
needed for constipation Disp #*30 Tablet Refills:*0
7. Novolog 18 Units Breakfast
Novolog 18 Units Lunch
Novolog 18 Units Dinner
8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
9. Aspirin EC 325 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. canagliflozin 100 mg oral DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Furosemide 20 mg PO DAILY
14. Gabapentin 400 mg PO QHS:PRN Neuropathic pain
15. Lidocaine 5% Patch 1 PTCH TD QPM
16. linaGLIPtin 5 mg oral DAILY
17. Losartan Potassium 25 mg PO DAILY
18. Metoprolol Succinate XL 150 mg PO DAILY
19. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY Rosacea
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
21. nystatin 100,000 unit/gram topical DAILY:PRN
22. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain
- Severe
23. Pantoprazole 40 mg PO BID
24. rOPINIRole 0.5 mg PO QHS restless leg syndrome
25. ___ SoloStar U-300 Insulin (insulin glargine) 300
unit/mL (1.5 mL) subcutaneous QHS
Inject 48U QHS
26. TraZODone 50 mg PO QHS:PRN insomnia
27.Outpatient Lab Work
ICD-10: E11.621
DATE: weekly: draw on ___ and ___
LAB TEST: CBC with differential, BUN, Cr, AST, ALT, Total
Bili, ALK PHOS, ESR, CRP
PLEASE FAX RESULTS TO: ATTN: ___ CLINIC - FAX:
___
28.Rolling Walker
EQUIPMENT: Rolling Walker
DIAGNOSIS: Left hallux amputation
ICD-10: ___
PX: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Osteomyelitis of left hallux
SECONDARY DIAGNOSES
===================
Hypertension
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you.
WHY WAS I ADMITTED TO THE HOSPITAL?
You had a diabetic foot ulcer on your left toe that was very
infected and had caused an infection in your bone.
WHAT WAS DONE WHILE I WAS HERE?
Your big left toe was removed because you had a bad bone
infection. You were treated with antibiotics to fight the
infection and will need to go home on IV antibiotics.
WHAT DO I NEED TO DO WHEN I LEAVE?
Please continue to take your medications as directed. You will
go home with an antibiotic infusion pump and will have a
visiting nurse come to your house to teach you how to use it.
You will need to administer antibiotics through the pump every 4
hours. We changed your diabetic medication regimen, so please
follow along as instructed below and keep close track of your
sugars at home. Check your sugars 4 times a day and log the
results. Bring the results in with you to your ___
appointment on ___ at 1:00 pm so that they can
adjust your medication regimen appropriately. Please follow-up
with Dr. ___ team on ___ at 11:00 am. Please
follow up with Dr. ___ your antibiotic regimen on
___ at 10:30 am. Please follow-up with Dr. ___
in ___ ___ on ___ at 1:00 pm.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10002013-DS-6 | 10,002,013 | 21,975,601 | DS | 6 | 2159-12-17 00:00:00 | 2159-12-21 10:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stenting with drug eluting stent to
the left circumflex
History of Present Illness:
___ year old woman with diastolic CHF, COPD, DM, HTN, HLD, and
CAD (h/o MI in ___ with LAD stenting, repeat stenting with DES
in ___ and ___, who presents with chest pain. She has been
having chest pain episodes over the past 2 weeks. A tightness
located in the ___ her chest that usually occurs with
exertion or when lying flat at night, but she has also
experienced at rest. It radiates to the left arm, and is
relieved with NTG. It is not pleuritic, but is reproducible when
she presses over the ___ her chest. Somewhat different
from the chest pain that she had prior to her previous PCIs.
Associated with dsyspnea and lightheadedness. She came to the ED
today after having a more severe episode yesterday.
.
In the ED initial VS were: 97.5, 67, 127/73, 16, 100%RA. EKG
showed SR with non-specific ST and T changes. CXR negative for
acute process. Labs notable for negative troponin but Creat 1.7
(was 1.4 in ___ and normal prior to that). She received ASA
325mg. VS prior to transfer were: 97.6, 70, 119/60, 16, 99%RA.
.
On arrival to the floor, patient is comfortable and denies chest
pain.
.
REVIEW OF SYSTEMS: As noted in HPI. In addition, denies fevers,
chills, sweats, presyncope, syncope, cough, PND, orthopnea, leg
swelling, abdominal pain, nausea, vomiting, hematemesis,
diarrhea, constipation, red or black stools, dysuria, hematuria,
myalgias, arthralgias, or rash. No history of DVT or PE.
Past Medical History:
- CAD: MI in ___ with LAD stenting, repeat stenting with DES in
___ and ___
- Diastolic CHF
- DM
- HTN
- HLD
- COPD
- Depression
- Right shoulder pain (bursitis, rotator cuff injury)
Social History:
___
Family History:
She was a ward of the ___ and does not know her family.
Physical Exam:
Admission physical exam:
VS: 98, 139/76, 71, 18, 100% RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. JVP not elevated.
CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. Pain
reproducible with palpation over ___ chest and left
breast.
LUNGS: Resp unlabored, no accessory muscle use. CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No edema. WWP.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
.
Discharge physical exam:
Vitals: Tc 98.1 BP 169/82 (130-169/63-86) HR 71 (70-77) RR 18 O2
Sat 98% RA
General: Patient lying in bed in NAD
HEENT: EOMI. MMM.
Neck: Supple. No JVD appreciated.
CV: RRR. No M/R/G
Lungs: Clear to auscultation bilaterally. No crackles or
wheezes. Nml work of breathing.
Abd: Obese. NABS+. Soft. NT/ND.
Ext: WWP. 2+ DPs bilaterally. No clubbing, cyanosis, or edema.
Pertinent Results:
Admission labs:
___ 10:10PM BLOOD WBC-10.9 RBC-3.78* Hgb-12.4 Hct-36.9
MCV-98 MCH-32.7* MCHC-33.6 RDW-12.5 Plt ___
___ 10:10PM BLOOD Neuts-58.7 ___ Monos-4.6 Eos-1.9
Baso-0.7
___ 06:05AM BLOOD ___ PTT-27.8 ___
___ 10:10PM BLOOD Glucose-338* UreaN-32* Creat-1.7* Na-134
K-4.3 Cl-100 HCO3-21* AnGap-17
___ 10:10PM BLOOD cTropnT-<0.01
Discharge labs:
___ 06:05AM BLOOD WBC-10.1 RBC-3.74* Hgb-12.5 Hct-35.5*
MCV-95 MCH-33.5* MCHC-35.2* RDW-12.8 Plt ___
___ 06:05AM BLOOD Glucose-99 UreaN-29* Creat-1.4* Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
___ 06:05AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
Cardiac enzymes:
___ 06:05AM BLOOD CK(CPK)-61
___ 06:05AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:10PM BLOOD cTropnT-<0.01
EKG:
Sinus rhythm at a rate of 69. Normal axis. The PR interval is
prolonged at 204ms (slightly more than prior ekg). Q wave in
III. Non-specific ST and T changes.
Nuclear Stress Test:
INTERPRETATION:
The image quality is adequate but limited due to soft tissue and
breast attenuation. There is activity adjacent to the heart in
the rest and stress images.
Left ventricular cavity size is increased.
Rest and stress perfusion images reveal a reversible, moderate
reduction in photon counts involving the mid and basal
inferolateral walls and the distal lateral wall. Gated images
reveal normal wall motion.
The calculated left ventricular ejection fraction is 52% with an
EDV of 107 ml (reprocessed at workstation).
IMPRESSION:
1. Reversible, medium sized, moderate severity perfusion defect
involving the LCx territory.
2. Increased left ventricular cavity size with normal systolic
function.
Compared to the prior study of ___, the defect is new.
.
Cardiac catheterization:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated three-vessel coronary artery disease. The ___ did
not
have angiographically-apparent flow-limiting stenoses. The LAD
had 60%
in-stent restenosis at the junction of the old Cypher stent
placed in
___ and the new Promus stent placed in ___ the D2 branch was
jailed
with 60% origin stenosis. The LCx had a 50% stenosis at its
origin;
there was a 90% stenosis of the OM1 branch. The mid-RCA had a
50%
stenosis.
2. Limited resting hemodynamics revealed mild systemic arterial
hypertension, with a central aortic pressure of 142/74 mmHg.
3. Successful PTCA and stenting of OM1 with a 3.0x15mm PROMUS
stent
which was postdilated to 3.5mm. Final angiography revealed no
residual
stenosis, no angiographically apparent dissection and TIMI III
flow (see
PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the OM1 with a DES.
.
Brief Hospital Course:
# Unstable angina: Description of the pain was somewhat atypical
for angina in that she experiences in when she lays down and it
is also reproducible. However, given her history of CAD status
post multiple PCIs and many risk factors, the patient underwent
stress test to rule out CAD. Nuclear stress test showed a
reversible, medium sized, moderate severity perfusion defect
involving the left circumflex territory. In light of these
stress test findings, the patient underwent cardiac
catheterization. Prior to cardiac catheterization, she was
prehydrated given her acute kidney injury. The patient had a
drug-eluting stent placed to the obtuse marginal branch. The
patient became acutely hypertensive during cardiac
catheterization and was started on a nitroglycerin drip (see
discussion below). The patient was weaned from this quickly. The
patient was continued on aspirin (full-dose), plavix,
metoprolol, and imdur. Her home dose of atorvastatin was
increased given evidence of coronary artery disease. Serial
cardiac enzymes were negative times 3.
OUTPATIENT ISSUES: Patient is to continue taking aspirin
325mg and plavix 75mg daily for the next year. Patient will have
cardiology follow-up as an outpatient with the ___
___ ___ group in ___.
.
# Acute kidney injury: Creatinine currently 1.7, up from 1.4 in
___. Renal function previously was normal. Upon admission,
the patient's lisinopril and furosemide were discontinued. Of
note, hte patient was started on furosemide approximately ___
months ago, which coincides with the development of the
patient's elevated serum creatinine. Serum creatinine was
trended through the admission and improved. The patient was
restarted on her home lisinopril, though her serum creatinine
was noticed to be increasing so was discontinued with
instructions to restart this medication after follow-up with her
primary care physician. The patient was instructed to have a
basic metabolic panel drawn ___.
.
# Diastolic heart failure: Patient was euvolemic through her
admission. Her home lasix was discontinued during this admission
given her acute kidney injury. The patient will follow-up with
her primary care physician regarding ___ of lasix.
OUTPATIENT ISSUES: Outpatient BMP for monitoring of serum
creatinine and reinitiation of lasix by the primary care
physician.
.
# Type 2 Diabetes Melltius, insulin dependent: Moderately
controlled with last A1c 7.9% in ___. Lantus and sliding
scale was continued through the hospitalization. She was
discharged home on her home doses of lantus and her home insulin
sliding scale.
.
# Hypertension: Through most of the patient's admission, her
blood pressure was well controlled (goal <130/80). She was
continued on metoprolol and imdur, though furosemide and
lisinopril were discontinued in light of the patient's elevated
serum creatinine. However, during the patient's cardiac
catheterization, she was noted to have elevated systolic blood
pressures and was started on a nitroglycerin drip for control of
blood pressures. The patient was weaned from the nitroglycerin
drip with in 4 hours after cardiac catheterization. The patient
received a dose of lisinopril, but because of rising serum
creatinine, the patient's next dose was held.
OUTPATIENT ISSUES: Follow-up with primary care physician
regarding recent hospitalization and anti-hypertensive regimen
in light of elevated serum creatinine.
.
# Hyperlipidemia: Well controlled with last LDL 50 in ___
(goal LDL<70), though triglycerides mildly elevated.
Atorvastatin was increased to 80mg daily given the new CAD
lesions. Patient also had a fasting lipid panel that was drawn,
which was pending at time of discharge.
OUTPATIENT ISSUES: Follow-up of pending fasting lipid panel.
.
# COPD: Currently asymptomatic. Patient was continue fluticasone
and albuterol as needed.
Medications on Admission:
- Clopidogrel 75 mg daily
- Asprin 325 mg daily
- Atorvastatin 40 mg daily
- Lisinopril 10 mg daily
- Metoprolol succinate 100 mg daily
- Isosorbide mononitrate 30 mg daily
- Furosemide 20 mg daily
- Nitroglycerin 0.4 mg SL prn
- Glargine insulin 80 units QHS
- Lispro insulin sliding scale
- Albuterol 90 mcg, 2 puffs Q4-6 hrs prn
- Fluticasone 110 mcg, 2 puffs BID
- Pantoprazole 40 mg BID
- Oxycode-Acetaminophen 5 mg-325 mg Q8h prn pain
- Potassium chloride 20 mEq BID
- Cholecalciferol 1,000 unit daily
- Metronidazole 0.75% lotion for ___
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual PRN as needed for chest pain.
7. insulin glargine 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
8. insulin lispro 100 unit/mL Solution Sig: Sliding scale units
of insulin Subcutaneous three times a day: As directed by
outpatient provider .
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every ___ hours as needed for SOB,
wheezing.
10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for pain.
13. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
14. metronidazole 0.75 % Lotion Sig: One (1) application
Topical as directed .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Atypical chest pain
Secondary diagnosis:
Coronary artery disease
Hypertension
Hyperlipidemia
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at ___.
You were hospitalized with chest pain and had a nuclear stress
test that was abnormal. You subsequently had a cardiac
catheterization and you were found to have a blockage in the
left circumflex coronary artery (one of the heart vessels).
Take all medication as instructed. Please note the following
medication changes:
1. Stop taking your potassium supplement for now, as your
potassium levels were normal in the hospital.
2. Increase your atorvastatin (lipitor) dose from 40mg to 80mg
daily.
3. Stop your lisinopril and lasix (furosemide) until otherwise
instructed by your primary care physician. You will need repeat
bloodwork on ___, which should be sent to your
primary care physician, ___.
Keep all hospital follow-up appointments. Your up-coming
appointments are listed below.
Followup Instructions:
___
|
10002131-DS-16 | 10,002,131 | 24,065,018 | DS | 16 | 2128-03-19 00:00:00 | 2128-03-19 16:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin Kapseal / Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ y/o F with PMHx CHF, Afib not on
anticoagulation, severe advanced Alzheimer's dementia,
osteoporosis, HTN, who presents from assisted living facility
with R hip pain.
The patient has severe dementia, with short term memory loss so
is unable to provide history. Much of the history is obtained
from multiple family members in the room. She has multiple
family members who live close by and are involved intimately in
her care. They were called from the assisted living facility
this morning when the patient was in ___ right hip pain. This
occurred suddenly. No trauma. No reported falls. She was not
complaining of other symptoms. She was brought to the ED.
Discussing with the patient, she moved into the Assisted living
facility in ___ in ___ given worsening of her
dementia. She was in her USOH, bowling weekly and very social,
until ___ when she developed acute SOB with ambulation
prompting admission to ___ where she was noted
to be in Afib. She had a week long hospital stay complicated by
an ICU course for an allergic reaction to a medication (family
thinks Zofran). Since returning from this hospitalization, she
has not been back to baseline and has deteriorated. She has
spent much of her time wheelchair bound given deconditioning.
She has worsening memory function, now with severe short term
memory loss. Decreased appetite and PO intake. She was recently
seen in ___ clinic by Dr. ___ new diagnosis of CHF. She
underwent an TTE at ___ yesterday ___ to evaluate her
systolic function.
In the ED, initial vitals were:
98.7, 96, 122/48, 20, 96% RA.
Exam was significant for:
R hip TTP greater trochanter, neg straight leg raise. ___
pulses 2+
LLE 2+ edema, unknown duration
Labs were significant for :
K 2.8
Cr 0.8
CBC: 13.9/12.5/39.2/168
UA: WBC 22, moderate leuks, negative nitrites
Studies:
Lower extremity ultrasound: 1. Deep vein thrombosis of the left
common femoral vein extending into at least the popliteal vein.
Left calf veins were not clearly identified and possibly also
occluded.
2. No DVT in the right lower extremity.
CXR
Bilateral pleural effusions, large on the right and small on the
left. No definite focal consolidation identified, although
evaluation is limited secondary to these effusions.
She was given 80 mEq of K and 60mg Enoxaparin Sodium.
Vitals on transfer were: 97.9, 79, 125/53, 18, 100% Nasal
Cannula.
On the floor, she is resting comfortably in bed. History is
obtained as above with family members. She sleeps with 2 pillows
at home and has DOE. She has not had a bowel movement in 2 days.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
Hypertension
Dementia
Osteoporosis
Irritable bowel syndrome
Macrocytosis of unclear etiology
Left ear hearing loss
Status post hysterectomy
Status post appendectomy
Status post ovarian cyst removal
Cataract surgery
Glaucoma
Social History:
___
Family History:
Not relevant to the current admission.
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 98.3, 107/43, 72, 16, 99 2L NC
General: AOx1, pleasant, smiling, at baseline per family members
at bedside
___: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft ___ systolic
murmur.
Lungs: Moderate inspiratory effort, decreased breath sounds
bilaterally at bases L>R. No wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, L>R lower extremity
swelling with left leg erythematous and tender to palpation, 2+
pitting edema tender, right lower extremity with e/o chronic
venous stasis changes, 1+ pitting edema non tender.
Neuro: AOx1, strength ___ upper and lower exteremities, all
facial movements in tact, sensation grossly in tact, gait
deferred.
DISCHARGE EXAM
==============
Vitals: T:97.9, 144/59, 72, 20, 93 RA
General: AOx1, pleasant, smiling, at baseline per family members
at bedside
___: Sclera anicteric, MMM
CV: Irregularly irregular, normal S1 + S2, soft ___ systolic
murmur.
Lungs: Moderate inspiratory effort, decreased breath sounds
bilateral bases
Ext: Warm, well perfused, 2+ pulses, L>R lower extremity
swelling with left leg erythematous and minimal tender to
palpation, 2+ pitting edema tender, right lower extremity with
e/o chronic venous stasis changes, 1+ pitting edema non tender.
Neuro: AOx1
Pertinent Results:
ADMISSION LABS
==============
___ 11:35AM URINE RBC-2 WBC-22* BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 12:00PM PLT COUNT-168
___ 12:00PM NEUTS-81.1* LYMPHS-10.8* MONOS-6.7 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-11.29* AbsLymp-1.51 AbsMono-0.94*
AbsEos-0.02* AbsBaso-0.03
___ 12:00PM WBC-13.9* RBC-3.78* HGB-12.5 HCT-39.2
MCV-104* MCH-33.1* MCHC-31.9* RDW-13.6 RDWSD-51.9*
___ 12:00PM CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-1.6
___ 12:00PM cTropnT-0.03* proBNP-8428*
___ 12:00PM GLUCOSE-118* UREA N-26* CREAT-0.8 SODIUM-144
POTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-38* ANION GAP-14
STUDIES
=======
CXR
Bilateral pleural effusions, large on the right and small on the
left. No
definite focal consolidation identified, although evaluation is
limited
secondary to these effusions.
Pelvis Xray
There is no acute fracture or dislocation. No focal lytic or
sclerotic
osseous lesion is seen. There is no radiopaque foreign body.
Vascular
calcifications are noted. The visualized bowel gas pattern is
nonobstructive.
IMPRESSION: No acute fracture or dislocation.
Lower extremity ultrasound
1. Deep vein thrombosis of the left common femoral vein
extending into at
least the popliteal vein. Left calf veins were not clearly
identified,
possibly also occluded.
2. No right DVT.
LAST LABS BEFORE DISCHARGE
===============================
___ 06:55AM BLOOD WBC-14.9* RBC-3.51* Hgb-11.5 Hct-36.8
MCV-105* MCH-32.8* MCHC-31.3* RDW-13.8 RDWSD-53.1* Plt ___
___ 06:55AM BLOOD Glucose-109* UreaN-32* Creat-0.9 Na-144
K-3.7 Cl-96 HCO3-37* AnGap-15
___ 06:55AM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.2
Mg-1.5*
Brief Hospital Course:
___ is a ___ y/o F with PMHx CHF, Afib not on
anticoagulation, severe advanced Alzheimer's dementia,
osteoporosis, HTN, who presents from assisted living facility
with R hip pain, found to have DVT left common femoral vein with
volume overload. During a meeting with patient and her family,
decision was made to transition care to comfort-directed
measures only and to pursue hospice services on discharge.
ACTIVE ISSUES
=============
# CMO. The team had a family meeting on ___ and decision was
made to transition care to CMO and pursue 24 hour hospice
services on discharge. Family did not want to pursue active
treatments such as Lasix, which would make her uncomfortable
given incontinence or shots such as lovenox for treatment of
DVT. Home medications metoprolol, donepezil and Memantine were
continued for comfort. She was discharged to an ___
___ facility.
OTHER HOSPITAL ISSUES
=====================
# DVT. Deep vein thrombosis of the left common femoral vein
extending into at least the popliteal vein diagnosed on
ultrasound on admission. This was likely acquired in the setting
of immobility, as the patient had been restricted to her
wheelchair at her assisted living for greater than 1 month due
to deconditioning. She was initially started on Lovenox for
treatment but this was discontinued in the setting of transition
to care to CMO as above.
# Acute CHF. Patient was volume overloaded on presentation with
pleural effusions. She was diuresed with IV Lasix. Home
metoprolol was continued at a decreased dose. In the setting of
transition to care to CMO, Lasix was discontinued. She was
continued on metoprolol for comfort. She remained on room air
without respiratory distress.
# Afib. She presented in sinus rhythm, rate controlled on
metoprolol. Metoprolol was continued at a decreased dose for
comfort.
# Hip pain. The right hip pain that she presented with was
resolved by the time of admission. Pelvic xray was without
fracture. She was treated with Tylenol scheduled for pain
control.
# Al___ Dementia. She was AOx1 at her baseline per family
members. She was continued on Aricept/Namenda.
TRANSITIONAL ISSUES
===================
- ___ facility to continue writing orders for
pain/anxiety/secretions and other symptoms.
- Continued metoprolol succinate and Memantine and donepezil on
discharge for comfort. Continuation of these medications can be
further decided at inpatient hospice.
- MOLST form: DNR/DNI, do not re-hospitalize
# CODE: DNR/DNI, CMO
# CONTACT: HCP ___ (daughter) ___ Primary,
secondary ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 150 mg PO BID
2. Torsemide 40 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. raloxifene 60 mg oral DAILY
6. Multivitamins 1 TAB PO DAILY
7. Namenda XR (MEMAntine) 21 mg oral DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Calcium Carbonate 1500 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Donepezil 10 mg PO QHS
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Namenda XR (MEMAntine) 21 mg oral DAILY
4. Acetaminophen 1000 mg PO TID
5. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
6. Hyoscyamine 0.125 mg SL QID:PRN excess secretions
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
---------------
Deep Vein Thrombosis
Secondary Diagnosis
------------------
Congestive heart failure
Atrial fibrillation
Constipation
Malnutrition
Hypertension
Alzheimer's dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were hospitalized with right hip
pain. We did Xrays of your hip which did not show any fractures.
We also found a blood clot in your left leg and noticed that
your heart wasn't pumping very efficiently. We talked with you
and your family, who shared with us many of your wishes about
being hospitalized and the type of care you would like to
receive. We decided to focus on your comfort. Because of this,
you are being discharged to ___ for hospice care.
We wish you and your family the ___,
Your ___ Treatment Team
Followup Instructions:
___
|
10002167-DS-10 | 10,002,167 | 24,023,396 | DS | 10 | 2166-05-15 00:00:00 | 2166-05-15 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Band adjustment
History of Present Illness:
Ms. ___ is a ___ s/p lap band in ___ who prsents with a 1
week history of nausea, non-bilious non-bloody emesis of
undigested food after eating, intolerance to solids/softs,
hypersalivation, and moderate post-prandial epigastric
discomfort. She denies fever, chills, hematemesis, BRBPR,
melena,
diarrhea, or sympotoms of dehydration, but was recently
evaluated
for dizziness in an ED with a diagnosis given of BPPV. Of note,
the patient underwent an unfill of her band from 5.8 to 3.8ml on
___ for similar symptoms, the band was subseqently been filled
to 4.8 on ___, 5.2 on ___, and most recently to 5.6ml on
___.
Past Medical History:
PMHx: Hyperlipidemia and with elevated triglyceride, iron
deficiency anemia, irritable bowel syndrome, allergic rhinitis,
dysmenorrhea, vitamin D deficiency, question of hypothyroidism
with elevated TSH level, thalassemia trait, fatty liver and
cholelithiasis by ultrasound study. A history of kissing tonsils
that was associated with obstructive sleep apnea and
gastroesophageal reflux, these have resolved completely after
the
tonsillectomy in ___. History of polycystic ovary
syndrome
Social History:
___
Family History:
bladder CA; with diabetes, breast neoplasia, colon CA, ovarian
CA and sarcoma
Physical Exam:
VS: Temp: 97.9, HR: 72, BP: 113/64, RR: 16, O2sat: 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, MMM
CV: RRR
PULM: No W/R/C, no increased work of breathing
ABD: Soft, nondistended, non-tender to palpation in epigastric
region, no rebound or guarding, palpable port
Ext: No ___ edema, warm and well perfused
Pertinent Results:
___ 12:16AM PLT COUNT-243
___ 12:16AM NEUTS-46.0 ___ MONOS-6.9 EOS-1.8
BASOS-0.5 IM ___ AbsNeut-4.88 AbsLymp-4.72* AbsMono-0.73
AbsEos-0.19 AbsBaso-0.05
___ 12:16AM estGFR-Using this
___ 01:02AM URINE MUCOUS-RARE
___ 01:02AM URINE HYALINE-1*
___ 01:02AM URINE RBC-4* WBC-4 BACTERIA-MOD YEAST-NONE
EPI-11
___ 01:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 01:02AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:02AM URINE UCG-NEGATIVE
___ 01:02AM URINE HOURS-RANDOM
___ 01:02AM URINE HOURS-RANDOM
Brief Hospital Course:
___ was admitted from ED on ___ for nausea and
vomiting after any po intake. Of note, she has had similar
symptomes last year. She was started on IV fluids for
rehydration. Her laboratory values were unremarkable on
admission and her symptoms gradually improved with anti-emetic
medications and IV fluid therapy. She was back to her baseline
clinical status after unfilling the band by 1.5cc. Water
challenge test was done after band adjustment and was negative
for any pain, nausea or vomiting. She was discharged in good
condition with instructions to follow up with Dr. ___
___ after 2.
Discharge Medications:
1. Lorazepam 0.5 mg PO BID:PRN anxiety
2. BusPIRone 5 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
nausea and vomiting due to tight band
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for your Nausea and vomiting. Your
band was tight enough to cause your nausea and vomiting, 1.5 cc
has been taken out from your band in which 2.5cc total left. you
subsequently tolerated a water bolus test. You have been deemed
fit to be discharged from the hospital. Please return if your
nausea becomes untolerable or you start vomiting again. Please
continue taking your home medications.
Thank you for letting us participate in your healthcare.
Followup Instructions:
___
|
10002221-DS-11 | 10,002,221 | 20,237,862 | DS | 11 | 2204-07-06 00:00:00 | 2204-07-06 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Augmentin / Topamax
Attending: ___.
Chief Complaint:
RLE pain and swelling
Major Surgical or Invasive Procedure:
Ultrasound guided steroid injection of the right trochanteric
bursa (right hip)
History of Present Illness:
This is a ___ woman with a history of breast cancer with
BRCA1 gene mutation, COPD, cerebral aneurysm, sleep apnea,
depression, hyperlipidemia, antiphospholipid syndrome with hx
DVT/PE ___ ago on warfarin who presents for evaluation of severe
right lower extremity pain.
She was just admitted to the hospital for lumpectomy
(infiltrating ductal carcinoma of left breast) and sentinel
lymph
node biopsy on ___, complicated by hematoma status post
evacuation on ___. Prior to these procedures, she had
severe
right lower extremity pain similar to today and underwent a DVT
ultrasound on ___ which was negative. Her anticoagulation was
held in the hospital due to the hematoma, and she had DVT
prophylaxis with pneumoboots.
During her postoperative hematoma her anticoagulation was held.
She did not have extremity pain during her time in the hospital.
However, upon returning home, she developed severe pain which
she
describes as cramps in her mid calf on the right. She also has
pain that intermittently occurs in the right thigh which she
describes as spasms. She has not had numbness, tingling, or
weakness on that side. She was seen in breast clinic today where
she complained of this pain, and was referred to the ED for
further evaluation. She initially triggered as a pulseless
extremity because of nonpalpable pulses in the right foot. She
has been taking Tylenol as well as tramadol with minimal pain
relief.
Of note, she resumed her warfarin without any enoxaparin bridge
this past ___. She has been wearing compression stockings and
elevating her leg in an attempt to relieve the pain.
In the ED, initial vitals:
T 98.7 HR 85 BP 175/77 RR 20 O2 Sat 98% RA
- Exam notable for:
Right lower extremity with dopplerable pulses, palpable pulses
in
the left lower extremity. The right lower extremity is warm.
There is tenderness to palpation of the right calf. Tenderness
to
palpation of the right thigh.
- Labs notable for:
Chem panel: Unremarkable with Cr 0.8
CK 67
CBC: WBC 5.6, Hgb 10.8 with MCV 93, Plt 264
Coags: ___ 14.8, PTT 28.2, INR 1.4
Lactate 1.1
UA: Mod Leuk, few bacteria
- Imaging notable for:
RLE Ultrasound ___
Right calf veins not visualized. Otherwise, no evidence of deep
venous
thrombosis in the right lower extremity veins.
CT Lower Extremity Right ___
Unremarkable contrast enhanced CT of the right calf with a two
vessel runoff to the foot.
The veins of the lower extremity are not opacified therefore
cannot be
assessed for patency. Consider repeat ultrasound to more fully
evaluate.
No focal collection or obvious muscular abnormality identified
by
CT.
- Pt given:
IV Morphine 4mg
IV APAP 1g
IV NS
IV Dilaudid 5 mg total (1mg x 5)
Warfarin 7.5mg
Atorvastatin 40mg
Omeprazole 20mg
Surgery was consulted: Recommend vascular surgery consult for
possible dvt with history of multiple vein stripping procedures
and DVTs. Also recommend admission to medicine for pain control.
Vascular surgery was consulted: There is no clear vascular
etiology for her pain.
- Vitals prior to transfer:
T 98.3 HR 83 BP 140/55 RR 20 O2 Sat 100% RA
Upon arrival to the floor, the patient reports the pain is ___.
She reports again that this pain is similar to the pain she had
on ___ but even then an ultrasound showed no DVT. She is able
to
move her toes but has pain with lifting her leg. She has never
had this kind of pain before, even with the vein stripping that
she had in the past (age ___. She has no chest pain or shortness
of breath. She has had no recent travel or trauma to her leg.
Past Medical History:
Dyslipidemia,
Varicose veins (R>L) s/p ligation,
COPD,
OSA (+CPap),
recent URI (received course of Zithromax),
bilateral PEs (___),
antiphospholipid antibody syndrome (on lifelong
anticoagulation),
T2DM (last A1C 6.2 on ___,
cerebral aneurysm (followed by Dr. ___, unchanged),
GERD,
diverticulosis,
h/o colon polyps,
depression,
s/p right CMC joint arthroplasty,
b/l rotator cuff repair,
excision right ___ digit mass,
CCY w/stone & pancreatic duct exploration (___),
hysterectomy,
tonsillectomy
Social History:
___
Family History:
Mother ___ ___ OVARIAN CANCER dx age ___
Father ___ ___ BRAIN CANCER
PGM OVARIAN CANCER
Aunt OVARIAN CANCER paternal aunt in
___
MGM ENDOMETRIAL CANCER
MGF PROSTATE CANCER
Brother ___ ___ KIDNEY CANCER
RENAL FAILURE
CONGESTIVE HEART
FAILURE
DIABETES MELLITUS
TOBACCO ABUSE
ALCOHOL ABUSE
Sister ___ ___ OVARIAN CANCER dx age ___
Brother ___ THROAT CANCER dx age ___, died in
___
Sister BRCA1 MUTATION, BREAST CANCER
Daughter Living ___ ABNORMAL PAP SMEAR ___
SUBSTANCE ABUSE
Son Died ___ SUBSTANCE ABUSE ___ - heroin overdose on ___.
Physical Exam:
ADMISSION EXAM:
==================
VITALS: T 97.9 BP 125 / 80 HR 82 RR 16 O2 Sat 94 RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not
elevated
Chest: L breast incisions well healed. S/p L axilla surgical
drain removal.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, right lower extremity is tender to
palpation and movement limited by pain. Swelling of RLE > LLE.
Palpable 2+ ___ pulses bilaterally.
Skin: Warm, dry, varicose veins noted in lower extremities.
Neuro: CNII-XII intact, grossly normal strength and sensation
and
symmetric bilaterally
DISCHARGE EXAM:
================
VITALS: Temp: 98.2 (Tm 98.9), BP: 133/74 (127-147/72-83), HR: 76
(76-91), RR: 18, O2 sat: 99% (90-99), O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not
elevated
Chest: L breast incisions well healed. S/p L axilla surgical
drain removal.
CV: RRR, no murmurs
Lungs: Clear
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused. No asymmetric swelling. Minimally
tender to palpation along the right trochanteric bursa and
minimally tender to palpation along the right tibia. Normal ROM
though pain elicited with knee flexion; improves with leg raise
and extension. Palpable 2+ ___ pulses bilaterally.
Skin: varicose veins noted in lower extremities.
Neuro: lower extremity sensation is equal on both sides to light
touch. Normal bilateral lower extremity strength. Negative
babinsky. Ambulating in hallway independently though it
precipitates
right tibial pain
Pertinent Results:
ADMISSION LABS:
================
___ 12:00PM BLOOD WBC-5.6 RBC-3.48* Hgb-10.8* Hct-32.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.7 RDWSD-48.6* Plt ___
___ 12:00PM BLOOD Neuts-73.6* ___ Monos-4.9*
Eos-0.9* Baso-0.7 Im ___ AbsNeut-4.09 AbsLymp-1.08*
AbsMono-0.27 AbsEos-0.05 AbsBaso-0.04
___ 12:00PM BLOOD ___ PTT-28.2 ___
___ 12:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139
K-4.0 Cl-100 HCO3-26 AnGap-13
___ 05:40AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.2 Iron-36
___ 05:40AM BLOOD calTIBC-291 VitB12-331 Ferritn-50 TRF-224
___ 07:15AM BLOOD 25VitD-45
___ 12:25PM BLOOD Lactate-1.1
DISCHARGE LABS:
================
___ 04:41AM BLOOD WBC-5.6 RBC-3.36* Hgb-10.1* Hct-31.1*
MCV-93 MCH-30.1 MCHC-32.5 RDW-14.5 RDWSD-48.7* Plt ___
___ 04:41AM BLOOD ___
___ 04:41AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-140
K-5.0 Cl-103 HCO3-26 AnGap-11
___ 04:41AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.4
IMAGING:
===================
Unilat lower extremity vein- R ___
Right calf veins not visualized. Otherwise, no evidence of deep
venous thrombosis in the right lower extremity veins.
CT RLE ___
Unremarkable contrast enhanced CT of the right calf with a two
vessel runoff to the foot.
The veins of the lower extremity are not opacified therefore
cannot be assessed for patency. Consider repeat ultrasound to
more fully evaluate.
No focal collection or obvious muscular abnormality identified
by CT
___:
1.. Uneventful ultrasound-guided injection of long-acting
anesthetic and
steroid into theright greater trochanteric bursa.
2. Prior injection, small amount of fluid in the right greater
trochanteric
bursa and dystrophic calcification within the bursal space.
Findings raise
suspicion for chronic trochanteric bursitis.
Brief Hospital Course:
SUMMARY:
==================
Ms. ___ is a ___ with a PMH significant for
antiphospholipid syndrome with DVTs and PEs on Coumadin, recent
L-sided breast cancer s/p lumpectomy, who presented to the ED
with acute on chronic right lower extremity and right hip pain,
making it difficult to ambulate. Right lower extremity U/S and
CT did not reveal a DVT though calf veins were not well
visualized.
ACTIVE ISSUES:
==================
# Right trochanteric bursitis
# Right anterior lower leg pain
# Right sided varicose veins
Pt endorsed >4mths of pain in RLE that became acutely worse over
the last few wks. Her initial exam was most consistent with
severe trochanteric bursitis on the right. She also has some
focal pain along the right tibia which she felt was most
consistent with pain from her varicose veins. The XRs of her
tibia/fibula and right hip were without obvious pathology. There
are no concerning neurologic symptoms to suggest a
radiculopathy, no weakness or numbness though she may have some
degree of chronic sciatica. Mildly decreased patellar reflex on
the right as compared to left may have been in the setting of
pain and guarding; strength was normal bilaterally as was her
sensation.
She underwent U/S guided steroid injection of her trochanteric
bursa w/ significant improvement in symptoms; ___ stated that
there was some fluid near the bursa, suggestive of acute on
chronic trochanteric bursitis. Her anterior shin pain improved
with initiation of gabapentin and lidocaine patch in addition to
her home tylenol and an increase in the frequency of her home
tramadol (q8h PRN to q4h PRN). Pt was not given her home
hydromorphone PRN, though she did require one dose of 0.5 mg IV
hydromorphone following her injection in the setting of an acute
pain episode. She was discharged with Tramadol 50mg x15 tablets
given increased requirement. By discharge, she was able ambulate
and was felt safe for discharge home with a cane per ___
evaluation. Pt was eager to leave and will reach out to her
vascular surgeon for an appointment early in the new year for
treatment of her painful varicose veins.
# Iron deficiency anemia:
Anemia is new since ___. Normocytic. Downtrended overnight to
8.9 from 10.8. No concern for active bleeding. Per iron studies,
she is iron deficient with a ferritin of 50. She endorses
fatigue and restless leg syndrome. Etiology is unclear, though
it may be related to the recent left breast hematoma of her
breast (unlikely though the timing fits). Prior EGD with
gastritis (___) for which she is on a BID PPI; prior
colonoscopy ___ with findings that may be suggestive of
celiac disease, though ttg at that time was normal with a normal
IgA. She also had two polyps biopsied and were normal. On this
admission, a vitamin D level was obtained to assess for evidence
of malabsorption iso daily supplementation: level was 45. She
was given ferric gluconate IV x1 on ___. TTG was repeated and
pending at discharge.
CHRONIC ISSUES:
===================
# History of DVT/PE on warfarin:
# Antiphospholipid antibody syndrome:
# Subtherapeutic INR:
Lupus anticoagulant positive in ___. She has been taking her
home dose of warfarin (5 mg ___ and 7.5 mg other days). Her
warfarin was held last ___ iso hematoma and she was not
bridged with Lovenox upon reinitiation. INR on this admission
was subtherapeutic at 1.4. Bridged during this hospitalization
with Lovenox for goal INR ___. She was given an increased dose
of warfarin, 7.5 mg daily while in house. INR at discharge was
1.9, with plan to continue home warfarin regimen. Patient will
get repeat INR on ___.
# Vitamin D deficiency: pt takes 2,000 U vitamin D daily. Repeat
level IS 45 which suggests against malabsorption to account for
her iron deficiency.
TRANSITIONAL ISSUES:
====================
Code status: Full, presumed
HCP: ___, granddaughter - ___.
- Right trochanteric bursitis:
[] Consider repeat injection
[] Consider physical therapy
- Right anterior leg pain
[] discharged on gabapentin 600 mg three times daily
[] discharged with tramadol 50mg, home regimen is Q8hrs and
required Q4hrs during hospitalization. Will give two day supply
of increased dose. Plan to see PCP next week.
[] Consider outpatient MRI of the lumbar spine for chronic pain
[] Consider EMG
[] Vascular surgery follow up as outpt for treatment of painful
veins
- Iron deficiency anemia:
[] Consider repeat IV iron infusion
[] F/u pending TTG
[] Consider further work up (though may be related to left
breast hematoma)
- History of DVT/PE, antiphospholipid antibody syndrome,
subtherapeutic INR:
[] F/u ___ clinic on ___. Patient can continue home
Warfarin regimen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Omeprazole 20 mg PO BID
4. Senna 8.6 mg PO HS
5. Sertraline 150 mg PO DAILY
6. TraZODone 50 mg PO QHS:PRN sleep
7. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze
12. Vitamin D ___ UNIT PO DAILY
13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
14. Furosemide 20 mg PO DAILY:PRN Leg swelling
15. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
16. Warfarin 7.5 mg PO 2X/WEEK (___)
17. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times daily
Disp #*90 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM right hip
RX *lidocaine 5 % Apply ___ patches daily Disp #*12 Patch
Refills:*0
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth Every six hours as
needed Disp #*15 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze
6. Atorvastatin 40 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
9. Furosemide 20 mg PO DAILY:PRN Leg swelling
10. Omeprazole 20 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
13. Senna 8.6 mg PO HS
14. Sertraline 150 mg PO DAILY
15. TraZODone 50 mg PO QHS:PRN sleep
16. Vitamin D ___ UNIT PO DAILY
17. Warfarin 5 mg PO 2X/WEEK (___)
18. Warfarin 7.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
=================
Right trochanteric bursitis
Right anterior leg pain
Right sided varicose veins
SECONDARY:
=================
Iron deficiency anemia
History of DVT/PE on warfarin
Antiphospholipid antibody syndrome
Subtherapeutic INR
Vitamin D 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 ___,
You were admitted because you were having a lot of leg pain,
making it difficult to walk.
In the hospital, we gave you a steroid injection near your right
thigh for a condition called, Trochanteric Bursitis. We also
gave you a medication called Gabapentin to help with your leg
pain lower down.
We also started you on a medication called Lovenox in order to
bridge you back to your warfarin - currently, your warfarin dose
is 7.5 mg daily and your INR was 1.9 at discharge (goal ___.
Finally, you received 1 dose of intravenous iron because you are
iron deficient which may be why you are more fatigued than
usual.
When you go home, please take your medications as prescribed and
make an appointment with your primary care doctor. We do not
know what exactly is causing the lower leg pain, so you may want
to talk to your doctor about having an MRI of your spine. You
can also ask your doctor about prescribing a medication called
DICLOFENAC GEL, also called VOLTAREN. This is essentially Motrin
or Advil in a topical form and may help your pain.
Additionally, please talk to your doctor about why you may be
iron deficient.
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely,
The team at ___
Followup Instructions:
___
|
10002348-DS-13 | 10,002,348 | 22,725,460 | DS | 13 | 2112-12-10 00:00:00 | 2112-12-10 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
___ - Suboccipital craniotomy for resection of cerebellar
lesion
History of Present Illness:
___ is a ___ female with hx cerebral aneurysm
clipping in ___ who presents from OSH with left cerebellar
hypodensity concerning for underlying lesion. Patient reports
that three weeks ago she started having headaches, which is
abnormal for her. She describes the headaches to be global and
resolve with Tylenol, but at the worst was an ___. She also
reports having difficulty walking, which also started about
three weeks ago. She describes her walking as "staggering side
to side." She denies any vision changes, nausea, vomiting,
confusion, or word finding difficulty. She saw her eye doctor
this morning for routine visit, who referred her to the ED for
evaluation of these symptoms. OSH CT showed an area of
hypodensity in the left cerebellum, concerning for underlying
lesion. She was subsequently transferred to ___.
Of note, patient reports her aneurysm clip is not MRI
compatible.
Past Medical History:
- ___
- Hypertension
- S/p aneurysm clipping ___ at ___ by Dr. ___
Social History:
___
Family History:
No known history of stroke, cancer, aneurysm.
Physical Exam:
ON ADMISSION:
O: T: 97.9 BP: 130/62 HR: 64 R 16 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: L ___, R ___ EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Left pupil 5-4mm, right 4-3mm, both equally reactive to
light.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. Slight left upward
drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger and heel to shin
======================================================
ON DISCHARGE:
Exam:
Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right 4-3mm Left 5-4mm - chronic
EOM: [ ]Full [x]Restricted - chronic, most prominent left
lateral
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
TrapDeltoid BicepTricepGrip
Right 5 5 5 5 5
Left 5 5 5 5 5
IPQuadHamATEHLGast
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
#Brain lesion
Patient was found to have cerebellar hypodensity on NCHCT from
OSH. CT w/wo contrast was obtained while in the ED at ___
which was concerning for underlying mass lesion and
hydrocephalus. (Of note, she was unable to get MRI due to
reportedly having a non-compatible aneurysm clip that was placed
in ___ at ___. Patient was admitted to the ___ for close
monitoring and surgical planning. She was started on
dexamethasone 4mg Q6hr for mass effect. CT torso was obtained
which showed two lung nodules, see below for more information.
Neuro and radiation oncology were consulted. Plan was made for
surgical resection of the lesion. On ___, it was determined
that her aneurysm clip was MRI compatible and she was able to
have a MRI Brain for surgical planning. She went to the OR the
evening of ___ for a suboccipital craniotomy for resection of
her cerebellar lesion. Postoperatively she was monitored in
Neuro ICU, where she remained neurologically and hemodynamically
stable. She was transferred to the ___ on POD#2 and made floor
status. Her Dexamethasone was ordered to taper down to a
maintenance dose of 2mg BID over the course of one week. Her
pathology finalized as small cell lung carcinoma.
#Lung lesions
CT torso was obtained which showed two lung nodules, one in the
left paramedian abutting the aortic arch and the other in the
right upper lobe. Pulmonary was consulted and stated that no
further intervention was indicated until final pathology was
back. Heme-Onc was also consulted, and made recommendations that
no further lung imaging or separate lung biopsy was needed. Both
Pulmonary and Heme-Onc stated that staging and treatment could
be determined based on the tissue pathology from resection of
the brain lesion. Her final pathology came back as small cell
lung carcinoma. She will follow-up with the thoracic oncologist
on ___.
#Steroid-induced hyperglycemia
Throughout her admission, the patient intermittently required
sliding scale Insulin for elevated blood sugars while on
Dexamethasone. She was evaluated by the ___ inpatient team on
___, who decided that she did not need to go home on Insulin.
They recommended discharging her with a glucometer so that she
could check her blood sugars daily with a goal blood sugar less
than 200. She was advised to record her readings and follow-up
with her PCP and ___.
#Bradycardia
She was due to transfer out to the ___ on POD1, however was
kept in the ICU for asymptomatic bradycardia to the ___. She
remained asymptomatic, and her heartrate improved with fluids,
and administration of her levothyroxine. She intermittently
dipped to the ___, however remained asymptomatic.
#Bell's palsy
The patient was resumed on her home Valacyclovir and Prenisolone
gtts.
#Urinary urgency
On POD 2, the patient complained of urinary urgency and
increased frequency. U/A was negative and culture was negative.
Her symptoms had resolved at the time of discharge.
#Dispo
The patient was evaluated by ___ and OT who cleared her for home
with services. She was discharged on ___ in stable condition.
She will follow up in ___ on ___.
Medications on Admission:
- ASA 81mg
- Alendronate 70mg weekly
- Vitamin D3 ___ units daily
- Levothyroxine 88mcg daily
- Lisinopril 20mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY
3. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
start ___: 3tabsq8hrs x2, 2tabsq8hrs x6, 2tabsq12hrs
maintenance dose.
This is dose # 2 of 3 tapered doses
RX *dexamethasone 1 mg 3 tablet(s) by mouth every eight (8)
hours Disp #*120 Tablet Refills:*1
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Senna 17.2 mg PO HS
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
11. ValACYclovir 1000 mg PO Q8H
12. Vitamin D ___ UNIT PO DAILY
13. HELD- Alendronate Sodium 70 mg PO 1X/WEEK (___) This
medication was held. Do not restart Alendronate Sodium until POD
___ - ___
14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until POD 14 - ___
___ glucometer
___ Freestyle glucometer. Check blood sugars ___ hours after a
starchy meal. Record numbers and show to your Oncologist.
___ test strips
#50. Check blood sugars QD. 3 refills.
___ Lancets
#50. Check blood sugars QD. 3 refills.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Brain tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid.
Discharge Instructions:
Surgery:
- You underwent surgery to remove a brain lesion from your
brain.
- A sample of tissue from the lesion in your brain was sent to
pathology for testing.
- Please keep your incision dry until your sutures are removed.
- You may shower at this time but keep your incision dry.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications:
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
We held your Aspirin 81mg daily. You are cleared to resume this
medication on POD 14 (___).
- We held your home Alendronate during this admission. You are
cleared to resume this medication on POD 14 (___).
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- You were started on Dexamethasone, a steroid that treats
intracranial swelling. This Dexamethasone is being tapered down
to a maintenance dose of 2mg BID. Please take this medication as
prescribed.
- While admitted, you had elevated blood glucose levels that
needed to be treated by Insulin. You should continue to check
your blood sugars daily at home with the prescribed glucometer.
You visiting nurse should teach you how to use this device at
home. Please record your blood sugars and follow-up with your
PCP and ___ regarding the results. Your goal blood sugar
is less than 200.
What You ___ Experience:
- You may experience headaches and incisional pain.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason
Followup Instructions:
___
|
10002428-DS-16 | 10,002,428 | 28,662,225 | DS | 16 | 2156-04-29 00:00:00 | 2156-04-30 22:51:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diarrhea - Transfer to MICU for Hypoxia
Major Surgical or Invasive Procedure:
___ line placement
Right pigtail pleural catheter placement
History of Present Illness:
Pt is an ___ year-old female with h/o Sjogren's syndrome, IBS,
who presents with diarrhea and fever. Patietn starting having
non-bloody, watery diarreha approximately three weeks ago. This
has been persistent since that time. For the past several days,
she has been experiencing crampy b/l lower quadrant abdominal
pain and distension. Today she developed subjective fever and
rigors at home. Denies nausea, vomiting, dysuria. Decreased
appetite over same time course.
In the ED, initial vs were: 98.5 125 111/63 22 100%. Patient
AAOx3. Subsequently febrile to 101.0. Exam remarkable for mild
discomfort to palpation in RLQ/LLQ. Labs notable for WBC 20.2
with 93.6% PMNs (no bands), Na 127, lactate 2.2, normal LFTs. UA
showed 5 hyaline casts, no mucus/WBC/RBC etc. BCx and UCx drawn.
CT ___ with contrast showed pancolitis without
perforation or obstruction, intrahepatic biliary duct dilatation
and prominent CBD, right lung base consolidation. CXR showed
bibasilar opacities +/- pulm edema and multiple dilated small
bowel loops. Patient given 2L NS, 2L LR, IV Cipro, IV Flagyl and
Tylenol. Patient was initially admitted to medicine floor, but
developed hypoxia while in ED and had new 5L O2 requirement. She
had a repeat CXR showing possible pneumonia vs. pulmonary edema.
She received ceftriaxone for possible pneumonia and was
transferred to MICU.
.
On arrival to the MICU, patient appears uncomfortable and is
rigoring. She reports crampy abdominal pain in her lower
abdomen, fevers, and rigors. She continues to have diarrhea, but
no nausea or vomiting. Mild cough productive of white sputum. Of
note, patient last received antibiotics in ___
(azithromycin for CAP).
.
Review of systems:
(+) Per HPI
(-) Denies night sweats. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes
Past Medical History:
Anemia
Borderline cholesterol
C. Diff
Heart Murmur
Hypertension
Hypothyroidism
Mitral Regurgitation
Osteoporosis
Pneumonia
Sinusitis
___
Social History:
___
Family History:
Long history of hypertension in her family. She does report
that her father's family has a history of multiple cancers. She
has a grandfather with a history of stomach cancer and an uncle
with a history of throat cancer. She denies any history of
colon cancers. Father had stroke. No family h/o MI. Mother had a
heart valve replaced (pt not sure which one).
Physical Exam:
Admission Exam:
General: Alert, oriented, rigoring, appears uncomfortable
HEENT: Sclera anicteric, dry mucus membranes, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachy, S1, S2, II/VI holosystolic murmur at apex
Lungs: Diffuse rhonchi, no wheezes
Abdomen: +BP, Firm, distended, tender to palpation in right and
left lower quadrant, no rebound/guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities
Discharge exam - unchanged from above, except as below:
General: tired but arousable to voice, appropriate
CV: RRR, ___ systolic murmur at the apex
Lungs: Slightly decreased breath sounds at the lung bases, right
pigtail catheter in place
Abd: Hypoactive BS, soft, non-tender, mildly distended
Extr: 2+ edema to the thigh bilaterally
Pertinent Results:
Admission Labs:
___ 10:20AM BLOOD WBC-20.2*# RBC-3.76* Hgb-11.6* Hct-36.1
MCV-96 MCH-30.9 MCHC-32.3 RDW-12.8 Plt ___
___ 10:20AM BLOOD Neuts-93.6* Lymphs-3.6* Monos-2.4 Eos-0.1
Baso-0.2
___ 07:24PM BLOOD ___ PTT-26.9 ___
___ 10:20AM BLOOD Glucose-121* UreaN-15 Creat-1.1 Na-127*
K-4.3 Cl-89* HCO3-25 AnGap-17
___ 10:20AM BLOOD ALT-26 AST-30 AlkPhos-78 TotBili-0.5
___ 10:20AM BLOOD Lipase-21
___ 07:24PM BLOOD Calcium-7.4* Phos-2.2* Mg-1.4*
___ 10:20AM BLOOD Albumin-4.1
___ 10:29AM BLOOD Lactate-2.2*
Discharge Labs:
___ 07:30AM BLOOD WBC-7.1 RBC-3.11* Hgb-9.3* Hct-30.3*
MCV-97 MCH-29.9 MCHC-30.7* RDW-14.0 Plt ___
___ 07:30AM BLOOD Glucose-122* UreaN-20 Creat-0.3* Na-133
K-4.0 Cl-92* HCO3-39* AnGap-6*
Micro:
Stool Culture (___):
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ --CC7D-- @ 09:40
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 12:50 pm Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
___ 10:42 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
2+ ___ 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.
Legionella Urinary Antigen (___): NEG FOR LEGIONELLA
SEROGROUP 1 AG
Urine Culture: negative or yeast in multiple cultures
Blood Cultures: NGTD or negative in multiple cultures
Imaging:
CT Abd/Plevis with Contrast (___):
IMPRESSION:
1. Diffuse colonic mucosal hyperenhancement and bowel wall
thickening is
consistent with pancolitis.
2. Ground-glass opacities within the right middle and right
lower lobes
compatible with acute infection and/or aspiration. Possible
mild pulmonary
edema.
3. Intrahepatic biliary ductal dilatation and prominence of the
common bile and pancreatic ducts could be better characterized
with non-emergent MRCP.
CXR (___):
IMPRESSION:
1. Bibasilar opacities would be consistent with pneumonia
and/or aspiration in the right clinical setting. Likely some
component of pulmonary edema given the interstitial thickening.
2. Multiple dilated loops of small bowel may represent ileus or
obstruction. Dedicated abdominal radiograph may be performed for
better characterization.
ECHO (___):
Left ventricular wall thicknesses are normal. Left ventricular
systolic function is hyperdynamic (EF>75%). There is a mild
resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. The mitral valve
leaflets are mildly thickened. There is severe mitral annular
calcification. There is moderate functional mitral stenosis
(mean gradient XXmmHg) due to mitral annular calcification. Mild
to moderate (___) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
mitral regurgitation is now less prominent. The mitral inflow
gradient is similar (although not reported in the previous
report).
AXR (___):
There is no subdiaphragmatic free air. There are multiple
distended loops of bowel, most likely representing both colon
and small bowel. Findings are most consistent with an ileus.
Air-fluid levels are seen on the left lateral decubitus view.
IMPRESSION: Dilated colon and small bowel consistent with
ileus.
Head CT (___): IMPRESSION: No acute intracranial process.
ECHO (___):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF 80%). Right ventricular chamber size and free
wall motion are normal. There is mild aortic valve stenosis
(valve area 1.6 cm2). Due to the technically suboptimal nature
of this study, LVOT obstruction cannot be excluded with
certainty. The mitral valve leaflets are mildly thickened. There
is severe mitral annular calcification (cannot exclude posterior
leaflet MVP). Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] There is no pericardial
effusion.
Repeat CT Abd/Pelvis (___):
IMPRESSION: Interval increase in bilateral pleural effusions,
and in
abdominal ascites. The colon remains dilated and ahaustral, in
keeping with C. difficile colitis.
CXR (___):
There is a Dobbhoff tube whose distal tip is in the body of the
stomach.
There are bilateral pleural effusions. There is a right-sided
pleural-based catheter. There is no pneumothoraces or signs for
overt pulmonary edema. Overall, these findings are stable since
prior study from ___.
Brief Hospital Course:
Pt is an ___ year-old woman with history of Sjogren's syndrome
and IBS presenting with fevers, diarrhea, tachycardia,
hypotension, leukocytosis, hypoxia, found to have pancolitis and
pneumonia.
# Septic Shock due to Cdiff Colitis: On admission meet criteria
for sepsis given fever, tachycardia, leukocytosis and likely
source being colitis. BP remained low and patient remained
mildly tachycardic for next ___ requiring aggressive IVF
(roughly 20L in first 72hrs). Initially started on IV flagyl/PO
vanco emperically for possible Cdiff as well as levofloxacin
over concern for PNA. Bcx, Ucx unrevealing. Stool for Cdiff
ultimately positive and levofloxacin changed to CTX/Azithro. PCP
(Dr. ___ visited and said that pt always has CXR infiltrate
so abx for CTX/Azithro for pneumonia stopped after pt had
received total of 3 days PNA treatment. Lactate and WBC count
trended up in first 48hrs and patient developed ileus on
abdominal imaging with worsening distension. GI and Gen Surg
followed and pt kept NPO initially, but ultimately illness
turned around with just Abx and IVF. By time of ICU call-out, BP
had stabilized without requiring fluids and abdominal exam was
improving with downtrending WBC. Came back to ICU on ___ due to
respiratory distress and hypoxia. Also had to be started back on
pressors, initially phenylephrine but then this was stopped as
extremities were cold and mottled. Pressors changed to
Norepinephrine and mottling of ext quickly resolved. SVO2 and
ECHO not consistent with cardiogenic shock and EKG/Trops were
negative. ID saw in consult and recommended starting Tigecycline
to help cover Cdiff which she completed an 8 day course of.
Abdominal exam improved and ileus resolved. Doboff was placed on
___ and tube feeds were started due poor ability to keep with
with nutritional requirements. Metronidazole d/c'd on ___. Plan
to continue Vancomycin 500mg PO Q6 for a total of 2 weeks after
all other antibiotics were stopped (last day ___.
# Hypoxia: No breathing issues at baseline but developed hypoxia
requiring 5L NC while in ED so was admitted to the ICU. Initial
concern for RLL PNA on CXR and received 3 days of Abx as noted
above until PCP informed MICU team that infiltrate had been
present for some time. Thought that hypoxia developed in setting
of aggressive fluids in patient with significant mitral regurg
(got 4L in ED and then aggressive IVF in first 72hrs) and the
development of pleural effusions. Had started diuresis by MICU
callout on ___ but then after couple days on floor, triggered
for hypoxia and increased work of breathing on ___. Found to
have significant worsening of R pleural effusion and development
of L pleural effusion. Required intubation for respiratory state
on ___. Cardiac w/u showed no cardiogenic component and when
spiked fever on ___ started on empiric HCAP coverage after
mini-BAL was performed. Interventional pulmonary (IP) consulted
on ___ and performed right sided thoracentesis with pigtail
placement. ID saw on ___ and recommended stopping
Vanco/cefepime as unclear if actual pneumonia and starting
Tigecycline as would cover many HCAP organisms and also treat
Cdiff. Mini-BAL and pleural fluid with negative cultures.
Started diuresis again on ___ as she was weaned off pressors
and extubated. She was weaned off all oxygen at the time of
discharge and right pigtail still draining 400-700cc per day,
will follow-up with IP after discharge. She will require
ongoing diuresis given her significant volume overload, she
responds well to ___ IV Lasix and had been ___ negative
in the days leading up to discharge.
# Altered Mental Status:
In setting of trigger for hypoxia and MICU transfer on ___,
there was concern that she was less responsive with concern for
focal defecits. Stat head CT without evidence of stroke or
bleed. Neuro was consulted and said nothing to do and deficits
resolved over next ___. EEG initially ordered but then
canceled after discussion with neuro. Rest of ICU stay had
intermittent delerium in the evenings requiring some doses of
Olanzapine. Delerium had improved by time of ICU callout but
still with some sundowning.
# Hyponatremia: Patient with Na of 127 in ED. Likely hypovolemic
hyponatremia in setting of diarrhea/poor PO intake. Could also
be SIADH given pneumonia, pain. Upon review of old labs, patient
often hyponatremic as outpatient as well. Urine lytes confusing
in setting of shock as urine Na elevated in ___ so some question
of sodium wasting renal injury. Hyponatremia started to resolve
as overall condition improved and did not re-develop even in
setting of ___ ICU readmission for hypoxia.
# ___: Patient with creatinine of 1.1 at admission up from
recent baseline of 0.7 - 0.8. Likely pre-renal etiology in
setting of infection, diarrhea, poor PO intake. Trended up
slightly to 1.3 after a few days likely with mild ATN in setting
of persistent boarderline hypotension. Lisinopril was held while
in ICU for this and hypotension. Cr trended back down to roughly
0.5 and stayed there for rest of hospitalization even in setting
of second ICU readmission.
--Inactive issues--
# Hypothyroidism: Continued levothyroxine 50 mcg daily
# Hypertension: Due to hypotension with sepsis, lisinopril was
held. BP remained well controlled and this will continue to be
held at discharge.
# GERD: Omeprazole stopped when Cdiff came back positive. For
time was put on H2 blocker for GI prophylaxis but this stopped
again when delerious and started feeeding.
# Code: Full (confirmed with patient, son-in-law)
# Transitional issues
-Right pigtail pleural catheter in place at discharge, she will
follow-up with interventional pulmonary after discharge. Tube
can be removed when output is <200cc per day.
-Will need ongoing diuresis given large volume of fluids she
received in the ICU this admission, she responds well to Lasix
10mg IV. Goal ___ negative as BP tolerates.
-Will continue on high dose PO vancomycin through ___ (___fter other abx stopped)
-She should continue tube feeds until taking adequate PO, would
benefit from ongoing nutrition evaluation
Medications on Admission:
fluticasone 50 mcg 1 - 2 nasal sprays BID PRN allergies
levothyroxine 50 mcg daily
lisinopril 10 mg daily
tiotropum bromide 18 mcg daily
Calcium
multivitamin
omeprazole 20 mg daily
acetaminophen PRN pain
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: ___ puffs
Nasal twice a day as needed for allergies.
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every four
(4) hours as needed for pain.
4. polyvinyl alcohol 1.4 % Drops Sig: One (1) drop Ophthalmic
every four (4) hours as needed for dry eyes.
5. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection twice a day.
7. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous three times a day: Sliding scale:
150-200 - 2 units;
201-250 - 4 units;
251-300 - 6 units;
301-350 - 8 units;
351-400 - 10 units;
over 400 - 10 units and call MD.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
9. ondansetron HCl 2 mg/mL Solution Sig: Four (4) mg Intravenous
every eight (8) hours as needed for nausea.
10. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety/insomnia.
11. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
12. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 12 days: Continue through ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Clostridium difficile colitis and sepsis
Pleural effusion with pigtail catheter placed
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for abdominal pain. You were found to have an infection
called C. diff. This was treated with antibiotics which you
will continue after discharge. You also had shortness of breath
and were found to have a large collection of fluid around your
right lung and a catheter was placed to drain this fluid. This
catheter will remain in place when you go to rehab and you will
follow-up with the lung doctors after ___.
The following changes have been made to your medications:
STOP lisinopril
STOP omeprazole
STOP tiotropium
START Zofran 4mg IV
START vancomycin 500mg by mouth every 6 hours through ___
START olanzapine 2.5mg twice daily as needed for anxiety
Followup Instructions:
___
|
10002428-DS-17 | 10,002,428 | 20,321,825 | DS | 17 | 2156-05-03 00:00:00 | 2156-05-04 20:25:00 |
Name: ___ ___ 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, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ year-old patient with history of Sjogren's
syndrome, moderate MR, recent hospitalization for sepsis
secondary to c. diff colitis complicated by hypercarbic
respiratory failure requiring intubation, who is presenting from
___ with worsening dyspnea for one day. Patient was
discharged from ___ yesterday (___) following hospitalization
for c. diff colitis. Patient had ABG at ___, which was
7.___. Her vitals on transfer were 97.9 99 24 113/68 92%
2L. She reports shortness of breath associated with the cough.
She denies chest pain. She denies nausea or vomiting. She denies
abdominal pain.
In the ED, initial vitals are 100.2 95 99/47 28 100% 4L nc.
Exam was notable for tachypnea with respiratory rates in the
___. While in ED, blood pressure dipped to ___, but improved on
it's own. Given the tachypnea, cough, and dyspnea, there was
concern for pneumonia. Patient received vancomycin and
levofloxacin. CXR appeared improved from most recent CXR.
Patiwnt was started on BIPAP. Patient underwent CTA to evaluate
for PE prior to leaving ED. On transfer vitals are, HR 93, BP
109/45, O2 sat 100% on BIPAP.
On arrival to the MICU, patient is wearing BiPAP, but wants it
removed and does not want any other supplemental oxygen. She
denies pain. She denies cough or shortness of breath.
Review of systems:
Unable to obtain, patient wearing BiPAP and is delerious.
Past Medical History:
Anemia
Borderline cholesterol
C. Diff
Flatulence
Health Maintenance
Heart Murmur
Hypertension
Hypothyroidism
Mitral Regurgitation
Osteoporosis
Pneumonia
Sinusitis
___
Social History:
___
Family History:
Long history of hypertension in her family. She does report
that her father's family has a history of multiple cancers. She
has a grandfather with a history of stomach cancer and an uncle
with a history of throat cancer. She denies any history of
colon cancers. Father had stroke. No family h/o MI. Mother had a
heart valve replaced (pt not sure which one).
Physical Exam:
Exam upon admission:
General: Awake, interactive, but delerious. Not oriented to
place or time, calling out, trying to get out of bed. Cachetic,
frail, elderly female.
HEENT: Sclera anicteric, dry mucus membranes.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur at apex.
Lungs: Dull at bases bilaterally, breathing comfortably, no
accessory muscle use.
Abdomen: soft, distended, non-tender, no rebound/guarding. bowel
sounds present. Flexiseal draining watery stool with blood in
it.
GU: foley in place foley
Ext: warm, 1+ DP pulses, Diffuse edema
Neuro: CNII-XII intact, disoriented, inattentive
Discharge exam - unchanged from above, except as below:
General: Awake, sleepy but arousable to voice, NAD
GU: Foley removed
Neuro: A&Ox2 (name and date), MS has been waxing/waning, no
focal defecits
Pertinent Results:
Labs upon admission:
___ 07:30AM BLOOD WBC-7.1 RBC-3.11* Hgb-9.3* Hct-30.3*
MCV-97 MCH-29.9 MCHC-30.7* RDW-14.0 Plt ___
___ 07:10PM BLOOD Neuts-68.2 ___ Monos-6.6 Eos-2.4
Baso-1.0
___ 07:30AM BLOOD Glucose-122* UreaN-20 Creat-0.3* Na-133
K-4.0 Cl-92* HCO3-39* AnGap-6*
___ 07:10PM BLOOD ALT-32 AST-40 AlkPhos-129* TotBili-0.2
___ 07:10PM BLOOD cTropnT-0.01
___ 07:30AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.9
___ 11:05PM BLOOD Type-ART Temp-36.7 Tidal V-300 PEEP-5
FiO2-50 pO2-133* pCO2-78* pH-7.37 calTCO2-47* Base XS-15
Intubat-NOT INTUBA
___ 07:16PM BLOOD Lactate-1.5
Discharge labs:
___ 06:30AM BLOOD WBC-4.9 RBC-2.67* Hgb-8.2* Hct-26.4*
MCV-99* MCH-30.8 MCHC-31.2 RDW-15.0 Plt ___
___ 06:30AM BLOOD Glucose-113* UreaN-6 Creat-0.3* Na-136
K-3.5 Cl-95* HCO3-37* AnGap-8
Micro:
-BCx x2 (NGTD)
-UCx ___ - Yeast, no bacterial growth
-Midline tip - NGTD
-C. diff PCR - neg
Imaging:
___: CXR: IMPRESSION: No significant interval change with
bilateral pleural effusions with right pigtail catheter in the
lower chest. Possible small right apical pneumothorax.
___: CT-A IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions, small to moderate on the left,
decreased
since the most recent prior examination and trace on the right,
markedly
decreased compared to ___ with pigtail catheter noted
in place on the right.
3. Ascites.
Brief Hospital Course:
___ year old woman, recently hospitalized for C. Difficile sepsis
and shock, re-admitted to ___ from ___ with altered
mental status, tachypnea and a mild respiratory acidosis.
#Hypoxia/hypercarbia: She initially required BiPAP and was
admitted to the MICU for monitoring of her respiratory status.
She was able to be weaned from BiPAP on ICU day 2 and remained
on 2L NC at the time of discharge. Cause of her respiratory
symptoms is unclear, but may be due to hypoventilation from
somnolence related to oversedation with Zyprexa. Zyprexa was
held at the time of discharge. CTA Chest was negative for PE
and showed no clear evidence of pneumonia. She was initially
started on HCAP antibiotics with vanc/cefepime which were
stopped on HD 4 prior to discharge given that all cultures were
negative and there was no consolidation on imaging.
# Delirium: Likely multifactorial, but thought to be related to
oversedation from Zyprexa. There was no evidence of infection
and antibiotics were quickly stopped as described above. UA was
dirty, but UCx was negative x2 (grew only yeast) and she had no
urinary symptoms. Most of her mental status changes were
probably related to her sedationg medications and hypercarbia at
admission, which improved with BiPAP and holding her
antipsychotics.
# C Diff Colitis: Recently admitted for C. diff colitis with
sepsis. Repeat C Diff PCR was negative during this
hospitalization. She continued to have high volume stool output
and Flexiseal is in place for skin ulceration. ID was curbsided
regarding vanco course given that she received a few days of
HCAP antibotics and her PO vanco was changed to 125mg q6h for 7
days after stopping IV vanc/cefepime (D7 will be ___.
Flexiseal in place at discharge.
# Anemia: Patient with guaiac positive stools this admission,
new from past admission. Felt to be secondary to sloughing and
mucosal oozing secondary to C diff. Normal lactate on admission
and benign abdominal exam. Hct has been variable recently, but
fairly stable, although still markedly below her baseline of low
to mid ___.
# Bilateral pleural effusions: Noted to have bilateral pleural
effusions last hospitalization in setting of massive fluid
resuscitation, right pleural pigtail catheter removed this
admission in the MICU. She is still volume overloaded on exam,
but her bicarb remained elevated, and she was not given any
further diuresis. The elevated bicarb is also be partially due
to compensation from her respiratory acidosis.
# Volume overload: She has some diastolic dysfunction and has 2+
MR on ___. She continues to appear total body overloaded, likely
in setting of volume resuscitation on prior admission for
sepsis, but with contraction alkalosis currently, so further
diuresis was held as above. Consider further diuresis once
hypercarbia improves and bicarb trends down.
# Hypothyroidism: Continued on levothyroxine 50 mcg daily
# Hypertension: Patient was previously on lisinopril which was
held since last admission in setting of sepsis and relative
hypotension. She remained normotensive
# GERD: Patient previously on omeprazole last hospitalization,
which was stopped after C. diff came back positive, and she was
transitioned to H2 blocker for GI prophylaxis but this was
stopped again when she became delirious last hospitalization.
She remains off H2 blocker at discharge because of concern that
it may be contributing to her AMS.
# Code status this admission: FULL
# Transitional issues:
-Foley was removed ___ and she has not voided as of discharge,
may need Foley replaced if she is unable to void
-Would restart diuresis when bicarb trends down
-Continue PO vanco 125mg q6h through ___
-Please follow Hct daily given melanotic stools, should resolve
as her C. diff resolves
-Midline removed ___
-Pigtail catheter removed this admission
-F/u pending BCx, catheter tip cx
Medications on Admission:
Medications at ___:
fluticasone 50 mcg nasal spray ___ puffs BID PRN
levothyroxine 50 mcg dialy
acetaminophen 650 mg Q4H PRN pain
polyvinyl alcohol 1.4% drops every 4H PRN dry eyes
heparin line flush
Humalog insulin sliding scale
Miconazole nitrate 2% powder, 1 application TID PRN rash
ondansetron 4 mg IV Q8H PRN nausea
Olanzapine 2.5 mg PO daily and qHS PRN anxiety/insomnia
Vancomycin 500 mg Q6H planned through ___
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: ___ puffs
Nasal twice a day as needed for allergies.
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every four
(4) hours as needed for fever or pain.
4. polyvinyl alcohol 1.4 % Drops Sig: One (1) drop Ophthalmic
every four (4) hours as needed for dry eyes.
5. insulin lispro 100 unit/mL Solution Sig: Sliding scale units
Subcutaneous three times a day: 150-200 - 2 units; 201-250 - 4
units; 251-300 - 6 units; 301-350 - 8 units; 351-400 - 10 units;
over 400 - 10 units and call MD.
6. miconazole nitrate 2 % Powder Sig: One (1) application
Topical three times a day as needed for rash.
7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: Last dose on ___.
8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Altered mental status
Hypoxia
Secondary diagnoses:
Clostridium difficule
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for hypoxia/hypercarbia and altered mental status. Your
mental status improved once we stopped your Zyprexa and your
breathing improved. We looked for an infection but were not
able to find a clear source. You received a few days of
antibiotics while your cultures were pending. You will continue
PO vanco for an additional 7 days.
The following changes were made to your medications:
CHANGE vancomycin 125mg by mouth every 6 hours for 7 days (last
dose ___
START albuterol neb every 4 hours as needed for SOB/wheezing
START ipratropium neb every 6 hours as needed for SOB/wheezing
STOP Zyprexa
Followup Instructions:
___
|
10002428-DS-18 | 10,002,428 | 23,473,524 | DS | 18 | 2156-05-22 00:00:00 | 2156-05-23 13:10:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meropenem
Attending: ___
___ Complaint:
Hypercarbic Respiratory Failure
Major Surgical or Invasive Procedure:
Mechanical Intubation, Arterial -Line, Central Venous Access
Line
History of Present Illness:
This is an ___ year old woman, recently hospitalized for C.
Difficile sepsis and shock, complicated by readmission
hypoxia/hypercarbia (___) who presents with respiratory
distress and respiratory failure.
.
The patient had reportedly been doing well ___ rehab until today
when she was noted to have an altered (depressed) mental status,
tachypnea, and dyspnea. EMS was called who found the patient ___
extremis, intubation was attempted x2 and failed. A ___ airway
was placed and the patient was transported to ___ emergency
department. There were no reports of increased coughing or
stooling from ___.
.
The patient has had a complicated medical course ___ the past
month -
.
___ brief, the patient was initially discharge on ___ after
a 14 hosptilazation for c.diff colitis complicated by sepsis and
hypercarbic respiratory failure requiring intubation. On the
day following discharge from that admission, the patient was
noted to be complaining of worsening SOB and ABG at ___
was 7.4/___. She was re-admitted to ___ on ___ to the MICU
and intially reuqired biPAP for HD1-2. Her oxygen requirement on
d/c was 2L NC. The etiology of her hypercarbic respiratory
failure was felt to be ___ hypoventilation from somnolence
related to oversedation with zyprexa which was held on
discharge. A CTA chest was negative for PE and showed no clear
evidence of pneumonia. She was initially started on HCAP
antibiotics with vanc/cefepime which were stopped on HD 4 prior
to discharge given that all cultures were negative and there was
no consolidation on imaging.
.
___ the ED, initial VS were: HR: 82 BP: 94 systolic Resp: No
spontaneous respirations O(2)Sat: 100; Initial labs
demonstrated hct 22.0, wbc 16.0, creatinine 0.3, BIN 18, lipase
148 and lactate 0.9. A cxr demonstrated bilateral pleural
effusions with R>L. A UA demonstrated large leuks, positive
nitrites and 104 wbc. Due respiratory failure the patient was
intubated.
.
An initial ABG was 7.___/128 which was 7.___/395 post
intubation. The patient was given vancomycin and cefepime for
coverage of both a urinary and pulmonary source. Post intubation
her BP dropped to the ___. She was started on levophed and
phenylephrine through her existing PICC line. Given her altered
mental status on arrival, a head CT was performed which showed
no acute findings. Vitals on transfer were: 36.3 66 118 107/58
99%.
.
Vent settings were: fio2 60% RR 18 Vt 400 peep 5. Sedation with
midazolam and fentanyl. She was transferred on levophed alone w/
MAPs> 70.
.
On arrival to the MICU, vitals were: 36.2 106/58 77 18 (vented)
100% on 40% FiO2. The patient was on a levophed drip, was not
sedated, was unresponsive to verbal and painful stimuli, was
thought to have a brief episode of decerebrate posturing with
the upper extremities.
.
Review of systems: Unable to Obtain
Past Medical History:
Anemia
Borderline cholesterol
Recurrent C. Diff
Flatulence
Heart Murmur
Hypertension
Hypothyroidism
Mitral Regurgitation
Osteoporosis
Pneumonia
Sinusitis
Sjogren
Social History:
___
Family History:
Long history of hypertension ___ her family. Father's family has
a history of multiple cancers. She has a grandfather with a
history of stomach cancer and an uncle with a history of throat
cancer. No history of colon cancers. Father had stroke. No
family h/o MI. Mother had a heart valve replaced.
Physical Exam:
ADMISSION PHYSICAL EXAM:
36.2 106/58 77 18 (vented) 100% on 40% FiO2
General: Intubated, unresponsive, pale, very thin
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
constricted and sluggish b/l; there is a dobhoff and an NGT
present
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, there is a ___ SEM
best heard over the LSB. There is a midline catheter present ___
the R arm
Lungs: Bilateral crackles R > L, no spontaneous respirations;
there is an ETT ___ place.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
GU: Foley present; there is a candidal rash ___ the groin area,
there is powder c/w miconazole powder present over the same
distribution
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unable to fully evaluate due to unresponsiveness. The
patient has 1+ DTRs bilaterally ___ all extremities;
decerebration briefly noted ___ the upper extremities.
.
DISCHARGE PHYSICAL EXAM: ****
Pertinent Results:
ADMISSION LABS:
___ 11:43AM BLOOD WBC-16.0* RBC-2.84* Hgb-8.4* Hct-29.0*
MCV-102* MCH-29.7 MCHC-29.1* RDW-16.4* Plt ___
___ 11:43AM BLOOD ___ PTT-38.4* ___
___ 11:43AM BLOOD ___ 02:46AM BLOOD Glucose-96 UreaN-12 Creat-0.4 Na-135
K-3.1* Cl-107 HCO3-23 AnGap-8
___ 11:43AM BLOOD CK(CPK)-28*
___ 11:43AM BLOOD Lipase-148*
___ 11:43AM BLOOD CK-MB-6 cTropnT-0.02*
___ 02:46AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 Iron-17*
___ 02:46AM BLOOD calTIBC-222* VitB12-726 Folate-15.3
Ferritn-101 TRF-171*
___ 11:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:44AM BLOOD pO2-128* pCO2-70* pH-7.22* calTCO2-30
Base XS-0 Comment-GREEN TOP
___ 11:44AM BLOOD Glucose-132* Lactate-0.9 Na-130* K-3.6
Cl-98
___ 11:44AM BLOOD Hgb-8.8* calcHCT-26 O2 Sat-96 COHgb-3
MetHgb-0
___ 12:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:30PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 12:30PM URINE RBC-18* WBC-104* Bacteri-MOD Yeast-NONE
Epi-0 TransE-2
___ 12:30PM URINE CastHy-3*
___ 12:30PM URINE CastHy-3*
___ 12:30PM URINE Mucous-RARE
DISCHARGE LABS: ****
MICROBIOLOGY:
-Urine culture (___): PSEUDOMONAS AERUGINOSA. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___ MCG/ML
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ =>16 R
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 8 I
-Blood culture (___): LACTOBACILLUS SPECIES. Isolated from
only one set ___ the previous five days.
SENSITIVITIES: MIC expressed ___ MCG/ML
AMPICILLIN------------ 1 S
GENTAMICIN------------ 2 S
PENICILLIN G---------- 0.5 S
-Sputum culture ___, endotracheal source):
GRAM STAIN: >25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
-Urine culture ___, foley): YEAST. 10,000-100,000
ORGANISMS/ML.
-Blood culture ___, final): NEGATIVE
-Blood culture ___, final): NEGATIVE
-Blood culture ___, pending): NO GROWTH TO DATE
AP CHEST X-RAY (___):
1. Bilateral pleural effusion, right greater than left.
Underlying
consolidation cannot be completely excluded.
2. Endotracheal tube terminates 1.8 cm above the carina.
Recommend
repositioning.
3. NG tube terminates ___ stomach with sidehole ___ distal
esophagus.
3. Right PICC terminates ___ the axilla.
CT HEAD WITHOUT CONTRAST (___): There is no evidence of
hemorrhage, edema, infarction, or mass effect. The ventricles
and sulci are prominent, suggesting age-related involutional
changes or atrophy. Periventricular white matter hypodensities
are compatible with chronic small vessel ischemic disease. Basal
cisterns appear patent, and there is preservation of gray-white
matter differentiation. No fracture is identified. There is
fluid within the nasal cavity, likely secondary to intubated
state. Atherosclerotic mural calcifications of the internal
carotid arteries are present. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are otherwise clear.
Bilateral ocular lenses have been replaced. IMPRESSION: No
intracranial hemorrhage or mass effect.
TTE (___): The left atrium is normal ___ size. There is mild
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF = 75%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
severe mitral annular calcification. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study dated ___ (images reviewed),
findings are similar.
AP UPRIGHT CHEST X-RAY (___): Compared to the most recent
study, there is improvement ___ the mild pulmonary edema and
decrease ___ the small left pleural effusion. Moderate right
pleural effusion and bibasilar atelectasis are stable.
AP UPRIGHT CHEST X-RAY (___): Cardiac size is normal. Lines
and tubes are ___ the standard position. Large right and moderate
left pleural effusions are grossly unchanged allowing the
differences ___ positioning of the patient. Right upper lobe
opacity has improved consistent with improving atelectasis.
Pleural effusions are associated with atelectasis, larger on the
right side. There is mild vascular congestion.
Brief Hospital Course:
HOSPITAL COURSE:
This is an ___ year old woman, recently hospitalized for C.
Difficile sepsis and shock, complicated by readmission
hypoxia/hypercarbia (___) p/w hypercarbic respiratory
failure and urinary tract infection.
.
# Hypercarbic Respiratory Failure: Etiology likely
multifactorial, primarily respiratory muscle weakness and pulm
edema with pleural effusions as noted on admission x-ray (has
history of 2+ mitral regurg). She remained intubated for most of
her MICU stay due to pulmonary edema and respiratory muscle
weakness with a poor negative inspiratory force (NIF). Her NIF
gradually improved with optimization of her nutrition and
supportive care. Her pulmonary edema was addressed with
aggressive diuresis with IV and PO Lasix boluses (responds well
to Lasix 10mg IV). With treatment of these issues, she was able
to be successfully extubated to nasal cannula on ___. She
was started on Lisinopril 5mg daily for afterload reduction ___
setting of her 2+ MR which may have been causing the pulmonary
edema. She may require further PRN doses of Lasix at rehab; if
so would try Lasix 20mg PO PRN. Consider increasing lisinopril
to 10mg for better afterload reduction pressure tolerating.
.
# Pseudomonas UTI: Patient grew out Pseudomonas sensitive to
everything but Gentamicin on ___ urine culture. She was
initially started on double coverage with Cipro/Cefepime while
cultures pending, then narrowed to Cefepime alone, then
broadened to Meropenam per ID recs. There was concern that
Meropenam caused a drug rash so she was then switched to IV
Zosyn. She completed Zosyn course on ___, received total of 10
days antibiotics for complicated UTI.
.
# RASH: pt noted to have red macular rash on extremities after
starting meropenam, initially presumed to be meropenam drug rash
so meropenam was stopped. However this was later believed to be
more consistent with contact dermatitis vs. eczema.
Triamcinolone cream was started and rash improved.
.
# C Diff Colitis: Patient was recently admitted for C. diff
colitis with sepsis. Repeat C Diff PCR was negative during last
hospitalization. She completed her PO vancomycin course on
___. Her PO vancomycin was continued during hospitalization
because of concurrent treatment with broad-spectrum antibiotics
(zosyn) for pseudomonas UTI. Her zosyn was completed on ___,
should continued PO vanco until ___.
.
# Anemia: Patient with guaiac positive stools during last
admission, new from past admission. Hct stable ___ high ___
throughout hospitalization; she did receive one unit pRBC for
colloid pressure support.
.
# Hypothyroidism: Continued on levothyroxine 50 mcg daily.
.
# GERD: Patient previously on omeprazole last hospitalization,
which was stopped after C. diff came back positive, and she was
transitioned to H2 blocker for GI prophylaxis which was held ___
setting of delirium. Famotidine was restarted at 20mg BID once
she was no longer delirious.
# EKG Changes: Patient had lateral STE and mildly elevated
troponin x3 (CK/MB flat)on admission, felt likely due to blunt
injury ___ compressions ___ ED vs. demand ischemia.
.
# A-line: patient had femoral A-line placed ___ ED ___ setting of
her hypotension. This was discontinued ___ ICU and replaced with
PICC. She had one set of BCx which grew Lactobacillus, likely
skin contaminant. Other surveillance cx negative.
.
TRANSITIONAL ISSUES:
- Code: Full
- Labs: She should have a daily chem 7 for phos repletions and
while being diuresed
- Nutrition: Tube Feeds + soft diet and thin liqiuds
Medications on Admission:
1. fluticasone 50 mcg/actuation Spray, Suspension ___ puffs BID
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
3. acetaminophen 325 mg Tablet Sig: ___ Tablets q4hr prn
4. polyvinyl alcohol 1.4 % Drops 1every four (4) hours prn
5. insulin lispro 100 unit/mL Solution SS TID Sliding scale
units
Subcutaneous three times a day: 150-200 - 2 units; 201-250 - 4
units; 251-300 - 6 units; 301-350 - 8 units; 351-400 - 10 units;
over 400 - 10 units and call MD.
6. miconazole nitrate 2 % Powder 1 TID prn rash
7. vancomycin 125 mg Capsule 1 PO Q6H for 7 days
8. heparin (porcine) 5,000 unit/mL Solution 5000 (5000) TID
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution 1 q4hr prn
SOB
10. ipratropium bromide 0.02 % Solution 1 q6hr prn SOB
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 12 Days
Last day = ___
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
pls apply thin layer to rash
5. Miconazole Powder 2% 1 Appl TP TID
to groin rash
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using lispro Insulin
7. Lisinopril 5 mg PO DAILY
HOLD for SBP<100
8. Famotidine 20 mg PO Q12H
9. Heparin 5000 UNIT SC TID
10. polyvinyl alcohol *NF* 1.4 % ___ q4 hours PRN dry eyes
11. Docusate Sodium (Liquid) 100 mg PO BID
12. Furosemide 20 mg PO DAILY
as needed for volume overload, please check electrolytes
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISSUES:
1. Hypercarbic respiratory failure
2. Sepsis due to urinary source
3. Recurrent C. difficile colitis
CHRONIC ISSUES:
1. Hypothyroidism
2. Chronic anemia
3. Mitral regurgitation
4. Osteoporosis
5. Sjogren syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating ___ your care at ___
___. You were admitted to the hospital with
respiratory failure requiring intubation and mechanical
ventilation. This was likely due to a combination of severe
weakness caused by chronic illness, pleural effusions and
pulmonary edema (fluid ___ the lungs). You were also found to
have a urinary tract infection causing sepsis (bloodstream
infection), which likely also contributed to your respiratory
failure. You were treated with antibiotics, your symptoms and
breathing improved, and you were successfully extubated on ___.
You will be discharged to rehab where you will receive intensive
physical therapy and your nutrition will be optimized to help
you continue regaining strength.
.
When you are discharged from rehab, you will need to follow up
with your primary care doctor ___.
.
We made the following changes to your medications:
1. STARTED famotidine 20mg by mouth twice daily for heartburn
2. STARTED triamcinolone acetonide 0.025% cream three times
daily for rash
3. RESTARTED lisinopril 5mg by mouth daily for high blood
pressure and heart failure
4. STARTED docusate (Colace) 100mg by mouth twice daily for
constipation
5. CONTINUED vancomycin oral liquid ___ by mouth every 6 hours
(last day = ___
6. START lasix po 20mg daily prn volume overload
Followup Instructions:
___
|
10002428-DS-19 | 10,002,428 | 28,676,446 | DS | 19 | 2157-07-18 00:00:00 | 2157-07-18 16:39:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
meropenem
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
Closed reduction and percutaneous pinning, left
femoral neck fracture
History of Present Illness:
This is a ___ yo woman in her USOH until the day of presentation
when she sustained a mechanical fall onto her left lower
extremity with immediate pain, inability to ambulate. The
patient denies LOC, premonitory symptoms and ROS is otherwise at
baseline.
Past Medical History:
Anemia
Borderline cholesterol
Recurrent C. Diff
Flatulence
Heart Murmur
Hypertension
Hypothyroidism
Mitral Regurgitation
Osteoporosis
Pneumonia
Sinusitis
Sjo___
Social History:
___
Family History:
Long history of hypertension in her family. Father's family has
a history of multiple cancers. She has a grandfather with a
history of stomach cancer and an uncle with a history of throat
cancer. No history of colon cancers. Father had stroke. No
family h/o MI. Mother had a heart valve replaced.
Physical Exam:
On admission:
Pelvis stable to AP and lateral compression.
BLE skin clean and intact
LLE
Shortened and externally rotated, painful with internal or
external rotation of the hip.
Thighs and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
Knee stable to varus and valgus stress.
Negative anterior, posterior drawer signs.
On discharge:
NAD, A+Ox3
INcision: dressing changed ___ - c/d/i
Neurovascularly intact, strenght intact, SILT s/s/dp/sp/t
distributions
WWP, 2+ DP pulse
Pertinent Results:
Hip XR ___: IMPRESSION: Impacted left subcapital femoral neck
fracture.
Brief Hospital Course:
On ___ the pt was admitted to the ortho trauma service and
found to have a valgus impacted left femoral neck hip fracture,
for which she underwent closed reduction and percutaneous
pinning, left
femoral neck fracture by Dr. ___
On ___ the patient was noted to be recovering well from
surgery. She became hypotensive with physical therapy, which
normalized after stopping exercise.
On ___ the patient continued to do well. She was seen by
physical therapy and cleared for discharge to a rehab facility.
SOcial work saw pt for her difficulty coping with decreased
mobility. Her labs showed sodium level of 130, unchanged from
___ and similar to 132 on admission. She was given instructions
to f/u with Dr. ___ in clinic in 2 weeks, and will be on
lovenox subq 40 mg daily in the interim.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
4. mirtazapine 30 mg Oral QHS
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
4. mirtazapine 30 mg Oral QHS
5. Acetaminophen 1000 mg PO TID
6. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO QID:PRN
Dyspepsia
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Biotene Dry Mouth Rinse (saliva substitution combo no.8) 1
application Mucous Membrane q2hr
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
10. Calcium Carbonate 1250 mg PO TID
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 40 mg SC DAILY DVT prophylaxis Duration:
14 Days Start: ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*14 Syringe
Refills:*0
13. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia
14. Multivitamins 1 CAP PO DAILY
15. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*60 Tablet Refills:*0
16. Pantoprazole 40 mg PO Q24H
17. Senna 2 TAB PO HS
18. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left femoral neck fracture
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:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
touch-down weight-bearing LLE
Physical Therapy:
Touch-down weight bearing LLE
Treatments Frequency:
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
10002430-DS-5 | 10,002,430 | 24,513,842 | DS | 5 | 2125-09-30 00:00:00 | 2125-10-02 10:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Corgard / Vasotec
Attending: ___
Chief Complaint:
leg edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is an ___ year old gentleman with history of CAD
(s/p 3V CABG ___, LM PCI ___, pulmonary HTN, AFib on
anticoagulation, ___ (EF 50%) who presents with volume overload
and new found RV dilation on office echocardiogram.
Patient reports he has had 10 days of waking up feeling nervous
and jittery. He also endorses weight gain, and new onset lower
extremity swelling. He has not had chest pain, palpitations,
orthopnea, or PND. He has not had any fevers, cough, recent
travel, medication non compliance, increased salty food intake.
He also has not had dyspnea on exertion and rides 4 miles per
day on a stationary bike and does 6 minutes of weight lifting.
He presented to Dr. ___ today for evaluation. There
he had a TTE that showed new RV dilation and was referred to the
___ ED for further evaluation with concern for pulmonary
embolism.
In the ED, initial vitals were:
T98. HR 70, BP 166/65, RR 16, 100% RA.
Exam in ED notable for bilateral pitting edema to knees. Labs
notable for mild hyponatremia, Cr 1.1. ALT/AST mildly elevated
at 81/64. WBC 4, Hgb 11.3, INR 1.3. DDimer <150. UA
unremarkable.
CXR with mild cardiomegaly but no evidence of consolidation or
pulmonary edema. CTA was negative for PE, showed severe
emphysema and dilated pulmonary artery.
Patient received 20 mg IV Lasix with significant urine output
per patient. He was then admitted to the heart failure service
for acute heart failure exacerbation and further workup of RV
dilation.
Vitals on transfer: Afebrile, HR 66, BP 129/54, RR 19, 95%RA.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
Past Medical History:
BILATERAL MODERATE CAROTID DISEASE
CONGESTIVE HEART FAILURE
CORONARY ARTERY DISEASE
GASTROESOPHAGEAL REFLUX
HYPERTENSION
SEVERE EMPHYSEMA
PULMONARY HYPERTENSION
RIGHT BUNDLE BRANCH BLOCK
BENIGN PROSTATIC HYPERTROPHY
HYPERLIPIDEMIA
PAROXYSMAL ATRIAL FIBRILLATION
H/O HISTIOPLASMOSIS
Past Surgical History:
CARDIOVERSION ___
RIGHT LOWER LOBE LOBECTOMY ___
CORONARY BYPASS SURGERY ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION
Vitals: 98 159/62 16 98% on RA weight 143 lbs (bed scale)
General: very pleasant older gentleman lying in bed speaking in
full sentences in NAD
HEENT: PERRL, EOMI, no scleral icterus, oropharynx clear
Neck: supple, JVP at 6cm, no adenopathy
CV: regular rate and rhythm, normal S1, physiologic split S2,
___ systolic murmur at LLSB. No rubs or gallops.
Lungs: CTAB, no crackles, wheezes, or rhonchi
Abdomen: soft, non distended, non tender to deep palpation, +BS
GU: no CVA tenderness, no foley
Extr: warm, well perfused, 2+ pulses in radial and DP, 2+ edema
in bilateral lower extremities to knees
Neuro: aoxo3, CN2-12 grossly intact, moving all 4 extremities
without deficit, stable gait
Skin: warm, well perfused, dry, no rashes or lesions
DISCHARGE
Vitals: 98.3 100-121/49-59 54-62 18 96RA
Tele: no tele
Last 8 hours I/O: ___
Last 24 hours I/O: 1200/3150
Weight on admission: 64.3
Today's weight: 63.1
General: elderly, NAD
Neck: JVP at base of clavicle when 90 degrees
Lungs: CTAB no crackles
CV: RRR, split S2
Abdomen: slightly obese, soft, NTND, NABS
Ext: no edema
Pertinent Results:
ADMISSION
___ 04:02PM BLOOD WBC-4.0 RBC-4.32* Hgb-11.3* Hct-35.1*
MCV-81* MCH-26.2 MCHC-32.2 RDW-16.3* RDWSD-48.3* Plt ___
___ 04:02PM BLOOD ___ PTT-35.8 ___
___ 04:02PM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-131*
K-3.8 Cl-93* HCO3-27 AnGap-15
___ 04:02PM BLOOD ALT-81* AST-64* AlkPhos-89 TotBili-0.7
___ 04:02PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1284*
___ 04:02PM BLOOD Albumin-4.2 Calcium-9.7 Mg-2.2
___ 04:34PM BLOOD D-Dimer-<150
___ 04:02PM BLOOD TSH-3.0
DISCHARGE
___ 04:04AM BLOOD WBC-6.5# RBC-4.57* Hgb-12.2* Hct-36.8*
MCV-81* MCH-26.7 MCHC-33.2 RDW-16.4* RDWSD-47.8* Plt ___
___ 04:04AM BLOOD ___ PTT-34.1 ___
___ 04:04AM BLOOD Glucose-113* UreaN-32* Creat-1.4* Na-133
K-3.9 Cl-94* HCO3-26 AnGap-17
___ 04:04AM BLOOD ALT-79* AST-57* AlkPhos-83 TotBili-0.6
___ 04:04AM BLOOD Calcium-10.0 Phos-4.4 Mg-2.0
ECHO ___
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the mid-anterior and mid-distal
inferior wall. The estimated cardiac index is normal
(>=2.5L/min/m2). Doppler parameters are indeterminate for left
ventricular diastolic function. The right ventricular cavity is
mildly dilated with depressed free wall contractility (RV free
wall is not well seen). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. The pulmonic valve leaflets are
thickened. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular dysfunction c/w
multivessel CAD, with overall mildly depressed global systolic
function. Mildly dilated right ventricle with depressed free
wall systolic function. Moderate tricuspid regurgitation with
moderate pulmonary hypertension.
Brief Hospital Course:
Mr. ___ is an ___ year old gentleman with history of CAD
(s/p CABG and PCI), pAF, PAH, diastolic CHF who presents with
weight gain, leg swelling and new evidence of right ventricle
dilation concerning for acute on chronic heart failure
exacerbation.
#Acute on Chronic Diastolic Heart Failure Exacerbation: with
component of RV failure by report of OSH echo. Likely primary
process is lung disease causing elevated RV pressures and
subsequent poor filling of LV. He diuresed quite well with 20
IV Lasix which is consistent with RV failure. Started on
torsemide 10 daily but this is likely too aggressive. We
obtained an echo but read PND at time of discharge. We sent him
home on a diuretic regimen on torsemide 5 mg daily (and
discontinued home triamterene-HCTZ). Close follow up with Dr.
___ ensured.
#Elevated Transaminases: Patient with mildly elevated AST and
ALT. Most likely etiologies in this patient include amiodarone
toxicity and congestive hepatopathy. Encouraged outpatient
trending.
#Pulmonary disease: patient with extensive emphysema on CTA
though patient has no history of smoking. As this may be
driving R heart failure, Dr. ___ requested pulmonology
consult prior to discharge but patient was insistent on leaving.
Instead scheduled outpatient appointment.
#Atrial Fibrillation: Continue home amiodarone 200mg daily,
Apixaban 5mg BID
#CAD: Continue ASA 81mg, rosuvastatin 40mg qHS
#HTN: continue home losartan 25mg qD.
TRANSITIONAL ISSUES
[] New medication: Torsemide 5 mg daily
[] Discontinued triamterene/HCTZ in favor of above
[] LFTs mild elevated in house; consider possible
discontinuing/changing amiodarone
[] Please check LFT's and Creatinine at follow up appointment as
these were elevated while hospitalized
[] Follow up appointment with cardiology, Dr. ___
[] Follow up appointment with pulmonology
[] Follow up appointment with PCP
***Discharge weight 63.1 kg***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Losartan Potassium 25 mg PO DAILY
6. Omeprazole 10 mg PO DAILY
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
8. Senna 17.2 mg PO HS
9. Align (bifidobacterium infantis) 4 mg oral DAILY
10. coenzyme Q10 100 mg oral DAILY
11. Rosuvastatin Calcium 40 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
13. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Losartan Potassium 25 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 capsule by mouth once a day Disp
#*30 Capsule Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
9. Torsemide 5 mg PO DAILY
RX *torsemide 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Align (bifidobacterium infantis) 4 mg oral DAILY
11. coenzyme Q10 100 mg oral DAILY
12. Omeprazole 10 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute on chronic diastolic congestive heart failure
Cor pulmonale
Secondary:
Pulmonary hypertension
Paroxysmal atrial fibrillation
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized for progressive leg swelling over the past
week and a half. We started you on a new medication here that
should help prevent this from happening. Of note, Dr. ___ was
concerned about a clot in your lungs, but our scans showed NO
clot. With this news, you were discharged home with PCP and
cardiology follow up.
Please continue to take your torsemide in order to maintain your
weight. Please weight yourself everyday and call your
cardiologist if you weight changes by three pounds.
You also have "pulmonary hypertension," which may be due to your
underlying lung disease. Amiodarone can also cause lung changes
and we recommend following up with the lung doctors as ___
outpatient to see if this may be contributing.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
10002557-DS-6 | 10,002,557 | 20,731,670 | DS | 6 | 2152-11-17 00:00:00 | 2152-11-17 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin Hcl
Attending: ___.
Chief Complaint:
RUQ and epigastric pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy.
History of Present Illness:
___ is an ___ year old female who presents
with a one day history of RUQ and epigastric pain. The pain has
been intermittent and associated with nausea. She reports that
the pain is somewhat improved now, but not completely
alleviated.
She denies any emesis. She denies any fevers or chills. She has
had a couple episodes of pain that was similar in the past. She
continues to have flatus and bowel movements.
She has not had any po intake since the pain began, so she is
not
sure if the pain is increased with po intake. She reports
decreased appetite today. Last po intake was this morning.
Past Medical History:
PMH: Multinodular goiter, Osteopenia, GERD, Gallbladder stone
disease, Breast Cancer, chronic constipation, chronic migraines
PSH: Right mastectomy, partial thyroidectomy x2, appendectomy
Social History:
___
Family History:
Unknown
Physical Exam:
Admission PE:
VS: 97.9 64 137/84 16 96% RA
Gen: no acute distress, alert, responsive
Pulm: unlabored breathing
CV: regular rate and rhythm
Abd: soft, mildly tender in the epigastric region and the RUQ,
non-distended, no rebound, no gaurding, negative ___ sign
Ext: warm and well perfused
Discharge PE:
VS: Temp: 98.9, HR: 64, BP: 128/61, RR: 18, O2: 95% RA
General: A+Ox3, NAD, MAE.
CV: RRR
Resp: CTA b/l
Abdomen: soft, non-distended, mildly tender to palpation
Skin: abd lap sites w/ dsgs c/d/i
Extremeties: no edema
Pertinent Results:
___ 08:10PM URINE HOURS-RANDOM
___ 08:10PM URINE HOURS-RANDOM
___ 08:10PM URINE UHOLD-HOLD
___ 08:10PM URINE GR HOLD-HOLD
___ 08:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 08:10PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:10PM URINE MUCOUS-RARE
___ 07:45PM GLUCOSE-90 UREA N-19 CREAT-0.7 SODIUM-140
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
___ 07:45PM estGFR-Using this
___ 07:45PM ALT(SGPT)-106* AST(SGOT)-309* ALK PHOS-140*
TOT BILI-0.7
___ 07:45PM LIPASE-36
___ 07:45PM ALBUMIN-4.1
___ 07:45PM WBC-8.8 RBC-3.83* HGB-11.6* HCT-33.9* MCV-89
MCH-30.4 MCHC-34.4 RDW-14.5
___ 07:45PM NEUTS-82.6* LYMPHS-12.5* MONOS-4.8 EOS-0.1
BASOS-0.1
___ 07:45PM PLT COUNT-169
Imaging:
___: Ultrasound: Porcelain gallbladder with calcification of
the wall of the gallbladder, similar to previous. Stable
dilatation of the common bile duct.
___: CXR: No evidence of acute cardiopulmonary disease.
___: Hida Scan: Findings are consistent with acute
cholecystitis
___: Intraoperative Cholangiogram Contrast is seen
opacifying the remaining biliary system, without filling defect.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound showed calcification of the wall
of the gallbladder as well as stable dilatation of the common
bile duct. Next she had a hida scan which was positive for acute
cholecystitis. On ___, the patient underwent laparoscopic
cholecystectomy with an introperative cholangiogram, which went
well without complication (reader referred to the Operative Note
for details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating a clear liquid diet, on
IV fluids, and po pain medicine for pain control. The patient
was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. On POD2, pt was
noted to have saturated RUQ lap site dsgs with ongoing oozing,
requiring a bedside cauderization which the patient tolerated
well. Post-cauderization, good hemostasis was achieved.
At the time of discharge the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient and her family received discharge teaching and
follow-up instructions with the use of an interpreter and the
patient verbalized understanding and agreement with the
discharge plan. She has a follow-up appointment scheduled in 2
weeks in the ___ clinic.
Medications on Admission:
amlodipine 10 mg', atorvastatin 40 mg', Fioricet 50 mg-325
mg-40 mg'', Premarin 0.625 mg/gram vaginal cream,
hydrochlorothiazide 25 mg', lorazepam 0.5 mg', metoprolol
succinate ER 50 mg', omeprazole 20 mg', tramadol 50 mg'',
valsartan 320 mg', zolpidem 5mg', aspirin 81 mg', Vit D
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
do NOT exceed more than 3gm in 24 hours.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*40 Tablet Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
7. Lorazepam 0.5 mg PO QHS:PRN insomnia
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 2.5-10 mg PO Q4H:PRN Pain
please do NOT drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. Senna 8.6 mg PO BID:PRN constipation
please hold for loose stools
13. TraMADOL (Ultram) 50 mg PO BID:PRN pain
14. Valsartan 320 mg PO DAILY
15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cholelithiasis
2. Chronic cholecystitis.
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 with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10002559-DS-7 | 10,002,559 | 22,034,413 | DS | 7 | 2179-06-07 00:00:00 | 2179-06-11 09:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Mr ___ is a ___ male presents with 1 day general
malaise, fever, altered mental status
Per patient notes one day of chills, sore throat, dry cough and
intermittent headache. He was later brought in by ambulance
after being noted by his roommates to be altered. While being
assessed by EMS patient was tachycardic to 160. Upon arrival to
ED patient was disoriented to time and place. VS: 102.7 136
117/62 18 100% 4L. He underwent LP due to concern for
meningitis. LP revealed protein 24 glucose 61. UA negative. CXR
wnl. Urine/blood tox screen negative. Patient received 4L IVF,
CTX 2gm, 4mg IV ativan pre-treatment for LP. VS prior to
transfer: 99.9 119 94/44 18 98%.
On arrival to the floor, patient is sleeping but arousable;
oriented x3 but intermittently confused. Reports mild HA, sore
throat, fever, dry cough, sweats, chills. No recent travel. No
known sick contacts. No recent sexual activity. No genital
ulcers/lesions. No skin rashes. Lives with 4roommates. Denies
recent exposures, ingestions. Last EtOH use on ___ night.
Past Medical History:
None
Social History:
___
Family History:
Father: HTN, pre-DM
No psych history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 110/52 113regular 18 97%RA
GENERAL: Sleeping but arousable, NAD, mildly diaphoretic
HEENT: NC/AT, PERRLA, EOMI, no nystagmus, sclerae anicteric, MMM
NECK: supple, no appreciable LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: tacycardiac, no MRG, nl S1-S2
ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
SKIN: no obvious rashes, petechiae
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, no clonus, no rigidity, unsteady gait.
DISCHARGE PHYSICAL EXAM:
VS: 98.3, 112/70, 91, 18, 100%RA
GENERAL: awake, NAD
HEENT: NC/AT, sclerae anicteric, MMM, red/swollen bilat tonsils
without evidence of exudate
NECK: supple, no neck stiffness
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
SKIN: no obvious rashes, petechiae
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: A&Ox3, CNs II-XII grossly intact, gait normal, no focal
deficits
Pertinent Results:
ADMISSION LABS:
___ 12:00AM GLUCOSE-104* UREA N-14 CREAT-0.8 SODIUM-136
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20
___ 12:12AM LACTATE-2.1*
___ 12:00AM ALT(SGPT)-25 AST(SGOT)-26 LD(LDH)-187
CK(CPK)-89 ALK PHOS-78 TOT BILI-1.0
___ 12:00AM CALCIUM-10.4* PHOSPHATE-0.8* MAGNESIUM-1.7
___ 12:00AM TSH-2.3
___ 12:00AM WBC-13.6* RBC-5.02 HGB-15.2 HCT-43.8 MCV-87
MCH-30.2 MCHC-34.7 RDW-12.3
___ 12:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
MICRO:
- ___ 1:17 am CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
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 (Final ___: NO GROWTH.
- ___ 1:15 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
- ___ 1:15 pm SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
- ___ 5:22 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
- Herpes Simplex Virus PCR
Specimen Source CSF
Result Negative
- Test (Serum) Result Reference
Range/Units
HSV 1 IGG TYPE SPECIFIC AB 3.61 H index
HSV 2 IGG TYPE SPECIFIC AB <0.90 index
Index Interpretation
<0.90 Negative
0.90-1.10 Equivocal
>1.10 Positive
___ 01:15PM BLOOD HIV Ab-NEGATIVE
Brief Hospital Course:
___ male presents with 1 day general malaise, fever; found to
be altered, febrile and tachycardic in the ED.
# Altered Mental Status: Was noted to have confusion when at
home with roommates, who called EMS given their concern. There
was no history of ingestion, and tox screen was negtaive. Blood
culture showed no growth, and influenza swab was negative as
well. He was noted to be febrile, raising concern for possible
meningitis/encephalitis. LP did not show any evidence of
infection, and culture results were negative. All other
infectious processes which were tested (HIV, RPR, lyme, CSF HSV)
were also negative, but arborovirus is still pending at this
time. His mental status returned to baseline shortly after he
was admitted.
# Throat Pain: Complained of throat pain with swallowing. Noted
to have erythematous, slightly enlarged tonsils without evidence
of exudates. Swab was negative for Strep. He was treated with 7
days of augmentin empirically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Fever, acute encephalopathy, pharyngitis
Secondary: None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for evaluation of your acute
confusion and fever. While you were here you had a lumbar
puncture and blood work to check for evidence of an infection.
You were treated with antibiotics, and your symptoms improved.
None of the tests which were run show any evidence of infection
around your brain or in your blood. The antibiotics were
stopped, and you continued to do well. The exact cause of your
acute confusion and fever is unknown.
Followup Instructions:
___
|
10002930-DS-10 | 10,002,930 | 25,696,644 | DS | 10 | 2196-04-17 00:00:00 | 2196-04-18 00:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypoglycemia, Alcohol intoxication, Suicidality
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F with a history of HCV, HIV, and
multiple prior admissions for suicidal ideation who presented to
the ___ ED this morning after being found down, somnolent and
was ultimately found to have an EtOH level of 117 and initial
FSBG 42. She was being observed in the ED but hypoglycemia did
not readily improve. She is being transferred to the MICU for
close monitoring and treatment of refractory hypoglyemia.
Per the patient she reports trying to drink "as much as
possible" to try and kill herself. She is not sure if she took
anything else. She does not recall any other details about last
evening.
In the ED, initial vitals were 98.0 84 110/65 12 100% RA
In the ED, she received:
- 4 amps of dextrose
- Started on D5 NS gtt
- Diazepam 10mg PO @ 10:45a
- Octreotide 100mcg
- Folic acid 1mg IV x 1
- Thiamine 100mg IV x 1
- Multivitamin
Labs/imaging were significant for:
- Urine tox: positive for cocaine and benzodiazepines
- Serum tox: positive for benzodiazepines, EtOH level of 117
- VBG ___ with AG = 18, lactate 3
- CT head without acute intracranial abnormality on prelim read
Vitals prior to transfer were T 95.6 HR 89 BP 106/65 RR 16 SpO2
100%
On arrival to the MICU, the patient reports no current
complaints.
Review of systems:
(+) Per HPI, headache
Past Medical History:
PAST MEDICAL HISTORY:
- HIV (dx ___: Previously on ARV
- Hepatitis C: Diagnosed ___, genotype 1
- Truamatic brain injury (1980s) - pt reports she was
"assaulted" and subsequently received 300 stitches, was
hospitalized x 2wks, and
underwent rehab at ___ she denies LOC or persistent
deficits but receives SSDI for this injury
PSYCHIATRIC HISTORY: (per OMR)
Dx/Sxs- Per pt, depression, panic attacks, polysubstance (ETOH,
crack, heroin) abuse/dependence.
Hospitalizations- Per pt, multiple hospitalizations at ___
(last, ___ and ___ (last, 5+ yrs ago). Per OMR, multiple
(>20) detox admissions. No record of treatment at ___ in
Partners system.
SA/SIB- Per pt, OD on Ultram "probably to hurt [her]self" ___
ago)
Psychiatrist- None
Therapist- None
Medication Trials- Amitriptyline
Social History:
___
Family History:
Denies h/o psychiatric illness, suicide attempts, addictions.
Physical Exam:
ADMISSION EXAM:
Vitals-
Tmax: 37.3 °C (99.2 °F)
Tcurrent: 37.3 °C (99.2 °F)
HR: 89 (87 - 89) bpm
BP: 104/51(62) {104/51(62) - 133/70(80)} mmHg
RR: 14 (14 - 20) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
General- Well appearing, no apparent distress
HEENT- Tattoo on right neck. Pupils 4mm, reactive.
Neck- No JVD
CV- RRR, III/VI SEM heard best at ___
Lungs- CTAB
Abdomen- Soft, nontender. Specifically no tenderness of RUQ.
No stigmata of chronic liver disease.
GU- No foley
Ext- Warm, well perfused. No edema.
Neuro- CN II-XII grossly intact. No tremor.
DISCHARGE PHYSICAL EXAM
Vitals: T98.3 HR83 BP106/73 RR18 100%RA
General- Well appearing, no apparent distress
HEENT- Tattoo on right neck. Pupils 4mm, reactive.
Neck- No JVD
CV- RRR, III/VI SEM heard best at ___
Lungs- CTAB
Abdomen- Soft, nontender. Specifically no tenderness of RUQ. No
stigmata of chronic liver disease.
GU- No foley
Ext- Warm, well perfused. No edema.
Neuro- CN II-XII grossly intact. No tremor.
Pertinent Results:
ADMISSION LABS:
___ 03:36AM BLOOD WBC-2.4* RBC-3.64* Hgb-7.7* Hct-27.6*
MCV-76* MCH-21.1* MCHC-27.8* RDW-18.5* Plt ___
___ 03:36AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-136
K-3.4 Cl-107 HCO3-21* AnGap-11
___ 07:35AM BLOOD ALT-49* AST-105* CK(CPK)-224* AlkPhos-69
TotBili-0.2
___ 03:36AM BLOOD Calcium-7.8* Phos-2.6*# Mg-1.8
___ 07:35AM BLOOD Osmolal-321*
___ 07:35AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 09:05AM BLOOD ___ Temp-36.7 pO2-47* pCO2-36
pH-7.26* calTCO2-17* Base XS--9 Intubat-NOT INTUBA
___ 11:10AM BLOOD Glucose-51* Lactate-2.1*
HeaD CT:
IMPRESSION:
1. No acute intracranial abnormality.
2. Prominence of the posterior nasopharyngeal soft tissues is
seen and
correlation with direct visualization is recommended.
3. Encephalomalacia in the left parietal lobe with overlying
bony defect,
possibly from prior trauma.
DISCHARGE LABS
___ 03:36AM BLOOD WBC-2.4* RBC-3.64* Hgb-7.7* Hct-27.6*
MCV-76* MCH-21.1* MCHC-27.8* RDW-18.5* Plt ___
___ 06:35AM BLOOD Glucose-97 UreaN-15 Creat-0.5 Na-139
K-3.7 Cl-109* HCO3-23 AnGap-11
___ 07:35AM BLOOD ALT-49* AST-105* CK(CPK)-224* AlkPhos-69
TotBili-0.2
___ 06:35AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.4*
Brief Hospital Course:
___ F with HCV, HIV presenting after being found down with +EtOH,
cocaine, benzodiazepines and transferred to the MICU for
hypoglycemia, now resolving.
1) HYPOGLYCEMIA: Suspect related to poor PO intake. Hypoglycemia
resolved with eating and patient has remained euglycemic for the
remainder of her hospital stay.
2) SUICIDALITY: Patient has had prior admissions to psychiatry
for SI and has active SI currently. On ___. Psych was
following in house. 1:1 sitter at all times. Patient transferred
to ___ for active suicidality.
3) ETOH WITHDRAWAL: No active etoh withdrawal during hospital
stay. CIWA scale but not scoring.
4) HEPATITIS C INFECTION: Chronic. Elevated transaminases
currently, but in classic 2:1 pattern for EtOH and given recent
ingestion history, this is more likely the explanation.
- Follow-up as outpatient issue
5) HIV: Will bear in mind as transitional issue to consider
re-initiating ARVs
CODE STATUS: Unable to assess given active suicidality
# Transitional issues
- New murmur work up
- chronic leukopenia
- reinitiating HIV treatment and consideration for initiation of
HCV treatment
- Nystagmus work-up as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO 1X Duration: 1 Dose
6. Senna 8.6 mg PO BID:PRN Constipation
7. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: hypoglycemia secondary to poor po intake,
suicidal ideation, severe depression
Discharge Condition:
Flat affect, active suicidal ideation
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted to the ICU for low blood sugars that you had when you
arrived. You have not had any further blood sugars since. They
were probably caused by not eating enough while drinking
excessive alcohol. You were transferred back to the general
floor and monitored. You continue to have suicidal thoughts and
will therefore be going to ___ when you leave ___. We
wish you all the best in your recovery.
Your ___ tem.
Followup Instructions:
___
|
10002930-DS-12 | 10,002,930 | 25,922,998 | DS | 12 | 2198-04-22 00:00:00 | 2198-04-22 18:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
alcohol intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o ___ homeless F with PMH of TBI, HIV+, HCV,
polysubstance abuse (alcohol, crack cocaine, and heroin),
unspecified mood disorder (MDD with psychotic features vs.
substance-induced mood disorder), and chronic AH who presented
from ___ station via EMS with complaint of multiple head strikes
found to have EtOH intoxication and SI admitted to MICU for EtOH
withdrawal and CIWA monitoring.
Patient is noted to be a poor historian; however she reports she
hit her head "multiple" times today ___ falling asleep. Of note,
she reports active EtOH use and states her last drink was at
1200 on ___. She is unsure if she used other drugs/medications.
In addition, she reports concern that she is having auditory
hallucinations with the voices increasing in frequency. In
addition, patient reports active SI although she does not have a
plan.
In the ED, initial vitals: 98.2 88 150/98 16 100% RA. During
time in ED, patient became febrile to 101; a urinalysis/urine
cx, CXR, and blood cultures were sent.
- Exam notable for: pleasant patient with poor hygiene/dress,
tangential and appearing to respond to internal stimuli, neuro
intact, no clear HEENT trauma, mild upper thoracic tenderness,
(+) tongue fasiculation
- Labs were notable for:
2.9>9.9/33.6<168
Na 140 K 3.5 Cl 103 HCO3 24 BUN 15 Cr 0.6 Gluc 111 AGap=17
ALT 77 AST 196 AP 98 Tbili 0.6 Alb 3.9
Serum EtOH 21
Serum ASA, Acetmnphn, ___, Tricyc Negative
Lactate 1.0
U/A with ketones, 6 WBCs, few bacteria, negative leuks, negative
nitrites
- Imaging showed:
NCHCT (___): 1. No acute intracranial abnormality. 2. Stable
left parietal encephalomalacia.
CXR (___): No acute cardiopulmonary abnormality or fracture.
- Patient was given:
40mg diazepam
100mg thiamine
MVI
1mg folic acid
30mg ketorolac
2L NS
1gm Tylenol
- Psychiatry was consulted who felt patient was disorganized and
endorsing AH and SI (no plan). Per their recommendations,
patient was placed on a ___ with a 1:1 sitter with
admission to medicine for EtOH withdrawal
On arrival to the MICU, she was sleeping comfortably. Would open
eyes to voice and answer questions, but was overall very sleepy.
Denies pain. Cannot articulate when last drink was, says
"yesterday." Denies taking anything else.
Past Medical History:
Per Dr. ___ (___), confirmed
with patient and updated as relevant:
- HIV
- Hepatitis C
- H/o head injury (Per Deac 4 DC summary ___: "pt reports she
was "assaulted" and subsequently received 300 stitches, was
hospitalized x 2wks, and underwent rehab at ___ she
denies
LOC or persistent deficits but receives SSDI for this injury"
Social History:
Per Dr. ___ (___),
confirmed with patient and updated as relevant:
"The patient reports that she was born and raised in ___
and that her parents were separated while she was growing up.
She
states that she lives with her grandmother her whole life until
___
years ago when her mother died and that she has been living in
the ___ since. She states that she has 2 daughters (age
___ and ___, named ___ and ___ who are both enrolled at
___ and that she also has 2 grandchildren. Denies contact with
parents, whom she reports are not supportive. "
On today's interview patient reports no contact with her family,
reports having 3 living children (2 daughters and 1 son) and 1
dead son. She has no contact with her children. She did not wish
to elaborate further. Confirms living at ___.
Family History:
Unknown (pt refused to answer in past)
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vitals: 98.2 103 138/77 22 99% ra
GEN: lying in bed, somnolent, but wakes to voice, NAD
HEENT: no scleral icterus, PERRL, mmm, nl OP
NECK: supple, no JVD
CV: tachycardic, regular rhythm, II/VI systolic murmur
PULM: nl wob on ra, LCAB, no wheezes or crackles
ABD: soft, mild distension, normal bs, nontender
EXT: warm, trace bilateral edema, 2+ DP pulses
SKIN: no rashes or visible track marks
NEURO: sleepy, oriented to person, didn't answer re place or
time, answering questions then falls asleep, moving all 4
extremities
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
===========================
stable vital signs
lying comfortably in bed.
bilateral knee ecchymosis.
Pertinent Results:
ADMISSION LABS:
===========================
___ 03:27PM BLOOD WBC-2.9* RBC-3.81* Hgb-9.9* Hct-33.6*
MCV-88 MCH-26.0 MCHC-29.5* RDW-17.9* RDWSD-56.8* Plt ___
___ 03:27PM BLOOD Neuts-74.0* ___ Monos-4.5*
Eos-0.7* Baso-0.3 AbsNeut-2.16 AbsLymp-0.60* AbsMono-0.13*
AbsEos-0.02* AbsBaso-0.01
___ 03:27PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-140
K-3.5 Cl-103 HCO3-24 AnGap-17
___ 03:27PM BLOOD ALT-77* AST-196* AlkPhos-98 TotBili-0.6
___ 03:27PM BLOOD Albumin-3.9
___ 03:27PM BLOOD Osmolal-295
___ 03:27PM BLOOD ASA-NEG Ethanol-21* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO:
===========================
-Blood cx pending
-Urine cx pending
IMAGING/STUDIES:
===========================
-NCHCT (___): 1. No acute intracranial abnormality. 2. Stable
left parietal encephalomalacia.
-CXR (___): No acute cardiopulmonary abnormality or fracture.
DISCHARGE LABS:
===========================
Brief Hospital Course:
___ y/o ___ homeless F with PMHx of TBI, HIV+, HCV,
polysubstance abuse (alcohol, crack cocaine, and heroin),
unspecified mood disorder (MDD with psychotic features vs.
substance-induced mood disorder), and chronic AH who presented
from ___ station via EMS with complaint of multiple head strikes
found to have EtOH intoxication and SI admitted to MICU for EtOH
withdrawal and CIWA monitoring, now stabilized and transferred
to the floor, now medically stable for discharge to psychiatric
facility
ACTIVE ISSUES:
========================
# EtOH intoxication/withdrawal: on phenobarbital withdrawal
protocol. Last drink ___. Patient was loaded with
phenobarbital, which may continue if the accepting psychiatric
facility is okay with administering, however there is no
contraindication to discontinuing.
-Phenobarb protocol while inpatient, stopped at discharge
-Continued MVI, thiamine, folate
-Hydroxyzine PRN for additional agitation
-seen by psychiatry and social work - appreciated.
# Suicidal ideation: patient repeatedly stating "I have suicidal
thoughts" and "I'm depressed," though is unable to fully
elaborate. Psychiatry saw the patient and had the following
recommendations: -Patient meets ___ criteria for
involuntary admission, may not leave AMA, should continue 1:1
observation.
-Would hold on any psychiatric medications given acute alcohol
withdrawal.
-If chemical restraint necessary, please call psychiatry for
specific recs. Please be aware that patient has cited "jaw
locking" with Haldol administration in the past, thus would
consider alternative antipsychotic.
- seen by psychiatry - recommended inpatient psychiatric
placement, and transferred to deac 4.
# FEVER: Patient febrile to 101 in the ED. No localizing signs
of symptoms of infection. Suspect that this was likely related
to acute ingestion, however given her murmur which has not been
documented previously, obtained TTE which showed no evidence of
vegetation or endocarditis.
# Psychosis: suspect this is part of underlying psych disorder
and not necessarily alcoholic hallucinosis. Will defer to
psychiatry.
-Appreciate Psychiatry recs
CHRONIC STABLE ISSUES:
========================
# HIV: not on HAART, started Bactrim for PCP prophylaxis given
last CD4 count was <200, will send repeat CD4 count on ___ if
still inpatient. Patient was previously not taking her HAART
medications, will defer to outpatient.
# HCV: not on active treatment
- Monitor LFTs, as above
Transitioanl issues:
Should see PCP re HIV and HCV once psychiatrically stabilized.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 25 mg PO QHS
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY (not taking)
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY (not taking)
5. Darunavir 600 mg PO BID (not taking)
6. RiTONAvir 100 mg PO DAILY (not taking)
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polysubstance abuse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for evaluation of numerous falls,
alcohol and substance abuse. While you were here you were
briefly in the intensive care unit where you were started on
phenobarbital to help you withdrawal from alcohol and prevent
delirium tremens. You also disclosed that you were not taking
any of your HIV medications. You were started on Bactrim as
prophylaxis for opportunistic infections, and should follow up
with your outpatient providers regarding restarting your HIV
medications and for evaluation of your hepatitis C. You were
deemed medically stable for discharge to a psychiatric facility.
Followup Instructions:
___
|
10003019-DS-19 | 10,003,019 | 24,646,702 | DS | 19 | 2174-10-25 00:00:00 | 2174-10-25 13:21:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Oxycodone / Ragweed
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Exploratory Laparotomy, ___
History of Present Illness:
___ year old male with history to intestinal sarcoidosis s/p
Ex.laparoscopy, right colectomy ___ (___), ITP s/p open
splenectomy, and inguinal hernia repair complaining of new
abdominal pain that started last night and has now progressed to
___ with 1 episode of foot particulate emesis. He denies fevers
and chills. He has never had an episode like this before. He
reports he urinated this am without difficulty. It is
difficult for him to breath this am. He also has new bilateral
shoulder pain with breathing.
Past Medical History:
1. Sarcoidosis, dx skin bx: intestinal & pulmonary involvement,
recurrent iritis
2. Inflammatory bowel disease; s/p ileo-hemicolectomy ___,
path +sarcoid
3. GERD.
4. Hyperlipidemia
5 OSA on CPAP
6. Asthma.
7. Osteoarthritis.
8. Fractured pelvis, ___ s/p fall.
9. BPH, status post prostatectomy.
10. Depression.
11. History of ITP, status post splenectomy in ___.
12. Hard of hearing and wears hearing aid.
Past Surgical History:
1. s/p Ex Lap, R hemicolectomy, ileocecal colostomy for
evaluation ileocecal mass.
2. Arthroscopic surgery of both knees.
3. Shoulder surgery.
4. Hernia repair.
Social History:
___
Family History:
Mother: ___, cardiac disease.
Father: diverticulosis, peptic ulcer disease, died at age ___.
Maternal grandfather: ___ cancer.
Two siblings, living and healthy.
Physical Exam:
Physical Exam upon admission:
Vitals:Temp 97.8, HR 87, BP 119/83, RR 26, 99% Room air
GEN: A&O x3, uncomfortable with movement of stretcher
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Firm abdomen with diffuse peritonitis. Well healed open
splenectomy, laparscopic right colectomy, and right inguinal
hernia repair incisions.
Ext: No ___ edema, ___ warm and well perfused
Physical Exam upon discharge:
VS: 98.1, 72, 152/83, 18, 98%/RA
Gen: NAD, ambulating in room
Heent: EOMI, MMM
Cardiac: Normal S1, S1. RRR
Pulm: Lungs CTAB No
Abdomen: Soft/nontender/nondistended staples OTA
Ext: + pedal pulses, no CCE
Neuro: AAOx3, normal mentation.
Pertinent Results:
___ 05:21AM BLOOD WBC-6.3 RBC-3.17* Hgb-8.4* Hct-27.2*
MCV-86 MCH-26.4* MCHC-30.7* RDW-22.4* Plt ___
___ 05:26AM BLOOD WBC-8.0 RBC-3.34* Hgb-9.0* Hct-28.5*
MCV-85 MCH-26.9* MCHC-31.5 RDW-22.7* Plt ___
___ 05:47AM BLOOD WBC-9.8 RBC-3.62* Hgb-9.7* Hct-31.4*
MCV-87 MCH-26.8* MCHC-30.8* RDW-22.7* Plt ___
___ 10:35AM BLOOD WBC-9.8 RBC-4.27* Hgb-11.4* Hct-37.1*
MCV-87 MCH-26.8* MCHC-30.8* RDW-22.8* Plt ___
___ 10:35AM BLOOD Neuts-81* Bands-0 Lymphs-12* Monos-3
Eos-3 Baso-0 Atyps-1* ___ Myelos-0 NRBC-1*
___ 05:21AM BLOOD Glucose-140* UreaN-18 Creat-0.8 Na-138
K-3.6 Cl-103 HCO3-27 AnGap-12
___ 05:26AM BLOOD Glucose-143* UreaN-18 Creat-0.9 Na-135
K-4.1 Cl-103 HCO3-24 AnGap-12
___ 05:47AM BLOOD Glucose-84 UreaN-24* Creat-0.8 Na-137
K-4.7 Cl-105 HCO3-23 AnGap-14
___ 10:35AM BLOOD Glucose-105* UreaN-34* Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-27 AnGap-12
___ 10:35AM BLOOD ALT-80* AST-54* AlkPhos-290* TotBili-0.5
___ 05:21AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
___ 05:26AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0
___ 05:47AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.7
___ 10:35AM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.6* Mg-1.9
___ 10:42AM BLOOD Lactate-2.0
___ Radiology CHEST (PORTABLE AP)
IMPRESSION:
1. Pneumoperitoneum.
2. Widening of the vascular pedicle may be related to low lung
volumes and intravascular volume status.
Brief Hospital Course:
This is a ___ year old male with history to intestinal
sarcoidosis s/p right colectomy ___ (___), ITP s/p open
splenectomy, and inguinal hernia repair who presented to ___
complaining of new abdominal pain and emesis. The patient was
admitted to the Acute Care Surgery service. A Chest Xray
demonstrated "Free air is present underneath both
hemidiaphragms". He was taken to the operating room on ___
for exploratory laparatomy, which revealed that the patient had
a perforated duodenal ulcer. Please see operative report for
full details. The patient was transferred to the surgical floor
post-operatively in stable condition. A nasogastric tube was
placed and the patient was kept NPO on POD 1. He received
intravenous dosing of his home medications. He also was started
on a proton pump inhibitor that he will continue taking after
his discharge. The patient's nasogastric tube was discontinued
on POD 2, however he was kept NPO. His abdominal pain was well
controlled with a Morphine PCA. He did not complain of any
nausea or vomiting at this time. On POD 3, the patient was
advanced to a regular diet and was passing flatus. He was
restarted on his previous home medications and was receiving an
oral pain regimen. The patient was also started on a proton pump
inhibitor to prevent ulcers in the future and was instructed
never to take NSAIDS. He was evaluated by physical therapy; they
recommended that the patient have a ___ home safety evaluation
and that he was cleared to go home.
On the day of discharge, the patient's vital signs were stable
and he remained afebrile. He was tolerating a regular diet. His
staples were open to air without any signs of erythema or
drainage. They are due to come out ___. He will have
scheduled followup in the ___.
Medications on Admission:
Prednisone 40'
Alendronate 70'
Azathioprine 50',
Ergocalciferol 1 capsule/week
Fluoxetine 40'
Vicodin ___,
simvastatin 20'
Bactrim 400/80'
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. PredniSONE 40 mg PO DAILY
3. Alendronate Sodium 70 mg PO QMON
4. Azathioprine 50 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Fluoxetine 40 mg PO DAILY
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*2 Tablet Refills:*0
8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
9. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated Duodenal Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after you experienced an ducodenal
ulcer perforation. You were taken to the operating room on
___ for exploration and placement of ___ patch.
Post-operatively, you received a 5 day course of antibiotics.
Upon discharge, you were tolerating a regular diet and your pain
was well controlled on an oral pain regimen. You will be
discharged with followup in the ___ in ___ weeks.
DO NOT TAKE ANY NSAIDS: ie Ibuprofen, Aleve, Advil, Naproxen,
Aspirin, Motrin
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10003019-DS-23 | 10,003,019 | 21,223,482 | DS | 23 | 2175-11-02 00:00:00 | 2175-11-02 22:33:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ragweed / morphine / Percocet
Attending: ___.
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with hx of systemic sarcoidosis and Hodgkins
lymphoma p/w pre-syncopal episode. Pt was receiving chemo on day
of admission (lying flat) when he suddenly felt nauseated. He
sat up at the edge of his bed but was unable to stay in seated
position d/t dizzines and lay back into bed. Pt said he did not
feel like himself and is unable to say whether he went fully
unconscious. Wife was present and did not witness any shaking
movement, though did report he was confused and not acting like
himself. Pt does admit to feeling confused when he woke up. He
denies any preceding chest pain, HPs, dyspnea. No other
associated sxs.
.
In the ED: AF/VSS. Neuro saw pt and recommended MRI brain and
EEG. CT head negative for acute changes. Labs notabel for WBC
71, hct 28 plt 190. CEs neg. chem 10 notable only for cr 1.3. Pt
admitted to OMED.
.
On the floor pt reports being asymptomatic and feeling well. ROS
is as above. Otherwise complete ROS negative.
Past Medical History:
1. Sarcoidosis, dx skin bx: intestinal & pulmonary involvement,
recurrent iritis
2. Inflammatory bowel disease; s/p ileo-hemicolectomy ___,
path +sarcoid
3. GERD.
4. Hyperlipidemia
5 OSA on CPAP
6. Asthma.
7. Osteoarthritis.
8. Fractured pelvis, ___ s/p fall.
9. BPH, status post prostatectomy.
10. Depression.
11. History of ITP, status post splenectomy in ___.
12. Hard of hearing and wears hearing aid.
Past Surgical History:
1. s/p Ex Lap, R hemicolectomy, ileocecal colostomy for
evaluation ileocecal mass.
2. Arthroscopic surgery of both knees.
3. Shoulder surgery.
4. Hernia repair.
Social History:
___
Family History:
Mother: ___, cardiac disease.
Father: diverticulosis, peptic ulcer disease, died at age ___.
Maternal grandfather: ___ cancer.
Two siblings, living and healthy.
Physical Exam:
ADMISSION EXAM:
t97.8 134/66 82 20 95%ra
NAD
eomi, perrl
neck supple
no ___
chest clear
rrr
abd benign
ext w/wp
neuro: cn ___ intact, strength/sensation intact,
DTRs intact, cerebellar signs neg
skin: no rash
DISCHARGE EXAM:
VITALS - T 97.7, 138/72, 74, 20, 97% RA, Wt 146.6kg
Telemetry: No events overnight
General: Pleasant, conversant, elderly gentleman, NAD
HEENT: PERRL, sclera anicteric, MMM, no mucositis
Neck: Supple, no JVD, no LAD
CV: RRR, nl S1/S2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: NABS, flat, soft, NTTP, no HSM
GU: No Foley
Ext: WWP, no ___ edema, no rashes
Neuro: No slurred speech, no facial droop, moving all
extremities equally
Pertinent Results:
ADMISSION LABS:
___ 12:55PM UREA N-28* CREAT-1.3* SODIUM-141
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
___ 12:55PM ALT(SGPT)-40 AST(SGOT)-58* ALK PHOS-304* TOT
BILI-0.3
___ 12:55PM TOT PROT-5.4* ALBUMIN-3.4* GLOBULIN-2.0
CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.7 URIC ACID-8.9*
___ 12:55PM WBC-71.0*# RBC-2.86* HGB-9.0* HCT-28.4*
MCV-99* MCH-31.4 MCHC-31.6 RDW-22.8*
___ 12:55PM NEUTS-71* BANDS-8* LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-6* MYELOS-8* PROMYELO-2* NUC RBCS-27*
OTHER-1*
___ 12:55PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-1+
TARGET-OCCASIONAL SCHISTOCY-1+ HOW-JOL-1+ PAPPENHEI-1+
ENVELOP-OCCASIONAL
___ 12:55PM PLT SMR-NORMAL PLT COUNT-190
PERTINENT LABS:
___ 12:55PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:03AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS:
___ 12:39AM BLOOD WBC-30.8*# RBC-2.35* Hgb-7.1* Hct-22.7*
MCV-97 MCH-30.4 MCHC-31.5 RDW-23.7* Plt ___
___ 12:39AM BLOOD Neuts-96* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-5*
___ 12:39AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+
Stipple-OCCASIONAL How-Jol-1+ Pappenh-1+
___ 12:39AM BLOOD Plt Smr-LOW Plt ___
___ 12:39AM BLOOD Glucose-171* UreaN-30* Creat-0.9 Na-135
K-4.0 Cl-105 HCO3-23 AnGap-11
___ 12:39AM BLOOD ALT-41* AST-56* LD(LDH)-1672*
AlkPhos-229* TotBili-0.4
___ 12:39AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.8 Mg-1.7
UricAcd-7.3*
IMAGING:
CT HEAD ___: 1. No evidence of acute intracranial process.
No focal enhancement or
pachymeningeal enhancement identified, although the study is
suboptimal for
assessment of neurosarcoidosis. If there is further clinical
concern, a
contrast-enhanced brain MRI should be performed.
2. Air-fluid levels in the sphenoid sinuses compatible with
acute
inflammatory sinus disease.
CXR ___: Allowing for differences in technique and
projection, there has
been little interval change in the appearance of the chest since
the previous
radiograph, with no new focal areas of consolidation to suggest
the presence
of pneumonia. Multifocal linear areas of scarring appear
unchanged,
previously attributed to sarcoidosis. Band-like opacity at
periphery of left
lung base has slightly worsened and is attributed to localize
atelectasis.
MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, MRA OF THE
HEAD WITHOUT
CONTRAST, MRA OF THE NECK WITH CONTRAST, ___
1. No acute intracranial abnormality.
2. Progressive multifocal T2-hyperintensities in bihemispheric
and central
pontine white matter, which may represent sequelae of chronic
small vessel
ischemic disease, neurosarcoidosis, or a combination of the two.
3. No pathologic parenchymal, leptomeningeal or dural
enhancement to suggest
active inflammation related to neurosarcoidosis.
4. Unremarkable cranial and cervical MRA, with no significant
mural
irregularity, flow-limiting stenosis or evidence of dissection.
5. Inflammatory disease involving, particularly the sphenoid
air cells, with
likely layering fluid, suggesting an acute component; this
should be
correlated clinically, as there is also a small amount of
layering fluid in
the nasopharynx and fluid-opacification of scattered mastoid air
cells, which
may relate to protracted supine positioning.
Brief Hospital Course:
Mr. ___ is a ___ M with stage IV Hodgkin's Lymphoma C2D3
(on ___ of ABVD, as well as h/o systemic sarcoid on
prednisone, here after altered mental status/pre-syncope during
dacarbazine infusion ___.
# Altered Mental Status/Pre-Syncope: Differential diagnosis on
admission included allergic reaction, stroke, seizure, and
cardiogenic syncope. The patient has a history of presumed
neurosarcoid making an intracranial process more likely. Seizure
less likely given no tonic-clonic movements and no post-ictal
confusion. Neurology was consulted in the ED. Head CT negative
for acute process. Head and neck MRI/MRA was checked on ___ and
showed progressive multifocal T2 hyperintensity in bihemispheric
and central pontine white matter; could represent small vessel
ischemic disease and/or neurosarcoidosis. There was no
pathologic enhancement to suggest active inflammation due to
neurosarcoidosis. The MRA of head and neck was unremarkable. An
EEG was checked but results were pending at the time of
discharge. The patient ruled out for cardiac ischemia/infarction
with a normal EKG and negative cardiac enzymes. He was monitored
on telemetry for 24 hours without event. Overall, it's unclear
what caused the pre-syncope and altered mental status. The
patient's cognitive function rapidly returned to normal even
prior to admission and remained stable throughout
hospitalization. He will be admitted to the hospital for all
future cycles of chemotherapy for closer monitoring.
# Stage IV Hodgkin's Lymphoma: Admitted on cycle 2 day 1 of
ABVD. Did not get full dose of decarbazine on ___ due to
pre-syncope. He received the remainder of the decarbazine dose
on ___. He was continued on prophylaxis with fluconazole 400 mg
PO/NG Q24H, Acyclovir 400 mg PO/NG Q8H, Sulfameth/Trimethoprim
SS 1 TAB PO/NG DAILY. The patient will start Neupogen and Cipro
on ___. He was started on allopurinol due to elevated uric
acid.
# Systemic Sarcoidosis: Involves skin, gut, eyes, lungs, and
presumed neurosarcoid. On prednisone daily. He was continued on
prednisone 25mg daily.
# Depression: Stable. Continued on fluoxetine 40mg daily
# Obstructive Sleep Apnea. Compliant with home CPAP, which was
continued during hospitalization.
# History of AVNRT. This was transient during prior
hospitalization and likely related to sepsis. At that time,
cardiology recommended conservative treatment with beta
blockers, since invasive ablation contraindicated in this
immunosuppressed pt. The patient was continued on metoprolol,
but switched to short acting metoprolol tartrate 12.5mg BID
while hospitalized.
TRANSITIONAL ISSUES:
-EEG results pending at discharge
-Patient will be admitted to the hospital for future
chemotherapy
-Will start Neupogen and Cipro ___.
-New Rx for allopurinol
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q8H
2. Fluconazole 400 mg PO Q24H
3. Fluoxetine 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Omeprazole 40 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN n/v
7. PredniSONE 25 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN n/v
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Fluconazole 400 mg PO Q24H
3. Fluoxetine 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Omeprazole 40 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN n/v
7. PredniSONE 25 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
10. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN n/v
13. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Pre-syncope during chemotherapy administration, unknown
etiology
SECONDARY:
-Stage IV Hodgkin's Lymphoma
-Systemic sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___. You were admitted
after having a period of confusion and near-loss of
consciousness while getting chemotherapy. A CT scan of your
brain was normal. The MRI showed small lesions scattered
throughout your brain that may be related to sarcoid, but could
also be related to low blood flow in the tiniest blood vessels
in your brain (a common finding as people age). The MRI did not
show active inflammation in your brain from sarcoid, nor did it
show a stroke- good news! An EEG was checked to look for seizure
activity and the result is still pending. We also monitored
your heart function. Blood tests and an EKG did not reveal a
heart attack. The electrical activity of your heart was normal
over 24 hours of monitoring.
Overall, it's unclear why you experienced near-loss of
consciousness and confusion with the chemotherapy. Dr. ___
___ that you be admitted to the hospital for all future
administrations of chemotherapy to be cautious and allow for
closer monitoring.
After returning home, please start Neupogen and Ciprofloxacin on
___.
Followup Instructions:
___
|
10003400-DS-15 | 10,003,400 | 26,467,376 | DS | 15 | 2136-12-15 00:00:00 | 2136-12-16 07:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
afib with rvr
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ with obesity, atrial fibrillation on
coumadin, CKD III (recent baseline 0.88-1.1), UPJ obstruction
s/p stent placement ___ c/b persistent Klebsiella bacteruria,
chronic multiple myeloma, and adenocarcinoma of anal canal dx
___ who presents with atrial fibrillation with rapid
ventricular response.
Pt was seen by PCP ___, ___, for pre-op visit re:
cystoscopy and right ureteral stent exchange. She presented with
complaints of fatigue, inability to stand due to pain in legs,
and bilateral leg swelling. Metoprolol had been hold at nursing
home due to intermittent hypotension. EKG in office showed AF
with RVR in 140s and she was sent to the ED.
In the ED, initial VS were 98.3 157 115/81 18
Exam significant for
Labs significant for Cr 1.2, (baseline .9), phos 1.7, WBC 3.8,
Hb 9.6, INR of 6.5, and troponin of 0.02.
Imaging significant for normal CXR.
Initially received 5 mg IV metoprolol tartrate, 50 mg metoprolol
tartrate PO, and 1L NS. Due to persistent tachycardia to the
130s, she received an additional 5 mg IV metoprolol x2 then
diltiazem 10 mg IV.
Transfer VS were 98.6 ___ 16 100% RA. On arrival to the
floor, patient reports that she has been feeling tired,
lightheaded and dizzy for several weeks. She has also had
bilateral leg pain both at rest and exacerbated with weight
bearing. She has also had decreased PO intake and describes dry
mouth. She also describes dysuria, but no frequency or flank
pain. She denies fevers and night sweats, but admits to feeling
cold.
REVIEW OF SYSTEMS:
Denies fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, or hematuria.
All other 10-system review negative in detail
Past Medical History:
Hypertension
Atrial fibrillation on coumadin
Obesity
Myeloma
Osteoarthritis of right knee
UPJ obstruction s/p stent placement ___ c/b persistent
Klebsiella bacteruria
Anal adenocarcinoma (dx ___ without evidence of metastatic
dz
? Perirectal cyst drainage in ___
Social History:
___
Family History:
Her parents died in their ___ or ___ of "old age." Her parents
and multiple siblings have hypertension. There is no family
history of significant arrhythmia or premature coronary disease.
Physical Exam:
ADMISSION EXAM:
VS: 98.9 112 18 112/61 100RA
Tele: irreg irreg 100s
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, poor dentition, dry oral mucosa
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregulary irregularm no murmurs, gallops, or rubs. no
carotid bruits
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, no CVA tenderness
EXTREMITIES: No cyanosis or clubbing; Diffuse anasarca, BLE >
BLE. 2+ pitting edema in BLE to knee. Bilateral knees edematous,
but non erythematous.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact (with the exception of mild left side of
mouth droop). Strength:
RUE flexor/extensors ___
LUE rlexor/extensors ___
RLE knee extensor ___
LLE knee extensor ___
Unable to elicit bilateral patellar reflexes; Downward babinkski
bilat
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS Tm 98 18 ___ 100RA
Tele: irreg 100s, excursions to 130s
IO: 24h 1140/inc + 5 BMs (small)
GENERAL: NAD
HEENT: AT/NC, EOMI, anicteric sclerae, pink conjunctivae, patent
nares, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CHEST: right-sided portacath accessed, bandage c/d/i, no
induration/ttp
CARDIAC: irregulary irregular, no murmurs, gallops, or rubs. no
carotid bruits
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis or clubbing; Diffuse anasarca, BLE >
BUE. 2+ pitting edema in BLE to knee, improved since admission.
Bilateral knees edematous, but non erythematous.
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS:
---------------
___ 01:30PM BLOOD WBC-3.8*# RBC-3.39* Hgb-9.6* Hct-29.4*
MCV-87 MCH-28.3 MCHC-32.6 RDW-19.4* Plt ___
___ 01:30PM BLOOD Neuts-77.1* Lymphs-14.1* Monos-8.4
Eos-0.4 Baso-0.1
___ 01:30PM BLOOD ___ PTT-35.9 ___
___ 01:30PM BLOOD Glucose-105* UreaN-18 Creat-1.2* Na-137
K-4.1 Cl-100 HCO3-23 AnGap-18
___ 01:30PM BLOOD cTropnT-0.02*
___ 01:30PM BLOOD Albumin-3.0* Calcium-8.1* Phos-1.7*
Mg-1.9
___ 01:56PM BLOOD Lactate-2.6*
PERTINENT LABS:
---------------
___ 01:30PM BLOOD CK(CPK)-77
___ 09:10PM BLOOD cTropnT-0.01
___ 04:46AM BLOOD Cortsol-30.5*
___ 09:24PM BLOOD Lactate-1.2
___ 10:59PM URINE Color-DkAmb Appear-Cloudy Sp ___
___ 10:59PM URINE Blood-MOD Nitrite-NEG Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:59PM URINE RBC-67* WBC->182* Bacteri-MANY Yeast-MOD
Epi-7
___ 10:33AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 10:33AM URINE Blood-MOD Nitrite-NEG Protein-600
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:33AM URINE RBC-46* WBC->182* Bacteri-MOD Yeast-FEW
Epi-25
MICROBIOLOGY:
-------------
BLOOD CULTURE ___: Negative
URINE CULTURE ___: YEAST ___, org/ml
URINE CULTURE ___: YEAST ___, org/ml
STOOL C. DIF TOXIN ___: POSITIVE
URINE CULTURE ___: YEAST ___, org/ml
DISCHARGE LABS:
---------------
___ 05:55AM BLOOD WBC-3.5* RBC-2.81* Hgb-8.1* Hct-24.6*
MCV-88 MCH-28.7 MCHC-32.7 RDW-19.8* Plt ___
___ 05:55AM BLOOD Glucose-159* UreaN-21* Creat-0.9 Na-138
K-4.1 Cl-109* HCO3-22 AnGap-11
___ 05:55AM BLOOD Calcium-7.7* Phos-2.7 Mg-2.0
STUDIES:
--------
___ CXR: IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ PMHx obesity, atrial fibrillation on coumadin, CKD III
(baseline 1.4) and chronic multiple myeloma and adenocarcinoma
of anal canal (dx'ed ___ presenting for AFib with RVR.
ACUTE ISSUES:
-------------
# Atrial fibrillation with RVR: Pt presented initially with RVR
in the 140s. Most likely in the setting of B-blocker and CCB
being held due to hypotension. C. diff infection (see below)
most likely contributing to hypotension. Pt received IV
metoprolol and IV diltiazem in ED and was started on PO
metoprolol/diltiazem on floor. She was also fluid resuscitated.
Patient discharged with control of afib with RVR with PO metop
and diltiazem at home doses. INR was supratherapeutic and
coumadin was held (see below).
# Hypotension: Per nursing home, she had intermittent
hypotension requiring discontinuation of her metoprolol and
diltiazem. Most likely secondary to decreased PO intake/loose
stools from C.diff infection. Adrenal insufficiency secondary to
chronic steroid use in the setting of infection was ruled out
with AM cortisol (30).
# Funguria, bacteruria: Pt initially reported dysuria and UA x2
showed large leuks/bacteria/yeast. Despite being contaminated,
due to symptoms of dysuria, she was initially treated with IV
CTX. Urine cultures eventually grew only yeast, prompting
discontinuation of CTX. She was no longer symptomatic at this
time, and she had no CVA tenderness or systemic symptoms of
infection. She had a foley place initially for urine output
monitoring, however, this was removed. Funguria will be treated
with fluconazole for total 7 days of therapy.
# C.difficile infection: Although no recent history of
antibiotics, patient immunosuppressed and at rehabilitation
facility. She was initially started on PO metronidazole on
___, but this was changed to PO vanc, given that she is
immunosuppresed and falls into the severe category. ___,
___.
# Coagulopathy: INR on admission was 6.5. Most likely secondary
to decreased PO ntake and exacerbated antibiotics. No active
signs of bleeding. Once INR reached 7.8, she was given 2.5 mg PO
vitamin K. She received additional 2.5 mg PO vitamin K on
___. Coumadin was held on discharge.
# Acute on chronic CKD (stage 3): Cr 1.2 (baseline 0.8-1.1).
Most likely secondary to decreased PO intake and decreased
cardiac output from afib with RVR. Creatinine improved with IVF.
# Lower extremity edema: Multi-factorial. Most likely venous
stasis vs diastolic heart failure, especially in the setting of
afib with RVR, vs hypoalbuminemia. Pa/lateral film in ED showed
no cardiomegaly or pulmonary vascualar congestion to suggest
decompensated systolic heart failure. Pt on furosemide at home.
Albumin was 3.0. Furosemide held on admission due to ___. Edema
was managed with pneumatic boots. Furosemide was restarted at 40
mg on discharge.
# UPJ obstruction s/p stent placement ___ c/b persistent
Klebsiella bacteruria: Pt scheduled for stent replacement soon.
She had no CVA tenderness on exam and creatinine was stable
after IVF. Pt was scheduled to have stent replaced on ___,
but procedure was cancelled due to supratherapeutic INR. Per
Urology, pt's INR needs to be <3.0 and she will need this
procedure in the next ___ months.
# Troponinemia: Most likely strain from RVR vs decreased
clearance in the setting of ___. Peaked at 0.02 before
downtrending.
# Hyperlactatemia: Lactate 2.6 on admission. Most likely
secondary to dehydration versus ineffective cardiac output from
RVR. Peaked at 2.6 before downtrending.
CHRONIC ISSUES:
---------------
# Weakness: She had generalized total body weakness, with the
lower extremities worse than upper extremities. Also with the
left ___ greater than right ___. No documented previous CVA
to which asymmetry can be attributed. Most likely deconditioning
and myopathy from dexamethasone, versus myositis or
cerebrovascular event, both thought unlikely. CK was within
normal limits. ___ worked with patient and she was discharged
back to rehab.
# Leg pain: Most likely osteoarthritis. She does not have
diabetes to suggest neuropathy. She continued home oxycodone 10
mg qHS.
# Pancytopenia: Patient with stable neutropenia, anemia,
thrombocytopenia improved from prior, thought to be secondary to
lenalidomide as well as anemia of chronic disease.
# Anal adenocarcinoma: Diagnosed recently in ___. T2N0M0.
Staging scans showed local disease without suspicious regional
LAD, and no distant mets. Baseline CEA 20. Has plans for
colorectal surgeon Dr. ___ diverting ostomy. S/p port
placement in ___. Plans for chemo/radiation. Updated
oncologist.
# Anorectal pain: Her bowel regimen included docusate, colace
and miralax, as well as being advised to increase and regulate
her fiber intake. She was also given nitroglycerin 0.02% cream,
2% lidocaine ointment, Tuck's ointment and perineum care
recommendations from wound care nursing. Bowel regimen was held
in the setting of loose stools.
# IgG myeloma: Patient with longstanding IgG MM, followed by
___ Oncology for which she is on lenolidamide days ___ of 28
days and dexamethasone 1x/week on weeks when she takes
lenolidamide. The patient completed her last 3 weeks of Revlamid
___. Also received Zometa ___.
Lenolidamide/dexamethasone was held during admission due to
infection.
TRANSITIONAL ISSUES:
--------------------
- C.diff infection, Severe: Needs PO vancomycin 125mg PO QID
until ___ for total 14 day treatment course.
- Funguria: Three urine cultures grew >100,000 cfu/ml of yeast.
She was started on fluconazole treatment, per her Urologist. D1
= ___, D7 = ___.
- Ureteral stent replacement: Was scheduled for replacement on
___, but cancelled due to supratherapeutic INR. Her stent
can be replaced when her INR is therapeutic (2.0 - 3.0). When
therapeutic, please call her Urologist Dr. ___ to schedule a
stent replacement. She will also see him on ___.
- Supratherapeutic INR: Will need daily INR checks to follow INR
until therapeutic so Coumadin may be restarted. If uptrending
x72hours, consider 2.5mg PO vitamin K (in the absence of normal
gut flora due to C. diff infection).
- Diastolic heart failure: Patient restarted on lower dose of
furosemide 40 mg. Uptitrate as necessary based on volume status
and kidney function.
- Myeloma: Revlamid/dexamethasone held during admission and on
discharge. Please call her Oncologist Dr. ___ to discuss
restarting on ___.
- Rectal adenocarcinoma: Stool softeners should be held until
frequency and consistency of BM normalizes.
# Emergency Contact/HCP: ___ (son) ___ and
___ (son) ___
# CODE: FULL, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY
3. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with
sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily
4. Senna 8.6 mg PO BID
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Furosemide 80 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO TID
8. Potassium Chloride 20 mEq PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Lenalidomide 15 mg PO DAILY
11. Dexamethasone 20 mg PO ASDIR
12. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO TID
Hold for HR<55 or SBP<90
4. Vitamin D 1000 UNIT PO DAILY
5. Fluconazole 200 mg PO Q24H Duration: 7 Days
Last day = ___
6. Vancomycin Oral Liquid ___ mg PO Q6H
Day 14 = ___
7. Docusate Sodium 100 mg PO BID
Hold for loose stools
8. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with
sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily
Hold for loose stools.
9. Polyethylene Glycol 17 g PO DAILY
Hold for loose stools
10. Potassium Chloride 20 mEq PO DAILY
11. Senna 8.6 mg PO BID
Hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
-atrial fibrillation with rapid ventricular response
-c.difficile infection, severe
Secondary diagnoses:
-multiple myeloma
-rectal adenocarcinoma
-pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___. You were admitted for a fast heart
rate. We treated this with intravenous medications, and then
restarted your home medications. You were also found to have an
infection of your colon called C.difficile. You will need to
continue antibiotics by mouth for this.
Your INR (measure of how thin your blood is from warfarin) is
still elevated. Your rehab will measure this and restart
warfarin when appropriate.
Please remember to weigh yourself every morning, and speak to
your MD if your weight rises by more than 3lbs.
On behalf of your ___ team,
We wish you a speedy recovery!
Followup Instructions:
___
|
10003400-DS-16 | 10,003,400 | 27,296,885 | DS | 16 | 2137-01-03 00:00:00 | 2137-01-04 22:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ALTERED MENTAL STATUS
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year-old woman a ___ significant for AFib on
coumadin, UPJ obstruction s/p stent placement in ___ c/b
chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and
recently diagnosed adenocarcinoma of the anal canal who presents
with altered mental status. Of note, patient is currently unable
to relay any of her medical information (only response to
questions is "I don't know"). As such, much of medical
information is obtained from medical records. Per ED note, the
patient was brought in from ___. Her
family reports that that she has had AMS for the last ___ days.
to the point that she does not recognize her family members and
does not know where she is. Upon arrival to ___ ED, initial VS
97.7 91 111/68 16 100%. Labs notable for Chem-7 wnl, P2.0, LFTS
wnl, Alb 2.8, CBC with pancytopenia 2.8>9.1<140, coags with INR
3.6. UA positive with large leuk, neg nitrites, 137 WBC, few
bacteria. CXR without cardiopulmonary process. Pateint was
administered 500cc LR, ceftriaxone 1g x1. She is now admitted to
medicine for further management. Vitals prior to transfer 98 88
140/80 18 100% RA.
On the floor, initial VS 97.7 110/57 72 18 98%RA. The patient in
lying in bed NAD but her only response to questions are "I don't
know."
Past Medical History:
Hypertension
Atrial fibrillation on coumadin
Obesity
Myeloma
Osteoarthritis of right knee
UPJ obstruction s/p stent placement ___ c/b persistent
Klebsiella bacteruria
Anal adenocarcinoma (dx ___
? Perirectal cyst drainage in 1980s
Social History:
___
Family History:
Her parents died in their ___ or ___ of "old age." Her parents
and multiple siblings have hypertension. Sibling with
Alzheimer's disease. No family history of significant arrhythmia
or premature coronary disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 110/57 72 18 98%RA
GENERAL: Elderly woman, lying in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregularly irregular, +S1/S2, no murmurs, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Anus with friable
mucosa.
EXTREMITIES: 2 piting edema up through shins bilaterally, no
cyanosis or clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII and motor grossly intact intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 99.0 (99.0) 119/71 (100-120/50-80) 85 (60-90) 18 100%RA
I/O: 1140/inc
Weight: 86.7 kg
GENERAL: elderly woman lying in bed in NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
CARDIAC: irregularly irregular, +S1/S2, no murmurs
LUNG: CTAB, no wheezes, mild crackles, breathing comfortably
ABDOMEN: non-distended, +BS, non-tender in all quadrants, no
rebound/guarding
EXTREMITIES: 2+ piting edema to shins bilaterally
NEURO: CN II-XII grossly intact, AA+O X 3. did not know day of
the week. uncooperative with other cognitive questions
SKIN: warm and well perfused, no rashes
Pertinent Results:
ADMISSION LABS
=============================
___ 05:30PM WBC-2.8* RBC-3.31* HGB-9.1* HCT-28.6* MCV-87
MCH-27.4 MCHC-31.6 RDW-20.8*
___ 05:30PM NEUTS-71.7* LYMPHS-17.9* MONOS-8.5 EOS-1.6
BASOS-0.2
___ 05:30PM PLT COUNT-140*
___ 05:30PM ___ PTT-35.1 ___
___ 05:30PM ALT(SGPT)-16 AST(SGOT)-20 ALK PHOS-83 TOT
BILI-0.6
___ 05:30PM LIPASE-24
___ 05:30PM GLUCOSE-99 UREA N-6 CREAT-0.6 SODIUM-141
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-31 ANION GAP-9
___ 04:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
___ 04:40PM URINE RBC-12* WBC-137* BACTERIA-FEW YEAST-NONE
EPI-1
PERTINANT LABS
==============================
___ 05:01AM BLOOD ___
___ 05:47AM BLOOD ___ PTT-33.4 ___
___ 05:47AM BLOOD VitB12-471
___ 05:47AM BLOOD TSH-2.6
DISCHARGE LABS
==============================
___ 05:19AM BLOOD WBC-3.1* RBC-2.90* Hgb-8.1* Hct-25.4*
MCV-88 MCH-28.1 MCHC-32.0 RDW-20.5* Plt ___
___ 05:19AM BLOOD ___ PTT-35.6 ___
___ 05:19AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-142
K-3.6 Cl-108 HCO3-27 AnGap-11
___ 05:19AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.9
IMAGING
==============================
CXR (___):
No evidence of acute cardiopulmonary disease.
Head CT w/o contrast (___):
1. No acute intracranial abnormality.
2. Please note MRI of the brain is more sensitive for the
evaluation of acute infarct.
3. Atrophy and probable small vessel ischemic changes as
described.
4. 15 mm right posterior neck probable dermal inclusion cyst as
described. Recommend clinical correlation and correlation with
direct examination.
MICROBIOLOGY
==============================
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURE x 2: NGTD
Brief Hospital Course:
___ with AFib on coumadin, UPJ obstruction s/p stent placement
in ___ c/b chronic Klebsiella bacturia, IgG myeloma on
lenolidamide, and recently diagnosed adenocarcinoma of the anal
canal who presents with altered mental status.
# Subacute congitive decline: Patient presenting from assisted
living facility with several days of progressive AMS. On
admission was A+O X 1 without focal deficits but quickly
improved to orientation x3. Differential included infectious
etiology (ie UTI), mild dementia per family report or subacute
hemorrhage given supratherapeutic INRs. NCHCT obtained on
___ and showed no acute intracranial abnormality.
Initially covered with ABX for possible to be UTI (see below)
but ABX stopped with urine culture unrevealing. TSH and B12 WNL.
Given hx of rectal adenocarcinoma, considered potential brain
metastasis, however with no localizing symptoms and low burden
malignancy so head MRI was deferred. Please arrange
neurocognitive work-up to exclude dementia vs
depression/pseudodementia as outpatient given mental status
largely notable for apathy and pt being withdrawn with
relatively good attention and orientation which makes an acute
encephalopathy less likely.
.
# Pyuria: Patient has a history of chronic Klebsiella
bacteriuria as a complication of UPJ obstruction s/p stent
placement in ___. Seen previously by ID who recommended not
treating unless symptoms. Given that she presented with altered
mental status, she was started on ceftriaxone. However, urine
culture on ___ returned with mixed flora and CTX stopped.
.
# Anal adenocarcinoma: Diagnosed recently in ___. T2N0M0.
Staging scans showed local disease without suspicious regional
LAD, and no distant mets. Baseline CEA 20. Has plans for
colorectal surgeon Dr. ___ diverting ostomy. Home bowel
regimen of metamucil, senna, colace was continued.
.
# AFib: CHADS = 2. Patient was rate-controlled during
hospitalization. INR 3.6 on admission. Home warfarin was held
given supratherapeutic INR. Rate-control agents with home
diltiazem and metoprolol was also continued. Warfarin restarted
at lower dose on ___.
.
# Hypertension: Normotensive. Home BB/CCB and furosemide were
continued.
.
# CKD Stage 3: Baseline Cr 0.8-1.1, currently 0.6.
.
# IgG Myeloma: Patient with longstanding IgG MM, followed by
___ Oncology.
.
TRANSITIONAL ISSUES:
========================
-will benefit from neurocognitive evaluation to further
elucidate possibility of dementia
-would also assess for pseudodementia/depression with psychiatry
evaluation
-will need to discuss with outpatient oncologist re: Revalmid
therapy
-pt requires motivation from staff for participation in ___
activities. Please promote OOB to chair for all meals and
encourage PO intake.
-f/u with colorectal surgeon (Dr. ___ for mgmt of anal
adenocarcinoma
-full code
-contact ___ (son) ___ and ___ (son)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO TID
4. Vitamin D 1000 UNIT PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with
sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily
7. Polyethylene Glycol 17 g PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Senna 8.6 mg PO BID
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Furosemide 40 mg PO DAILY
4. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with
sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily
5. Metoprolol Tartrate 100 mg PO TID
Hold for HR<55 or SBP<90
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Warfarin 1 mg PO DAILY16
10. Potassium Chloride 20 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Subacute Encephalopathy
Secondary Diagnosis: Atrial Fibrillation, Anal Adenocarcinoma,
Hypertension, CKD Stage 3
Discharge Condition:
Mental Status: Clear and Coherent.
Level of Consciousness: Alert and interactive - usually.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for confusion. You were initially put on antibiotics, but your
urine culture did not how infection and these medications were
stopped. Other tests including blood tests and a CAT scan of
your brain were reassuring. Your mental status remained at
baseline throughout your hospitalization and you will need
further testing as an outpatient to further define your
cognition.
Please follow-up with the appointments listed below and take
your medications as instructed below.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10003502-DS-9 | 10,003,502 | 29,011,269 | DS | 9 | 2169-08-28 00:00:00 | 2169-08-29 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nifedipine / Amitriptyline / Prilosec OTC / Terazosin /
Amlodipine / Atenolol / Oxybutynin / Hydrochlorothiazide /
spironolactone / furosemide
Attending: ___.
Chief Complaint:
Fall, bradycardia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ YO F w/ PMH significant for CAD, mild AS, afib/flutter on
dabigatran, HFpEF, HTN, HLD, chronic hyponatremia, who presents
after a fall at her nursing home.
Pt unable to provide history, but per nursing home and OSH
notes, in early AM on ___, pt fell and was discovered by nursing
home RN. RN at that time noted that pt was confused and
lethargic. HR at that time per report was in the ___. EMS was
activated and pt brought to OSH ER. En route, EMS report
indicates that heart rates were labile, but there are no EKG
strips and unclear if pt received any cardiac medications. At
OSH ER, pt's EKG revealed bradycardia to 20 with ventricular
escape and no signs of atrial activity. The pt was then given 1
mg of atropine with no effect and then transcutaneously paced
for 1 hour. She was then noted to have HRs in the ___ and atrial
activity. She was then transferred to ___ for possible PPM.
Here at ___, noted to be intermittently lethargic and poorly
responsive. CT head and neck negative. EP was consulted for
possible PPM and initially recommended admission to ___,
deferred PPM for the time being. She continued to be
intermittently bradycardic to the ___ in the ED, but given that
she has a history of previous bradycardia and has been
asymptomatic with her episodes, she was felt to be stable for
the floor. However, after this she had increasing respiratory
distress requiring a NRB. Due to this she was admitted to the
CCU. Received Lasix 60mg IV x1.
Of note, pt's HCP reports that she had been more altered over
the last week in the setting of higher doses of seroquel that
the nursing home had started for increased agitation.
In the ED initial vitals were: 98.3, HR 90, 142/73, 18, 93% RA
EKG:
Labs/studies notable for: Na 140, K 4.6, Cl 98 HCO3 35 BUN 58 Cr
1.2 glu 125, WBC 7 Hct 34.8 AST 219 ALT 178 Trop 0.05 ___: 14.8
PTT: 42.4 INR: 1.4 AGap=12 BNP 2900 Lactate 1.5. ABG:
___
On arrival to the CCU: Awake but not answering questions. Pt
does not speak ___, per report. On NRB.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD (100% LAD occlusion). MI ___ year ago. Unclear history of
PCI.
- Afib/flutter on dabigatran
- Mild aortic stenosis
3. OTHER PAST MEDICAL HISTORY
- Chronic hyponatremia
- Dementia
Social History:
___
Family History:
Mother deceased at ___ yo from breast cancer. Father deceased at
___ yo. Son deceased at ___ yo from heart attack.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.6 BP 132/103 HR 80 RR 21 O2 SAT 100% NRB
GENERAL: Ill appearing. Not answering questions.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP unable to assess due to restlessness.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular. Normal S1, S2. II/VI systolic
murmur at R sternal border.
LUNGS: No chest wall deformities or tenderness. Tachypneic but
withoug increased work of breathing. Faint crackles.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL
VS: T 97.6 BP 144/75 HR 54 RR 22 O2 SAT 92% 2 L NC
GENERAL: Skinny, somewhat anxious. Oriented to self only.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP unable to assess due to restlessness.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular. Normal S1, S2. II/VI systolic
murmur at R sternal border.
LUNGS: No chest wall deformities or tenderness. Tachypneic no
signs respiratory distress. Lungs clear to auscultation
bilaterally.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-10.0 RBC-3.55* Hgb-10.5* Hct-34.8
MCV-98 MCH-29.6 MCHC-30.2* RDW-13.1 RDWSD-46.9* Plt ___
___ 12:45PM BLOOD Neuts-87.3* Lymphs-5.0* Monos-7.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.76* AbsLymp-0.50*
AbsMono-0.70 AbsEos-0.00* AbsBaso-0.02
___ 12:45PM BLOOD ___ PTT-42.4* ___
___ 12:45PM BLOOD Glucose-125* UreaN-58* Creat-1.2* Na-140
K-4.6 Cl-98 HCO3-35* AnGap-12
___ 12:45PM BLOOD proBNP-2915*
___ 12:45PM BLOOD cTropnT-0.05*
___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13*
___ 05:51AM BLOOD Calcium-10.1 Phos-4.6* Mg-2.5
___ 08:10PM BLOOD ___ pO2-23* pCO2-79* pH-7.29*
calTCO2-40* Base XS-6
___ 12:52PM BLOOD Lactate-1.5
PERTINENT RESULTS:
___ 12:45PM BLOOD cTropnT-0.05*
___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13*
___ 12:52PM BLOOD Lactate-1.5
___ 11:47PM BLOOD Lactate-1.0
___ 06:04AM BLOOD Lactate-2.9*
DISCHARGE LABS:
___ 05:51AM BLOOD WBC-7.8 RBC-3.90 Hgb-11.3 Hct-37.7 MCV-97
MCH-29.0 MCHC-30.0* RDW-13.2 RDWSD-46.2 Plt ___
___ 05:51AM BLOOD ___ PTT-36.7* ___
___ 05:51AM BLOOD Glucose-89 UreaN-56* Creat-1.2* Na-141
K-4.1 Cl-97 HCO3-31 AnGap-17
___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13*
IMAGING:
CHEST XRAY ___: Large right and moderate left pleural
effusions and severe bibasilar atelectasis are unchanged.
Cardiac silhouette is obscured. No pneumothorax. Pulmonary edema
is mild, obscured radiographically by overlying abnormalities.
MICROBIOLOGY:
None.
Brief Hospital Course:
Ms. ___ is ___ year old female with a past medical history
significant for CAD, mild AS, afib/flutter on dabigatran, HTN,
HLD, chronic hyponatremia, who presented to ___ on transfer
from OSH after a fall and headstrike when subsequently found to
be bradycardic to the ___. She was transferred here externally
paced and was seen by our EP physicians. After discussion with
patient's healthcare proxy, it was decided not to purse
pacemaker placement and to withdraw external pacemaker. She
initially became profoundly bradycardic from ___ beats per
minute but stabilized to the ___ overnight. She was made
DNR/DNI/DNH and sent back to senior living facility
hemodynamically stable. Of note CT head at outside facility was
negative.
TRANSITIONAL ISSUES
====================
- Per discussion with patient's sister, ___,
patient was made DNH in addition to her DNR/DNI. She will need a
new MOLST signed by her sister and the doctors at ___
___
- She will also need a palliative care consult with possible
escalation to hospice care as needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES BID
2. Aspirin 81 mg PO DAILY
3. Dabigatran Etexilate 75 mg PO BID
4. Vitamin D ___ UNIT PO EVERY 3 WEEKS
5. Escitalopram Oxalate 15 mg PO DAILY
6. Losartan Potassium 37.5 mg PO DAILY
7. QUEtiapine Fumarate 12.5 mg PO QHS
8. Senna 17.2 mg PO QHS
9. Sodium Chloride Nasal ___ SPRY NU BID:PRN congestion
10. Torsemide 60 mg PO DAILY
11. OxyCODONE (Immediate Release) 2.5 mg PO QAM
12. LORazepam 0.5 mg PO Q6H:PRN anxiety
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES BID
3. Dabigatran Etexilate 75 mg PO BID
4. Escitalopram Oxalate 15 mg PO DAILY
5. LORazepam 0.5 mg PO Q6H:PRN anxiety
6. Losartan Potassium 37.5 mg PO DAILY
7. OxyCODONE (Immediate Release) 2.5 mg PO QAM
8. QUEtiapine Fumarate 12.5 mg PO QHS
9. Senna 17.2 mg PO QHS
10. Sodium Chloride Nasal ___ SPRY NU BID:PRN congestion
11. Torsemide 60 mg PO DAILY
12. Vitamin D ___ UNIT PO EVERY 3 WEEKS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You originally went to another hospital because you fell and
hit your head.
- You were found to have a very slow heart rate and transferred
here to ___ for further management
What was done while I was in the hospital?
- A CT scan of your head and neck at the outside hospital was
done and was normal.
- You were transferred here with an external pacemaker to bring
your heart rate up but we eventually decided to withdraw this
device.
- You were seen by our electrophysiologists, who did not decided
to put in a pacemaker at this time.
What should I do when I get home?
- Take your old medications as prescribed.
All the best,
Your ___ team
Followup Instructions:
___
|
10003637-DS-18 | 10,003,637 | 23,487,925 | DS | 18 | 2146-01-26 00:00:00 | 2146-01-26 15:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
perianal fistula and abscess
Major Surgical or Invasive Procedure:
Examination under anesthesia, incision and drainage of abscess,
placement of Malecot drain
History of Present Illness:
___ with PMH significant for fistula in ano with rectal abscess
s/p 3 OR drainages, CAD, CHF, hx of stroke and ___ s/p CABG &
pacemaker who presents with rectal pain. The patient states that
he has been having worsening rectal pain for the past week.
Patient first noticed pain on ___ and described as mild. He
did his typical routine of warm shower which in the past has
worked for rectal pain with mild abscess. On ___ he was
admitted to ___ with cough c/w pulmonary edema
and
was treated with lasix. He was discharged on ___ with
continuing worsening rectal pain. On presentation, he describes
his pain as
___, with warm baths helping the pain. He had taken no
medications to improve his pain. He felt a palpable mass on his
inner right buttock and feels it has gotten larger. He had been
bedridden with pain for several days. His last bowel movement
was
the morning of presentation. His last urine output was also that
morning. He
endorsed trouble passing stool and urine since this morning
(even
if he were to try he is unable). He endorsed that all 3 times he
has required OR intervention, he has had these same set of
symptoms. He denied fever, chills, abdominal pain, nausea,
vomitting, diarrhea, constipation, bloody bowel movements, or
blood from his rectal mass.
In the ED, his temp max was 99.5. Lactate is 2.1. WBC 15.8 and
H/H is 10.3/32.3.
Past Medical History:
Illness: HTN, HLD, CAD c/b MI s/p PCI/stent (___), Hx
perirectal
abscess s/p I&D (___)
___: I&D perirectal abscess (___), EUA, ___ placement
(___)
Medications: ASA 81', metoprolol succinate ER 25'
Allergies: NKDA
Social History:
___
Family History:
Noncontributory
Physical Exam:
Discharge PE:
VS: AVSS
Gen: well appearing male, NAD
HEENT: no lymphadenopathy, moist mucous membranes
Lungs: CTAB
Heart: rrr
Abd: soft, nt, nd
Incisions: cdi
Extremities: wwp
Pertinent Results:
___ 11:43PM ___ PTT-32.4 ___
___ 05:30PM URINE HOURS-RANDOM
___ 05:30PM URINE GR HOLD-HOLD
___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:30PM URINE HYALINE-1*
___ 05:30PM URINE MUCOUS-RARE
___ 01:02PM LACTATE-2.1*
___ 11:30AM GLUCOSE-103* UREA N-37* CREAT-1.6* SODIUM-135
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-22 ANION GAP-21*
___ 11:30AM estGFR-Using this
___ 11:30AM WBC-15.8*# RBC-3.37* HGB-10.3* HCT-32.3*
MCV-96 MCH-30.6 MCHC-31.9* RDW-14.7 RDWSD-52.4*
___ 11:30AM NEUTS-78.2* LYMPHS-9.6* MONOS-11.3 EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-12.33* AbsLymp-1.51 AbsMono-1.79*
AbsEos-0.05 AbsBaso-0.03
___ 11:30AM PLT COUNT-183
Brief Hospital Course:
Patient was taken to the OR on ___ for an examination under
anesthesia, drainage of abscess, and placement of Malecot drain
for perianal fistula and abscess. He tolerated the procedure
well and was transferred to the floor with no issue.
Neuro: Pain was well controlled on oxycodone 5 mg q6 hours.
CV: Vital signs were routinely monitored during the patient's
length of stay.
Pulm: The patient was encouraged to ambulate, sit and get out
of bed, use the incentive spirometer, and had oxygen saturation
levels monitored as indicated.
GI: The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge.
GU: Patient had a Foley catheter that was removed at time of
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever. The patient was started on/continued on
antibiotics as indicated.
Heme: The patient had blood levels checked post operatively
during the hospital course to monitor for signs of bleeding. The
patient had vital signs, including heart rate and blood
pressure, monitored throughout the hospital stay.
On ___, the patient was discharged to home. At discharge, he
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Medications on Admission:
ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth
once a day
CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth
twice a day - (Prescribed by Other Provider)
DIGOXIN - digoxin 125 mcg tablet. 1 tablet(s) by mouth daily -
(Prescribed by Other Provider)
LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth daily -
(Prescribed by Other Provider)
SPIRONOLACTONE - spironolactone 25 mg tablet. 1 tablet(s) by
mouth daily - (Prescribed by Other Provider)
TORSEMIDE - torsemide 20 mg tablet. 2 tablet(s) by mouth daily -
(Prescribed by Other Provider)
WARFARIN [COUMADIN] - Coumadin 5 mg tablet. 1 tablet(s) by mouth
daily x 5 days per week, 3mg on M and F - (Prescribed by Other
Provider)
Medications - OTC
ASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
IRON - Dosage uncertain - (Prescribed by Other Provider) (Not
Taking as Prescribed)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. sodium chloride 0.9 % 0.9 % mallencot drain irrigation BID
RX *sodium chloride [Saline Wound Wash] 0.9 % please irrigate
rectal mallenot drain with 60cc of sterile normal saline twice a
day Refills:*3
3. Tamsulosin 0.4 mg PO QHS
please take for 10 days
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*10
Capsule Refills:*0
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 12.5 mg PO BID
6. Digoxin 0.125 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Torsemide 20 mg PO DAILY
10. Warfarin 6 mg PO 1X/WEEK (FR)
11. Warfarin 4 mg PO 6X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perianal fistula and abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ on ___ for a perianal
fistula with abscess. You underwent an examination under
anesthesia with incision and drainage and placement of a drain.
You have recovered from the procedure well and are ready to
return home.
You were seen by cardiology while you were here prior to your
surgery. They recommended that you have close follow up with
your cardiologist once you are discharged from the hospital. You
required diuresis with Lasix several times during your hospital
stay with good improvement in your shortness of breath. Please
ensure that you make an appointment with both your PCP and your
cardiologist once you are discharged for management of your
diuretic regimen.
The drain placed in your abscess site should remain until you
follow up with Dr. ___ in his clinic. You will receive ___ to
help you flush the drain twice daily.
Followup Instructions:
___
|
10003637-DS-19 | 10,003,637 | 22,082,422 | DS | 19 | 2146-02-19 00:00:00 | 2146-02-21 02:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of ischemic cardiomyopathy sent from ___ clinic
when his BP was noted to be systolic ___. Patient reports that
at 9am his vision was a little blurry and he felt diffusely weak
and tired, the subjective feelings completely resolved prior to
admission. He states he had been taking his blood pressure
medication regularly and drinking only about one small bottle of
water daily. He reports over the last year his blood pressure
has been regularly with systolic in the ___. He denies fevers or
recent illness. Had perirectal abscess drained in ___, site
looked well at evaluation today in clinic. No chest pain,
palpitations, or cough. No abd pain/n/v/d/urinary symptoms.
In the ED, initial vitals were: HR 82 BP79/42 RR16 SaO298% RA
Exam notable for
Labs notable for BNP 5890, Cr 2.8, WBC 13.4
Imaging notable for ___ CXR: No acute cardiopulmonary
abnormality.
Patient was given: 500 cc IVF
Decision was made to admit for hypotension and ___
Vitals prior to transfer: HR 73 BP101/57 RR20 SaO2 100% RA
On the floor, Patient was resting comfortably in bed and
asymptomatic.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
*Cards: HTN, HLD, CAD c/b MI s/p PCI/stent and CABG, CHF with
reduced EF (LVEF 27%), Single lead ICD pacemaker
*Neuro: L MCA ischemic stroke
*GI: Perirectal abscess s/p I&D (___), Anal
fistula, s/p EUA, ___ placement
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
Vital Signs: T97.9 PO, BP97/50, HR60 RR16 SaO2: 100% RA
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, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE EXAM:
Vital Signs: Tmax 98.2 T97.4 BP 102/67 HR 71 RR 18 O2 100%RA
General: No acute distress
HEENT: Sclera anicteric, conjunctiva without injection. PERRLA.
Oropharynx clear with MMM. Neck supple, no JVP elevation.
Lungs: Clear to auscultation bilaterally with no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Left-sided AICD.
Abdomen: Soft, non-tender, non-distended. Bowel sounds present
with no renal bruits. No rebound tenderness or guarding, no
organomegaly, no pulsatile mass.
Ext: Warm, well perfused with no cyanosis of the toes or
fingers. No calf tenderness or edema.
Skin: Without rashes or lesions on gross exam. Tattoos over the
forearm bilaterally.
Neuro: Alert and oriented. Face symmetric. Speech is fluent and
logical with no evidence of dysarthria. Moves all extremities
purposefully.
Pertinent Results:
ADMISSION LABS:
___ 02:05PM WBC-13.4*# RBC-4.11*# HGB-12.1*# HCT-35.6*#
MCV-87 MCH-29.4 MCHC-34.0 RDW-14.0 RDWSD-43.9
___ 02:05PM NEUTS-72.3* LYMPHS-13.0* MONOS-12.7 EOS-1.2
BASOS-0.4 IM ___ AbsNeut-9.68* AbsLymp-1.74 AbsMono-1.70*
AbsEos-0.16 AbsBaso-0.05
___ 02:05PM PLT COUNT-223
___ 02:21PM ___ PTT-34.1 ___
___ 02:05PM GLUCOSE-143* UREA N-78* CREAT-2.8*#
SODIUM-133 POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-23 ANION GAP-25*
___ 02:05PM CALCIUM-10.4* PHOSPHATE-4.6* MAGNESIUM-2.4
___ 02:05PM CK(CPK)-59
___ 02:05PM cTropnT-0.04*
___ 02:05PM CK-MB-2 proBNP-5890*
___ 07:30PM URINE HOURS-RANDOM
___ 07:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:30PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___:30PM URINE MUCOUS-RARE
___ 07:30PM URINE HYALINE-13*
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-7.7 RBC-3.84* Hgb-11.3* Hct-33.8*
MCV-88 MCH-29.4 MCHC-33.4 RDW-14.1 RDWSD-44.8 Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD ___ PTT-34.7 ___
___ 07:35AM BLOOD Glucose-105* UreaN-91* Creat-2.6* Na-134
K-3.5 Cl-91* HCO3-25 AnGap-22*
___ 03:14PM BLOOD Glucose-96 UreaN-84* Creat-1.8* Na-134
K-3.4 Cl-95* HCO3-22 AnGap-20
___ 07:35AM BLOOD CK-MB-4 cTropnT-0.03*
___ 07:35AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.6
___ 03:14PM BLOOD Digoxin-0.2*
DIAGNOSTICS:
ECHO (CHA ___
CONCLUSIONS
1. LV ejection fraction is 27%.
2. The apical portion of the anterior wall and the LV apex are
akinetic.
3. The left atrium is mildly dilated.
4. There is mild-to-moderate mitral regurgitation.
5. Estimated RV systolic pressure is moderately elevated at 55
mmHg.
6. Compared to the previous echo of ___, there is no
significant change.
CXR ___
FINDINGS:
Patient is status post median sternotomy and CABG. Left-sided
AICD is noted with single lead terminating in the right
ventricle. Heart size is normal. Mediastinal and hilar contours
are normal. Lungs are clear. No pleural effusion or
pneumothorax. No acute osseous abnormalities are detected.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ M with h/o ischemic cardiomyopathy (s/p PCI/stent, CABG,
ICD pacemaker) c/b systolic CHF (LVEF 27%), L MCA stroke, and
perirectal abscess who presents with hypotension and new ___ in
the setting fluid restriction while taking multiple diuretics
and anti-hypertensives.
#Hypotension: Pt presented with a baseline SBP in ___ over past
year, was fluid restricting given history of pulmonary edema,
presented with SBP in 60-70s in ED. After 500cc fluid bolus, SBP
returned to baseline and pt was asymptomatic. Patient was not
orthostatic. Bolused additional 1L NS. Hypotension seemed likely
attributable to self fluid restriction in the setting of
multiple diuretic and anti-hypertensive medications. Losartan,
Spironolactone, Carvedilol and Torsemide were held on discharge.
Patient was instructed to schedule primary care to have
follow-up of his laboratory values.
___: Rise in pt's Cr to 2.8 from baseline of 1.1 with
associated BUN/Cr >20. UA was unremarkable. Pt was maintaining
UOP, w/ no history to suggest post-renal obstruction. Elevated
pro-BNP suggestive of ventricular overload c/w history of
ischemic cardiomyopathy, possible cardiorenal contribution to
___. Overall findings were pre-renal ___, likely ___ decreased
effective circulating volume in the setting of hypotension and
fluid restriction in pt with underlying ischemic cardiomyopathy.
He responded well to 1.5L IVFs, with a creatinine of 1.8 at time
of discharge. He was instructed to improve his PO intake to 1.5L
per day (has hx of CHF exacerbations). Antihypertensives were
held at time of discharge.
#Hyperphosphatemia: Phos to 5.1 on ___. Likely ___ renal
insufficiency. He was given a low phosphate diet for one day.
#Normocytic Anemia: H/H down to 11.3/33.8 on ___ AM. Had low
suspicion for hemolysis or acute blood loss. Was thought to be
likely dilutional after fluids and was consistent with pt's
normal range.
RESOLVED ISSUES:
#Leukocytosis: Patient presented with transient leukocytosis,
which downtrended to wnl ___ AM, likely ___ acute stress
reaction. CXR/UA was not concerning for infection. Further
infectious workup was not pursued.
CHRONIC ISSUES:
#Ischemic Cardiomyopathy: s/p L ICD placement. No evidence of
volume overload on exam ___. Losartan, Spironolactone,
Torsemide, Carvedilol in were held in the setting of hypotension
and ___, and also held on discharge.
#Hypertension: Losartan, Spironolactone, Torsemide, Carvedilol
were held as above.
#Hyperlipidemia: atorvastatin was continued without issue.
#History of MCA stroke: continued home warfarin without issue.
TRANSITIONAL ISSUES:
-patient was instructed to drink 1.5 L of fluid per day
-patient's home antihypertensives were held at time of
discharge.
-patient was instructed to follow-up with his PCP within one
week
-patient may benefit from a repeat Na, K, Cl, bicarb, BUN, Cr at
time of follow-up
-consideration of when to restart home antihypertensives can be
considered at follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Warfarin 4 mg PO DAILY16
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Digoxin 0.125 mg PO DAILY
6. Ferrous Sulfate uncertain mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Torsemide 20 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Digoxin 0.125 mg PO DAILY
4. Ferrous Sulfate uncertain mg PO DAILY
5. Warfarin 4 mg PO DAILY16
6. HELD- Carvedilol 12.5 mg PO BID This medication was held. Do
not restart Carvedilol until following up with your primary care
doctor
7. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until following up with
your primary care doctor
8. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until following up with your
primary care doctor
9. HELD- Torsemide 20 mg PO BID This medication was held. Do
not restart Torsemide until following up with your primary care
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-------------------
Hypotension
___
Secondary Diagnosis
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital when it was discovered that
you had low blood pressures and evidence of kidney injury after
having reduced fluid intake while still taking your
antihypertensives. You were evaluated with bloodwork and
imaging, and given intravenous fluids. Your blood pressure
medications were held and we have not restarted these on
discharge from the hospital.
Please follow-up with your primary care doctor with ___ visit in
the next week before resuming your home antihypertensives.
Please continue to drink 1.5L of fluids per day.
It was a pleasure to be involved with your care!
-___ Team
Followup Instructions:
___
|
10003731-DS-2 | 10,003,731 | 23,646,008 | DS | 2 | 2146-11-19 00:00:00 | 2146-12-04 16:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Doxycycline / Sulfa(Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
needle aspiration of subcutaneous hematoma
History of Present Illness:
___ with A. fib on rivaroxaban, hypertension, and venous stasis
presents with 7 days of increasing erythema on the left leg.
One week ago, patient was walking down stairs and struck her
left shin on a metal plant holder. Two days ago she noticed some
erythema in her lower left leg and went to an urgent care and
was placed on clindamycin. Over the last couple days the
erythema had increased and she was seen by her PCP on ___ and
again on ___. At that time, erythema was noted to expand
beyond the marked edges, and she was advised to be admitted for
IV antibiotics, but she declined. On the day of presentation,
patient's erythema extended even further which prompted her to
come to the emergency department. Patient denies any fevers,
chest pain, shortness of breath, nausea or vomiting. There has
not been any purulent drainage from the leg.
In the ED intial vitals were: T 98.3 HR 88 BP 157/86 RR 16 Sat
99%. Labs were significant for lactate of 2, K of 3.4, Cr 1.1,
BUN 21, INR 1.3, PTT 40. Patient was given tylenol and IV
vancomycin 1 gram x1. Blood cultured were drawn and pending.
On the floor, patient states that her leg pain is improved and
she has no other acute complaints at this time.
Review of Systems:
(+) per HPI. 10-point ROS conducted and otherwise negative.
Past Medical History:
venous insufficiency in lower extremities
Paroxysmal a-fib on rivaroxaban for anticoagulation
CKD w/ baseline creatinine 1.2 - eGFR 45-50
HTN
obesity
Depression
GERD
HSV
rosacea
sleep disorder
PCOS
H. pylori by EGD biopsy in ___
Social History:
___
Family History:
Sister: DVTs
Father: a-fib. CVA
Mother: vascular disease
Physical Exam:
On Admission:
Vitals - 98.2 160/80 76 18 97%RA
GENERAL: NAD. Well-appearing. Very pleasant.
HEENT: AT/NC, EOMI, PERRL
CARDIAC: irregularly irregular rhythma, ___ SEM heard best at
LUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, obese
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. No focal deficits
SKIN: Large area of erythema extending across left anterior shin
and ___ surface of left foot. Area of erythema is
extending beyond previously marked lines. This area is warm to
touch and tender to palpation. No areas of fluctuance or
purulence. No calf tenderness. Right leg w/o any significant
skin changes.
On Discharge:
97.5 142/84 70 18 100%RA
GENERAL: NAD. Well-appearing.
HEENT: AT/NC
CARDIAC: rrr, no murmurs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, obese
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. No focal deficits
SKIN: erythema improving w/in pen marks. Small fluid collection
ant shin
Pertinent Results:
On Admission:
___ 08:40AM GLUCOSE-102* UREA N-15 CREAT-0.9 SODIUM-144
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-32 ANION GAP-15
___ 08:40AM WBC-6.8 RBC-4.48 HGB-14.2 HCT-42.0 MCV-94
MCH-31.6 MCHC-33.7 RDW-12.4
___ 08:40AM PLT COUNT-279
___ 08:40AM ___ PTT-38.4* ___
___ 09:00PM LACTATE-2.0
___ 08:46PM GLUCOSE-133* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-13
___ 08:46PM WBC-8.7 RBC-4.51 HGB-14.1 HCT-43.6 MCV-97
MCH-31.2 MCHC-32.3 RDW-13.0
___ 08:46PM NEUTS-69.8 ___ MONOS-4.7 EOS-1.6
BASOS-1.2
___ 08:46PM PLT COUNT-317
___ 08:46PM ___ PTT-40.0* ___
On Discharge:
___ 08:15AM BLOOD WBC-5.6 RBC-4.40 Hgb-14.4 Hct-42.3 MCV-96
MCH-32.6* MCHC-34.0 RDW-12.6 Plt ___
___ 08:15AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-143
K-4.1 Cl-106 HCO3-27 AnGap-14
Imaging:
lower extremity ultrasound ___:
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Subcutaneous edema in the area of redness in the mid to
distal left shin.
Microbiology:
Left Shin Fluid Aspiration ___ 1:57 pm SWAB Source: left shin ABSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Blood Culture ___ x 2: no growth
Brief Hospital Course:
Ms. ___ is a ___ year old woman with A. fib on rivaroxaban,
hypertension, and venous stasis who presented with left leg
cellulitis that had not improved on PO clindamycin, admitted for
IV antibiotics.
ACTIVE ISSUE:
# Cellulitis:
She presented with a large area of erythema extending across her
left anterior shin and ___ surface of left foot. The
area of erythema extended beyond previously marked lines. It was
warm to the touch and tender to palpation. She had one area of
fluctuance noted on her anterior shin which was aspirated and
found to be a hematoma; fluid culture of the aspirated fluid was
negative for growth. DVT was ruled out with ultrasound. She was
treated with vancomycin and her symptoms and erythema improved.
Given her multiple medication allergies and previous failure on
clindamycin, she was discharged on linezolid to complete
treatment of her cellulitis outpatient.
CHRONIC/INACTIVE ISSUES:
# Paroxysmal Afib: continued metoprolol and rivaroxaban. Rate
controlled.
# HTN: continued home losartan, metoprolol, and HCTZ
# Depression/sleep disorder: continued aderral, lamotrigine and
risperidone
TRANSITIONAL ISSUES:
- Code: Full (confirmed with patient)
- Emergency Contact:
HCP ___ (friend) ___.
Alternative: ___ (brother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Adderall XR (dextroamphetamine-amphetamine) 40 mg oral daily
2. Hydrochlorothiazide 25 mg PO DAILY
3. LaMOTrigine 300 mg PO HS
4. Losartan Potassium 50 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Rivaroxaban 20 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Multivitamins 1 TAB PO DAILY
9. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Linezolid ___ mg PO Q12H Duration: 10 Days
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. LaMOTrigine 300 mg PO HS
6. Losartan Potassium 50 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. Adderall XR (dextroamphetamine-amphetamine) 40 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure meeting you during your hospitalization at
___. You were admitted with cellulitis for IV antibiotics.
Your infection improved with IV vancomycin. You will be
discharged on linezolid to continue to treat the infection.
While taking this antibiotic, you will need to follow a low
tyramine diet. Please take your medication as prescribed and
follow up with your doctor.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10004322-DS-23 | 10,004,322 | 20,356,134 | DS | 23 | 2135-02-12 00:00:00 | 2135-02-13 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old male with history of
schizophrenia with most recent ED visit ___, COPD, DM,
mechanical falls most recently in ___ and s/p negative
syncope workup in ___, history of urinary retention s/p
indwelling foley in ___, admission in ___ for sepsis
from pneumonia, presenting with complaints of fever and altered
mental status.
___ presented to the ED from his group home after reportedly
being febrile yesterday. The group home care staff changed his
foley yesterday and noted that he his mental status was altered
this morning.
Seen in ___ on ___ by Dr. ___
for evaluation of need for chronic foley which was placed in
late ___ after ___ presented to the ED after a fall and
was found to be in ___ (prior to this, he had no problems
voiding) and have obstructive uropathy. Noted to have a
hypersensitive bladder with normal compliance, terminal detrusor
overactivity, no obstruction, and was able to empty bladder
completely despite over activity. The plan was to leave the
foley catheter out and monitor PVRs ___ times daily with foley
re-insertion if PVR>400-450cc and to continue tamsulosin.
In the ED, initial vital signs were: T99.1 HR112 BP91/58 RR16
SaO2 95% on RA
- Exam notable for: lethargy, arousable only to pain, oriented
x1
- Labs were notable for:
1) Chem 10 -
134|94|28
---------<159
4.2|20|1.5
2) CBC - 27.3>10.5/32.5<376
Diff - 85.6%, 4.5%, Monos 8.7%
3) LFTs - ALP 167 (ALT 5, AST 14, Tbili 0.5, Alb 3.8)
4) U/A - hazy appearance with large leuks (WBC>182), small
amount of blood (RBC>10), Few bacteria, Negative Nitrites, 30
Proteins
5) FluAPCR and FluBPCR - negative
6) Lactate - 1.6
7) Blood cx - pnd
8) Urine cx - pnd
- Studies performed include:
1) CT C-spine w/o contrast: No acute fracture or malalignment of
the cervical spine.
2) NCHCT: No acute intracranial process
3) CXR: No acute cardiopulmonary process. No focal consolidation
to suggest pneumonia.
- Patient was given:
1) IV NS
2) Ceftriaxone 2 gm
- Vitals on transfer:
___, 99.2F, HR111(106-113), BP135/67 (91-135/55-67), RR25
(___), SaO2 100% on RA
Upon arrival to the floor, the patient was somnolent but
arousable, oriented to name only. History could not be completed
as patient could not answer questions.
REVIEW OF SYSTEMS:
(+) per HPI
(-) chills, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Paranoid schizophrenia, well-controlled on Clozaril
- Previous auditory and visual hallucinations, none "for awhile"
per patient
2. Mechanical falls with negative syncope workup (___)
3. T2DM (last HbA1c 7.1 in ___
4. COPD (last FEV1 unknown)
5. GERD/Reflux Esophagitis
6. CAD
7. HTN
8. Hyperlipidemia
Social History:
___
Family History:
Unknown to patient
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.9, 109bpm, BP129/66, RR18, SaO2 96% on RA
GENERAL: A&Ox1 (name only), somnolent, responsive to voice and
gentle touch but quickly falls asleep, unable to answer
questions comprehensibly
HEENT: Normocephalic, atraumatic. Pupils equal (3mm), round,
and unreactive bilaterally. No conjunctival pallor or
injection, sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants though difficult to assess
given patient's altered sensorium. Tympanic to percussion. No
organomegaly. well-healed mid-line incision measuring ___ inches
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: could not complete due to lack of patient
cooperation
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.0PO, Tmax 98.1, 156/79 (149-156/79-87), 83 (71-85), 18,
SaO2 95% on RA
GENERAL: A&Ox2 (name and place), able to engage in conversation
and keep eyes open
HEENT: Normocephalic, atraumatic. Pupils equal (3mm), round,
and unreactive bilaterally. No conjunctival pallor or
injection, sclera anicteric and without injection. Moist mucous
membranes, good dentition. Oropharynx is clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, soft, non-tender/non-distended.
Tympanic to percussion. No organomegaly. well-healed mid-line
incision measuring ___ inches
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: could not complete due to lack of patient
cooperation
Pertinent Results:
ADMISSION LABS:
===============
___ 12:54PM PLT SMR-NORMAL PLT COUNT-376
___ 12:54PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 12:54PM NEUTS-85.6* LYMPHS-4.5* MONOS-8.7 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-23.37*# AbsLymp-1.23 AbsMono-2.36*
AbsEos-0.00* AbsBaso-0.05
___ 12:54PM WBC-27.3*# RBC-3.75* HGB-10.5* HCT-32.5*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.2 RDWSD-44.6
___ 12:54PM ALBUMIN-3.8
___ 12:54PM ALT(SGPT)-5 AST(SGOT)-14 ALK PHOS-167* TOT
BILI-0.5
___ 12:54PM estGFR-Using this
___ 12:54PM GLUCOSE-159* UREA N-28* CREAT-1.5* SODIUM-134
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-20* ANION GAP-24*
___ 01:19PM LACTATE-1.6
___ 01:53PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 03:00PM URINE MUCOUS-RARE
___ 03:00PM URINE HYALINE-4*
___ 03:00PM URINE RBC-10* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-<1
___ 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 03:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
oxycodn-NEG
___ 03:00PM URINE UHOLD-HOLD
___ 03:00PM URINE HOURS-RANDOM
___ 09:32PM PLT COUNT-334
___ 09:32PM WBC-19.8* RBC-3.39* HGB-9.4* HCT-29.7* MCV-88
MCH-27.7 MCHC-31.6* RDW-14.5 RDWSD-46.8*
___ 09:32PM GLUCOSE-123* UREA N-24* CREAT-1.2 SODIUM-139
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-21* ANION GAP-21*
DISCHARGE/PERTINENT LABS:
=========================
___ 07:05AM BLOOD WBC-8.9 RBC-3.32* Hgb-9.2* Hct-27.7*
MCV-83 MCH-27.7 MCHC-33.2 RDW-13.9 RDWSD-42.4 Plt ___
___ 07:05AM BLOOD Glucose-118* UreaN-6 Creat-0.6 Na-140
K-3.5 Cl-101 HCO3-24 AnGap-19
___ 07:00AM BLOOD ___ PTT-35.2 ___
___ 07:00AM BLOOD ALT-6 AST-14 LD(LDH)-176 AlkPhos-127
TotBili-0.4
___ 07:05AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7
MICROBIOLOGY:
==============
___ 3:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
Fosfomycin Susceptibility testing requested by ___. ___
___
(___) ON ___. FOSFOMYCIN = 24MM = SUSCEPTIBLE.
FOSFOMYCIN sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 8 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
========
___ Imaging ABDOMEN (SUPINE & ERECT)
Nonobstructive bowel gas pattern in the stomach, small bowel and
colon. No evidence of pneumoperitoneum.
___ Imaging CHEST (SINGLE VIEW)
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
___-SPINE W/O CONTRAST
No acute fracture or malalignment of the cervical spine.
___ Imaging CT HEAD W/O CONTRAST
No acute intracranial process.
Brief Hospital Course:
Mr. ___ is a ___ man with history of paranoid
schizophrenia, COPD, Type 2 DM, urinary retention s/p indwelling
foley catheter placement in ___, who presented from his
group home with report of 1 day of fever prior to admission and
altered mental status on the day of presentation to the ED
(___).
# Altered mental status/catheter associated urinary tract
infection:
Patient hemodynamically stable on admission, but drowsy and not
oriented. Afebrile, but WBC count of 27. Urinalysis consistent
with infection in the setting of indwelling foley catheter. Head
and neck imaging without acute abnormalities. He was without
headaches, photophobia, or neck stiffness to suggest
meningoencephalitis. Patient initially started on ceftriaxone;
however, urine culture revealed ESBL E. coli resistant to
ceftriaxone. Patient switched to meropenem, which he received
from ___ to ___. Patient was switched to fosfomycin (1 dose)
on discharge to complete a full antibiotic course. Foley
catheter was replaced.
# Acute kidney injury:
Patient also noted to have acute kidney injury with Cr 1.5,
likely prerenal in etiology, that resolved with IV fluids. Cr on
discharge 1.0.
# Paranoid schizophrenia:
Patient's clozapine was held on admission, given altered mental
status. He was seen by the psychiatry service for assistance
with management. Clozapine was resumed at the suggestion of
psychiatry at 100mg PO QHS, with plan for outpatient uptitration
by primary psychiatrist.
# Normocytic anemia:
He was found to have Hgb of 8.8-10.5 as compared to most recent
baseline of 11.8. He was without signs of overt bleeding. There
was low suspicion for hemolysis in the setting of normal TBili
and lack of schistocytes on manual smear.
# Abdominal pain:
He experienced transient abdominal pain with benign abdomen,
possibly related to urinary tract infection, though not
specifically suprapubic. KUB was without signs of obstruction or
perforation. Abdominal pain resolved prior to discharge.
# T2DM
He received long-acting insulin with sliding scale as needed.
Home metformin was held throughout admission and resumed at
discharge.
# COPD
Home fluticasone and tiotropium inhaler were held throughout
admission and resumed at discharge.
# GERD/Reflux esophagitis
He received omeprazole in place of home ranitidine in the
inpatient setting.
# CAD
Home ASA was continued.
# Hyperlipidemia
Home gemfibrozil was held throughout admission and resumed at
discharge.
# Orthostatic hypotension
Home fludrocortisone was continued.
TRANSITIONAL ISSUES:
====================
# Patient's clozapine was stopped on admission and restarted at
100mg PO QHS by recommendation from psychiatry. Patient should
follow up with outpatient psychiatrist for uptitration.
# Patient was found to have anemia with Hgb of 9.2. He should
have a follow-up CBC with differential within 1 week and should
be worked-up for iron-deficiency or other causes anemia if not
improved; downtrending monocyte count, likely elevated on
admission in the setting of infection, also should be ensured.
# Follow-up of coagulation studies to ensure downtrending INR
(elevated to 1.4 on this admission likely in the setting of
infection and poor PO intake, without overt signs of DIC) also
advised.
# Patient found to have 10 RBC on urinalysis on this admission,
likely in the setting of urinary tract infection; please assess
for resolution of hematuria following resolution of urinary
tract infection, though may be confounded if ongoing foley
catheter needed.
# Patient should follow up with urology for foley catheter care
and to assess whether ongoing foley catheter is needed.
Appointment was made for ___.
# CODE: Full
# CONTACT: ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Clozapine 200 mg PO BID
5. Clozapine 75 mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Gemfibrozil 600 mg PO BID
9. Levemir (insulin detemir) 32 units subcutaneous BREAKFAST
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Ranitidine 150 mg PO BID
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Clozapine 100 mg PO QHS
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gemfibrozil 600 mg PO BID
8. Levemir (insulin detemir) 32 units subcutaneous BREAKFAST
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Ranitidine 150 mg PO BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. HELD- Clozapine 200 mg PO BID This medication was held. Do
not restart Clozapine until until you see your psychiatrist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Toxic Metabolic Encephalopathy
Catheter-associated UTI
Acute Kidney Injury
SECONDARY DIAGNOSES:
====================
Paranoid Schizophrenia
Type 2 Diabetes
COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you were confused
and had a fever. You were found to have a urinary tract
infection and you were started on IV antibiotics and your mental
status improved significantly. Your Clozaril was also stopped
and restarted at a lower dose because of your confusion.
You should follow-up with your PCP and outpatient psychiatrist
within ___ weeks of discharge.
Wishing you a speedy recovery,
___ Care Team
Followup Instructions:
___
|
10004606-DS-21 | 10,004,606 | 23,517,634 | DS | 21 | 2159-03-22 00:00:00 | 2159-03-29 12:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with past medical
history notable for hypertension, prior small intestinal bleed
(sounds like distal upper AVM), recent hospitalization for
seizures in the setting of gallstone pancreatitis status post
cholecystectomy who was discharged on ___ who presents to
the hospital with several days of weakness. She reports that
initially following discharge she was feeling well. She reports
that after several days at home she started to feel increasingly
fatigued. She reports that she felt similar to when she was
bleeding in ___ and required the upper GI which found a
likely AVM. She reports the records from that hospitalization
or
at ___ in ___. She reports that at that
time
her bowel movements were normal. She reports that on the
evening
prior to admission she developed diarrhea with black stools.
She
reports that this is the exact same happened last time she had
the upper GI bleed. She reports that she continue to feel
further fatigue. She touch base with her primary care doctor
who
referred her into the emergency department for further
evaluation. She also reports that while at home she had a
decreased appetite. Per her daughter she started to look
increasingly pale. She became lightheaded and dizzy in the
shower on several occasions. She also reports that she had
urinary symptoms from around the time she got home. She reports
that over the last 6 days she has had increased lower abdominal
pain, burning on urination, pressure. She reports that she
feels
like it got so bad she decreased her p.o. intake to reduce the
amount that she would have to urinate. She also reports that
she
had some blood in the urine.
In the emergency department she was seen and evaluated. Her
initial vital signs were unremarkable. She was afebrile with a
heart rate of 81, blood pressure 157/94, respiratory rate of 18.
Her H&H was notable for 11.3/35.3 which is up from her discharge
hemoglobin and hematocrit of 8.7/26.8. She had a UA that was
checked which unfortunately contained 9 epithelial cells. It
did
have positive nitrates, large leukocyte esterase, greater than
184 white blood cells as well as few bacteria. She received 1 g
of IV ceftriaxone, 2 L of normal saline, and was admitted to the
medical service for further evaluation and management. She was
also evaluated by the surgery service while in the emergency
department he felt like if she had anything was likely a slow GI
bleed and would not require acute surgical intervention and
would
recommend admission to medicine for a GI workup.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Gallstone pancreatitis status post cholecystectomy ___
Seizures in the setting of the above gallstone pancreatitis
Hypertension due to renal artery stenosis, difficult to control
Prior history of upper GI bleed from a likely AVM
Prior history of DVT no longer on anticoagulation
Social History:
___
Family History:
___ and found to be not relevant to this
illness/reason for hospitalization. She specifically denies any
family history of seizures or strokes.
Physical Exam:
ADMISSION EXAM
--------------
VITALS: 98.4 PO 147 / 72 60 18 100 RA
GENERAL: Alert and in no apparent distress, laying in bed
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation over the
suprapubic region. Laparoscopic cholecystectomy incisions
healing well. Bowel sounds present. No HSM. No CVA tenderness
GU: No suprapubic fullness but significant tenderness to
palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
--------------
VS: Reviewed
GENERAL: Alert and in no apparent distress, laying in bed
EYES: Anicteric, pupils equally round
CV: Heart regular, no murmur.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation over the
suprapubic region. Laparoscopic cholecystectomy incisions
healing well. Bowel sounds present.
GU: No suprapubic fullness but significant tenderness to
palpation
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
--------------
___ 03:46PM BLOOD WBC-10.6*# RBC-3.78*# Hgb-11.5# Hct-35.3#
MCV-93 MCH-30.4 MCHC-32.6 RDW-14.0 RDWSD-47.6* Plt ___
___ 03:46PM BLOOD Neuts-71.9* Lymphs-17.5* Monos-6.9
Eos-2.6 Baso-0.7 Im ___ AbsNeut-7.65* AbsLymp-1.86
AbsMono-0.73 AbsEos-0.28 AbsBaso-0.07
___ 02:22PM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-145
K-4.8 Cl-104 HCO3-24 AnGap-17
___ 02:22PM BLOOD ALT-18 AST-17 AlkPhos-121* TotBili-0.5
MICROBIOLOGY
------------
___ 4:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
PREDOMINATING ORGANISM. INTERPRET RESULTS WITH
CAUTION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS
--------------
___ 08:10AM BLOOD WBC-5.6 RBC-2.92* Hgb-8.9* Hct-27.2*
MCV-93 MCH-30.5 MCHC-32.7 RDW-13.3 RDWSD-45.4 Plt ___
___ 08:10AM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-142
K-4.6 Cl-101 HCO3-30 AnGap-11
___ 07:10AM BLOOD ALT-16 AST-17 AlkPhos-91 TotBili-0.4
___ 07:45AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.7
___ 03:46PM BLOOD calTIBC-411 Ferritn-___-___
___ 02:35PM BLOOD Lactate-1.8
KUB:
IMPRESSION:
Normal bowel gas pattern.
Brief Hospital Course:
___ female with past medical history notable for
hypertension, prior small intestinal bleed (sounds like distal
upper AVM), recent hospitalization for seizures in the setting
of gallstone pancreatitis status post cholecystectomy who was
discharged on ___ who presents to the hospital with
several days of weakness.
# Possible upper GI bleed
# Gastritis: Patient reported several episodes of black stools,
but none during admission. Hemoglobin downtrended over the
course of admission. Awaiting records from ___
in ___. GI following patient, but did not plan on
EGD/colonoscopy. H. pylori antigen was sent. She was placed on
PO pantoprazole, as well as home famotidine and simethicone,
given complaints of indigestion, as well as antiemetics.
# Urinary tract infection: Patient reported approximately five
days of urinary tract symptoms with pain on urination, burning
on urination, and suprapubic fullness. Pan-sensitive E.coli on
urine specimen, placed on ceftriaxone and switched to
ciprofloxacin for 7-day course. She was also placed on three
day course of pyridium.
# Weakness: suspect related to UTI and possible slow GI bleed,
see above. ___ consulted. She progressed and was able to be
discharged home.
#Constipation
Patient noted to constipated likely ___ to opioids and decreased
mobility. KUB without obstruction. She received bowel regimen.
She had a bowel movement prior to discharge.
# HTN due to
# RAS: Patient has renal artery stenosis as documented on her
prior admission. She has difficult to control blood pressures.
She was stabilized on a regimen during her prior
hospitalization. Continued home antihypertensive regimen of
amlodipine, labetalol, lisinopril.
# Seizure Disorder: Patient had generalized tonic-clonic seizure
during her prior hospitalization in the setting of her gallstone
pancreatitis. She was seen by neurology during her prior
hospitalization and is now on antiseizure medication with
outpatient follow-up. She was continued on her home Keppra.
# GERD: continued on home famotidine and added PO pantoprazole.
I updated her son and daughter with the plan of care.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY hypertension
2. Atorvastatin 40 mg PO QPM
3. LevETIRAcetam 1500 mg PO Q12H
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Lisinopril 40 mg PO DAILY
6. Famotidine 20 mg PO BID
7. Aspirin 81 mg PO DAILY
8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
9. Labetalol 400 mg PO BID Hypertension
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Ondansetron 4 mg PO Q8H
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours
Disp #*6 Capsule Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*30 Packet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. amLODIPine 10 mg PO DAILY hypertension
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Famotidine 20 mg PO BID
11. Labetalol 400 mg PO BID Hypertension
12. LevETIRAcetam 1500 mg PO Q12H
13. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Gastritis/peptic ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your recent admission at
___. You came for further evaluation of weakness, pain when
urinating and black stools.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Please follow up with your PCP ___.
Please arrange to have you labs checked.
Good luck!
Followup Instructions:
___
|
10004606-DS-23 | 10,004,606 | 28,691,361 | DS | 23 | 2159-09-22 00:00:00 | 2159-09-22 19:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Presyncope, Fall
Major Surgical or Invasive Procedure:
EGD ___
Capsule endoscopy ___
Colonoscopy ___
History of Present Illness:
___ with history of CVA, seizures, upper GI AVM's with chronic
anemia, HTN, presents after presyncopal fall.
On ___ she was at home and went to linen closet to grab
something. Then felt presyncopal, dizzy, warm feeling, and fell
backwards, hitting her head first against a bedroom door which
gave way, and then against the floor. No LOC. Daughter came to
her aid. She did not want to go to the hospital. The next day
she went to ___. CT head and CT C-spine
negative for
acute bleed or fracture. Today she went to her GI appointment
and was referred to ___. Last ___ she reported a seizure
episode where her arms were shaking and she was in a daze. This
lasted for a few minutes. Consistent with prior seizures
episodes.
In the ___, initial VS were:
- 98.3 77 147/45 19 100% RA
- Exam: diffuse mild abd tenderness, scant brown stool in rectal
vault +guaiac,
- Labs: Hgb 7.4, Creatinine 1.1, Lactate 1.3, urine WBC 35, lg
leuk, hazy, few bac
- Imaging: CXR clear. CT A/P no acute process.
On interview she reports acute on chronic "soreness" in neck,
back, hips, for which she takes oxycodone at home. Otherwise no
acute complaints.
REVIEW OF SYSTEMS:
+tinnitus; all other positives per HPI
otherwise 10 point ROS reviewed and negative except as per HPI
Past Medical History:
- Hypertension
- Renal Artery Stenosis
- Seizures
- CVA
- Gallstone pancreatitis
- Iron deficiency anemia
- AVM's in stomach and duodenum
- Lumbar radiculopathy
- Chronic opioid use, with pain contract
- Hypothyroidism
- Hyperlipidemia
- COPD
- Neuropathic pain
- GERD
- DVT
Social History:
___
Family History:
Mother had dementia.
Father had asbestosis and mesothelioma.
Physical Exam:
ADMISSION PHYSICAL
==================
VS: 98.3 130 / 55 58 18 99 ra
GENERAL: NAD
HEENT: PERRL, EOMI, no nystagmus, tongue moist
NECK: +L carotid bruit
HEART: RRR, S1, S2, no murmurs
LUNGS: LCAB
ABDOMEN: s, lower abdominal tenderness
GU: suprapubic tenderness
EXTREMITIES: no edema
NEURO: A&Ox3, moving all 4 extremities with purpose, RLE
weakness
DISCHARGE PHYSICAL
==================
___ ___ Temp: 97.9 PO BP: 162/62 HR: 56 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: NAD, sitting in bed
NECK: +bilateral carotid bruits
HEART: RRR, S1, S2, no murmurs
PULM: CTABL
ABDOMEN: soft, mildly distended without tenderness, +BS
EXTREMITIES: warm, 1+ ___ pulses bilaterally, no edema
NEURO: A&Ox3, no facial asymmetry, moving all 4 extremities with
purpose
Pertinent Results:
ADMISSION LABS
==============
___ 05:50PM BLOOD WBC-5.5 RBC-2.49* Hgb-7.4* Hct-22.3*
MCV-90 MCH-29.7 MCHC-33.2 RDW-15.3 RDWSD-50.4* Plt ___
___ 05:50PM BLOOD Neuts-47.5 ___ Monos-8.9 Eos-7.5*
Baso-0.5 Im ___ AbsNeut-2.60 AbsLymp-1.94 AbsMono-0.49
AbsEos-0.41 AbsBaso-0.03
___ 05:50PM BLOOD ___ PTT-34.2 ___
___ 05:50PM BLOOD Glucose-101* UreaN-12 Creat-1.1 Na-138
K-4.2 Cl-99 HCO3-24 AnGap-15
___ 05:50PM BLOOD ALT-14 AST-13 AlkPhos-43 TotBili-0.3
___ 05:50PM BLOOD Lipase-22
___ 05:50PM BLOOD proBNP-78
___ 05:50PM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD Albumin-4.8 Calcium-9.6 Phos-3.7 Mg-1.8
PERTINENT INTERVAL LABS
=======================
___ 09:10AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8 Iron-16*
___ 09:10AM BLOOD calTIBC-382 VitB12-318 Folate-14
Ferritn-14 TRF-294
___ 06:48AM BLOOD TSH-3.6
___ 06:48AM BLOOD Free T4-0.9*
DISCHARGE LABS
==============
___ 05:35AM BLOOD WBC-5.0 RBC-3.62* Hgb-10.7* Hct-34.0
MCV-94 MCH-29.6 MCHC-31.5* RDW-15.5 RDWSD-53.1* Plt ___
___ 05:35AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-144
K-4.5 Cl-104 HCO3-24 AnGap-16
___ 05:35AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.0
MICROBIOLOGY
============
Urine Culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION
IMAGING AND STUDIES
===================
___ CXR
AP upright and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact.
No free air below the right hemidiaphragm is seen.
___ CT ABD/PEVLIS W CON
1. Colonic diverticulosis without evidence of diverticulitis.
No signs of
colitis or bowel obstruction. Normal appendix.
2. Status post cholecystectomy with stable mild prominence of
the intrahepatic
and extrahepatic biliary tree.
3. Extensive aortoiliac atherosclerotic calcification with
stents in the
bilateral external iliac arteries which appear patent.
4. Atrophic right kidney.
5. Trace free pelvic fluid, nonspecific.
___ ECHO (TTE)
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no left ventricular outflow obstruction at
rest or with Valsalva. There is no ventricular septal defect.
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 appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity size and global/regional
systolic function. No pathological valvular flow identified. No
structural cause for syncope identified.
___ CAROTID ULTRASOUND
Moderate-to-marked predominantly heterogeneous soft plaque
within the
bilateral carotid arteries most profound within the mid ICAs,
right greater
than left, resulting in hemodynamically significant stenosis
estimated to be 80-99% bilaterally.
___ EGD
Mucosa suggestive of ___ Esophagus
Erosion in pylorus
Angioectasias in stomach and second part of duodenum (Thermal
Therapy applied)
Capsule released in duodenum
___ COLONOSCOPY
Aborted due to high residue material
___ pMIBI
FINDINGS: There was soft tissue attenuation.
Left ventricular cavity size is within normal limits.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 71%.
IMPRESSION: 1. No evidence of myocardial perfusion defect. 2.
Normal left
ventricular cavity size with normal systolic function.
___ KUB
Endoscopy capsule in the proximal descending colon.
___ KUB
Endoscopy pill capsule has migrated since ___, now
possibly in the sigmoid colon.
Brief Hospital Course:
___ with history of CVA, seizures, upper GI AVM's with chronic
anemia, HTN, peripheral vasculopathy, who presented after
presyncopal fall.
ACUTE ISSUES
============
# Acute on Chronic Blood Loss Anemia
# Upper GI Bleed
Presented with ongoing intermittent melena and known gastric and
duodenal AVMs per prior EGD's s/p single balloon enteroscopy
with APC to small bowel AVMs. Stool guaiac positive in ___.
Required 2u pRBCs during her hospitalization. EGD showed several
duodenal/gastric AVMs that were cauterized, as well as likely
___ esophagus. Patient was iron deficient and was given 2
125mg IV infusions of ferric gluconate. Patient was continued
on PPI prophylaxis.
# Seizures
Patient reported that her last seizure 1 week prior to admission
and involved extremity shaking and AMS that lasted several
minutes, consistent with previous episodes. Neurology was
consulted for optimization of her AEDs. EEG was performed and
the patient was continued on Keppra with plans for outpatient
followup in neurology clinic. She had no seizures in house.
# Severe, Bilateral Carotid Artery Stenosis
Carotid US done as part of pre-syncope work-up revealed severe
bilateral carotid artery stenosis (80-99%). She was seen by
vascular surgery in house, who recommended no urgent treatment.
This could certainly contribute to pre-syncope, however vascular
surgery will followup with patient for CEA consideration.
# Presyncope
Presented 4 days after presyncopal episode at home with fall and
head trauma. CT head and c-spine were negative at OSH. Signs and
symptoms not consistent with prior seizures. Initial ddx
included CNS process (TIA, carotid stenosis), cardiac (had old
RBBB on EKG, and new LBBB on this admission), orthostasis (had
previously documented orthostatic hypotension), vasovagal event,
peripheral vertigo (has tinnitus), or symptomatic anemia.
# Concern for Cardiac Conduction Disease
Noted patient has HRs usually in ___, even when standing and
lightheaded. There was concern that she was not adequately
augmenting her cardiac output with exertion due to conduction
disease and this blunted response was contributing to her
pre-syncope. Also noted to initially have RBBB on EKG, but then
LBBB on EKG done later in the same day (in ___ on presentation).
Unusual and concerning for conduction disease, so cardiology was
consulted and beta-blocker (home med) was held. pMIBI revealed
no overt ischemia and ambulatory telemetry revealed that
patients heart rates increased to ___. Cardiology felt that this
was an appropriate response and the patient did not require
further electrophysiologic evaluation during this
hospitalization.
# Hypertension
Patient has history of hypertension (renal artery stenosis) with
orthostatic hypotension. Antihypertensives were held in the
setting of GI bleed but were restarted once her GI bleed was
addressed. She was continued on home doses of blood pressure
medications and was also started on chlorthalidone 12.5mg daily
for better control.
# Chronic Back and Neck Pain
Has narcotics contract w PCP for oxycodone 5mg BID since
___. Review of MassPMP indicates pt also prescribed
vicodin in OSH ___ three days prior to presentation. Likely that
pain is exacerbated by recent fall, so increased pain regimen
while in-house.
CHRONIC ISSUES
==============
# Neuropathic pain: continued gabapentin 300mg TID.
# GERD: continued PPI and famotidine.
# Chronic nausea: continued ondansetron PRN.
TRANSITIONAL ISSUES
===================
[]Ensure passage of capsule, on discharge KUB ___ noted to be
in sigmoid colon/rectum. Consider repeat KUB to assess if
concerned. Per GI, very unlikely to cause obstruction once in
colon.
[]Labetalol/Beta-Blockade: Recommend avoiding all beta-blockade
given heart rates in the ___. Patient's labetalol was
discontinued to avoid negative chronotrope effect
[]Chlorthalidone: titrate dose as needed for adequate blood
pressure control
[]ASA 81: discharged on ASA 81 given stroke risk in the setting
of severe carotid disease, if GI bleed recurs, risk/benefit
should be discussed with patient (okay to hold per inpatient
cardiology recommendations but neurology would recommend
continuing)
[]Atorvastatin: increased to 80mg (although less data in
secondary prevention) due to severe vascular disease
___ esophagus: Noted on EGD. Will have follow up
endoscopy with plan for biopsy in ___
[]Labs: Repeat CBC at clinic visit to ensure stability,
discharge Hgb 9.9
[]Vascular Followup: Has appointment with Dr. ___ ___ for
CEA evaluation
[]Neurology Followup: Has appointment for further management of
anti-seizure medications
# Contact/HCP: ___ (daughter) ___
# Code status: Full, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY hypertension
2. Atorvastatin 40 mg PO QPM
3. LevETIRAcetam 1500 mg PO Q12H
4. Lisinopril 40 mg PO DAILY
5. Simethicone 40-80 mg PO QID:PRN abd pain
6. Famotidine 20 mg PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Pantoprazole 40 mg PO Q12H
9. Aspirin 81 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Ascorbic Acid ___ mg PO BID
12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH
PAIN
13. Labetalol 200 mg PO BID
14. Gabapentin 300 mg PO TID
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY hypertension
2. Atorvastatin 40 mg PO QPM
3. LevETIRAcetam 1500 mg PO Q12H
4. Lisinopril 40 mg PO DAILY
5. Simethicone 40-80 mg PO QID:PRN abd pain
6. Famotidine 20 mg PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Pantoprazole 40 mg PO Q12H
9. Aspirin 81 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Ascorbic Acid ___ mg PO BID
12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH
PAIN
13. Labetalol 200 mg PO BID
14. Gabapentin 300 mg PO TID
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Chlorthalidone 12.5 mg PO DAILY
RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 [PEG___] 17 gram/dose 17 g by
mouth daily Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
7. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at nightime Disp
#*30 Tablet Refills:*0
8. amLODIPine 10 mg PO DAILY hypertension
9. Ascorbic Acid ___ mg PO BID
10. Aspirin 81 mg PO DAILY
11. Famotidine 20 mg PO BID
12. Ferrous Sulfate 325 mg PO BID
13. Gabapentin 300 mg PO TID
14. LevETIRAcetam 1500 mg PO Q12H
15. Lisinopril 40 mg PO DAILY
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH
PAIN
18. Pantoprazole 40 mg PO Q12H
19. Simethicone 40-80 mg PO QID:PRN abd pain
20.Rolling Walker
Please provide rolling walker.
Dx: Seizure Disorder (ICD-9: 780.39)
Prognosis: Good
___: 13 Months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Acute on chronic upper GI bleed
Severe, bilateral coronary artery stenosis
Seizure disorder
Orthostatic hypotension
Secondary Diagnoses
===================
Bipolar Disorder
Hepatitis B
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you in the hospital.
WHY DID YOU COME TO THE HOSPITAL?
-You felt lightheaded and suffered a fall
WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY?
-You were given blood to increase your blood counts
-Your bloody bowel movements were evaluated and treated by the
gastroenterologists
-You were evaluated for seizures by the neurologists and was
started on a medication to prevent seizures
-You were found to have severe blockages in both arteries
supplying blood to brain and need to follow-up with the vascular
surgeons in vascular surgery clinic to discuss surgical
correction of these blockages
-Your heart was evaluated by the cardiologists who do not
recommend any further testing at this time
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
please take all of your medications as prescribed, details
below
Please keep all of your appointments as scheduled
-Please keep track of whether you have passed the capsule in
your bowel movement. If you have not passed the capsule in 2
days since discharge, you should be seen in clinic by your PCP.
Please call your PCP right away if you have any symptoms such as
constipation, vomiting, anorexia, and if you are not passing any
gas.
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10004648-DS-13 | 10,004,648 | 26,599,786 | DS | 13 | 2135-12-08 00:00:00 | 2135-12-08 15:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
presumed ectopic pregnancy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G1 with LMP ___ with presumed ectopic (never seen on
ultrasound) presents to ED with severe abdominal pain after
treatment with MTX on ___.
She was having some mild abdominal pain responsive to Tylenol
but this morning her pain became ___ and unresponsive to
Tylenol. She describes the pain as located across her low
abdomen, left > right. It was "unbearable" and she had trouble
walking although wasn't lightheaded, just overwhelmed with pain.
In the ambulance ride, she received 50mcg fentanyl and 4mg
zofran IV. Her pain is
now ___. She also notes vaginal bleeding, ~3 pads per day. No
clots.
___
TVUS (prelim): Focal thickening of the endometrium, portion with
vascular flow -> consistent with ongoing SAB. Cystic structure
in left ovary most likely corpus luteum.
Past Medical History:
PGynHx: Notes severe dysmenorrhea, normally takes Aleve.
Previously on OCPs.
PMHx: denies
PSHx: denies
Social History:
___
Family History:
NC
Physical Exam:
VS on arrival: 97.4 58 106/55 100% RA
General: NAD
Cardiac: RRR
Pulm: CTA
Abdomen: Soft, no focal tenderness with NO rebound or guarding.
+BS
Bimanual: Mildly enlarged AV uterus without tenderness or CMT.
Some left adnexal fullness without discrete tenderness (pt notes
diffuse "tenderness")
Ext: NT, NE
Labs:
HCG 1845
CBC 7.8>41.7<221
Blood type O+
Pertinent Results:
___ 11:57AM BLOOD WBC-7.8# RBC-4.77 Hgb-13.3 Hct-41.7
MCV-88 MCH-27.9 MCHC-31.9 RDW-14.0 Plt ___
___ 11:57AM BLOOD ___ PTT-28.0 ___
___ 11:57AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-136
K-4.4 Cl-105 HCO3-25 AnGap-10
___ 11:57AM BLOOD Mg-2.0
___ 11:57AM BLOOD HCG-1845
Brief Hospital Course:
Ms. ___ is a ___ year old G1 with LMP at end of ___ and a
presumed ectopic who presents with severe abdominal pain after
methotrexate administration. On arrival in the ED, she was
hemodynamically stable with a hematocrit of 41 and benign
abdominal exam. Ultrasound showed a small amount of material in
the lower uterine segment, no adenxal masses or free fluid. She
was admitted for observation in the absence of any signs of
ruptured ectopic. She did well overnight, only requiring
tylenol for analgesia. She remained hemodynamically stable
without change in abdominal exam. She was discharged to home on
HD 2 in good condition.
Medications on Admission:
none
Discharge Medications:
1. Percocet 7.5-325 mg Tablet Sig: ___ Tablets PO every ___
hours.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRESUMED ECTOPIC PREGNANCY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with abdominal pain in the setting of
suspected ectopic pregnancy. This was thought to be due to
either ongoing miscarriage or aborting tubal ectopic. There was
no evidence of a ruptured ectopic pregnancy.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Followup Instructions:
___
|
10004719-DS-15 | 10,004,719 | 21,197,153 | DS | 15 | 2183-09-03 00:00:00 | 2183-09-03 18:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Right leg/foot pain
Major Surgical or Invasive Procedure:
___ Right lower extremity angiogram, angioJet mechanical
thrombectomy of occluded bypass graft, balloon angioplasty of
outflow stenosis.
___ Right lower extremity angiogram, angioJet mechanical
thrombectomy of occluded bypass graft, balloon angioplasty of
outflow stenosis.
History of Present Illness:
___ w Rt AK pop to ___ bypass with NRGSV for a thrombosed
popliteal aneurysm in ___ present with worsening new onset
right foot claudication.
Past Medical History:
PMH: DVT R pop v (___), asthma, Rt pop artery thrombus with
negative hypercoagulable workup
PSH: Rt AK pop to ___ bypass with NRGSV ___
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP 104/54 HR 72 RR 16
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: palp throughout.
Feet warm, well perfused. No open areas
Left groin puncture site: Dressing clean dry and intact. Soft,
no hematoma or ecchymosis.
Pertinent Results:
___ 05:45AM BLOOD WBC-9.0 RBC-3.91 Hgb-11.5 Hct-34.2 MCV-88
MCH-29.4 MCHC-33.6 RDW-12.9 RDWSD-40.8 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-141
K-3.7 Cl-107 HCO3-26 AnGap-12
___ 05:45AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0
Arterial Duplex:
Findings. Doppler evaluation was performed of both lower
extremity arterial
systems at rest.
On the right the tibial waveforms are monophasic and there is no
audible
Waveforms are flat.
The left all waveforms are triphasic. The ankle-brachial index
is 1.3.
Impression severe ischemia right lower extremity
Brief Hospital Course:
___ sp Rt AK pop to ___ bypass with NRGSV ___ for arterial
thrombosis presents with worsening right leg pain that occurred
over predictable distances and acute change over past 24 hours
with fullness in her right leg. Her motor and
sensation are intact with no signs of limb threat. A heparin
infusion was started.
Arterial duplex showed occluded right popliteal to posterior
tibial artery bypass. She was taken to the OR for right lower
extremity angiogram, angioJet mechanical
thrombectomy of occluded bypass graft, balloon angioplasty of
outflow stenosis. A tpa catheter was left in place overnight.
She return the next day for right lower extremity angiogram,
angioJet mechanical thrombectomy of occluded bypass graft and
balloon angioplasty of outflow stenosis. At that session, we
were able to remove residual thrombus in the native right
popliteal artery and bypass with good outflow to the foot via
the anterior tibial, and peroneal arteries. At this point she
was pain free with a palpable graft AT and DP pulse.
The next morning, we discontinued the heparin infusion and
started xarelto. She was ambulatory ad lib, voiding qs and
tolerating a regular diet. She was discharged to home. We will
see her again in followup in one month with surveillance duplex.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
2. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN
3. metroNIDAZOLE 0.75 topical BID
4. ALPRAZolam 0.5 mg PO TID:PRN anxiety
5. Lovastatin 10 mg ORAL DAILY
6. Montelukast 10 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY
8. Pantoprazole 40 mg PO Q24H
9. Aspirin 81 mg PO DAILY
10. Loratadine 10 mg PO BID
Discharge Medications:
1. Rivaroxaban 15 mg PO/NG BID
FOR THE NEXT 3 WEEKS ONLY.
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily
Disp #*42 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
For the next ___ days.
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. metroNIDAZOLE 0.75 topical BID
4. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN
5. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
6. ALPRAZolam 0.5 mg PO TID:PRN anxiety
7. Aspirin 81 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY
9. Loratadine 10 mg PO BID
10. Montelukast 10 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Rivaroxaban 20 mg PO DAILY
Start ___ after loading dose of 15 mg twice daily.
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
13. Lovastatin 10 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Arterial Disease
Right Posterior Tibial Deep Vein Thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital with right
leg pain that we found was secondary to a blockage in your
bypass graft. We also noted a clot in a vein in your calf. We
did a peripheral angiogram to open up the graft with special
catheter and balloons. To do the procedure, a small puncture
was made in one of your arteries. The puncture site heals on
its own: there are no stitches to remove. You tolerated the
procedure well and are now ready to be discharged from the
hospital. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
Peripheral Angiography
Puncture Site Care
For one week:
Do not take a tub bath, go swimming or use a Jacuzzi or hot
tub.
Use only mild soap and water to gently clean the area around
the puncture site.
Gently pat the puncture site dry after showering.
Do not use powders, lotions, or ointments in the area of the
puncture site.
You may remove the bandage and shower the day after the
procedure. You may leave the bandage off.
You may have a small bruise around the puncture site. This is
normal and will go away one-two weeks.
Activity
For the first 48 hours:
Do not drive for 48 hours after the procedure
For the first week:
Do not lift, push , pull or carry anything heavier than 10
pounds
Do not do any exercises or activity that causes you to hold
your breath or bear down with abdominal muscles. Take care not
to put strain on your abdominal muscles when coughing, sneezing,
or moving your bowels.
After one week:
You may go back to all your regular activities, including
sexual activity. We suggest you begin your exercise program at
half of your usual routine for the first few days. You may
then gradually work back to your full routine.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
Followup Instructions:
___
|
10004749-DS-21 | 10,004,749 | 27,481,198 | DS | 21 | 2129-03-22 00:00:00 | 2129-03-27 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old female with a history of GERD and
prior C.diff infecion ___ years ago who presents with right lower
quadrant abdominal pain.
.
She reports that the pain started when she awoke this morning.
It is localized to the mid abdomen with radiation to the RLQ.
She had some associated nausea without vomiting. The abdominal
pain very similar to the pain with her previous C.diff colitis.
She presented to her ___ clinic, where there was concern for
appendicitis. She was also given Acetaminophen 975 mg PO.
.
After arriving in the ED, she began to have diarrhea, about ___
episodes. The pain was briefly relieved with defecation. She was
incontinent of stool at times. There was no bright red blood per
rectum or melena. She has felt slightly feverish, but did not
check her temperature. Her appetite has been poor today. She
denies any vaginal bleeding or discharge.
.
Prior to this morning, she was feeling at her baseline without
any symptoms. She denies any recent antibiotics. Last week, she
was on a cruise to ___. She did not have any diarrhea or GI
symptoms on the trip. She did not drink any unbottled water or
local food.
.
Initial vitals in ED triage were T 99.7, HR 110, BP 145/84, RR
16, and SpO2 98% on RA. Exam was notable to RLQ tenderness.
Pelvic exam showed no CMT or adnexal tenderness. Her CBC was
notable for WBC 17.6 with N 86.4%. Her chemistry panel showed Cr
0.7, K 3.4, bicarb 21, and anion gap 14. LFTs were unremarkable
except for Lipase 61. UCG was negative and UA appeared
contaminated with WBC 6 and few bacteria, but Epi 18. CT
abd/pelvis showed several loops of small bowel in the right
lower quadrant and pelvis with wall edema, minimal surrounding
fat stranding, and trace free fluid. The appendix was minimally
hyperemic but only 5-6 mm in diameter, and unlikely to represent
acute appendicitis.
.
She was given NS ___ ml IV. Stool samples were sent for C.diff
and bacterial culture. Antibiotics were held pending culture
results. She received Morphine x3 and Dilaudid 0.5 mg IV x2. She
continued to have abdominal pain and was admitted to medicine
for pain control and further workup of her enteritis.
.
Vitals prior to floor transfer were T 99.2, HR 89, BP 119/74, RR
14, and SPO2 99% on RA. On reaching the floor, she reported
continued abdominal pain in the periumbilical area with
radiation to the RLQ. She reported baseline loose stool, but
that the current diarrhea is abnormal for her.
.
REVIEW OF SYSTEMS:
(+) Per HPI. Mild sore throat and hoarse voice, which she thinks
is from not drinking anything in the ED. Some slight chills and
mild fatigue. Recent sunburn while on cruise.
(-) No fevers. No weight loss. No headache, rhinorrhea, or nasal
congestion. No vertigo, presyncope, syncope, vision changes,
hearing changes, focal weakness, or paresthesias. No chest pain,
pressure, palpitations, SOB, cough, or hemoptysis. No dysphagia
or odynophagia. No melena or BRBPR. No hematuria, dysuria,
frequency, urgency, incontinence, or discharge. No back, neck,
joint, or muscle pain. No rashes or concerning skin lesions. No
easy bleeding or bruising. No depression or anxiety. Review of
systems was otherwise negative.
Past Medical History:
# Asthma -- mild intermittent, rare Albuterol use
# Chronic Sinusitis -- improved after ENT surgery ___ years ago
# GERD -- high dose Omeprazole
# C.diff Colitis (___)
# Migraines -- few per year
# Overweight
Social History:
___
Family History:
No famil history of inflammatory bowel disease or GI malignancy.
# Mother: Healthy
# Father: Died at age ___ from asthma exacerbation
# Siblings: Brother who is well
Physical Exam:
ADMISSION:
VS: T 98.7, BP 132/81, HR 98, RR 16, SpO2 97% on RA,
Wt 153 lbs, Ht 62 in
Gen: Young female in NAD. Oriented x3. Pleasant, bright affect.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: JVP not elevated. No concerning cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Active bowel sounds. Soft, ND. No organomegaly or masses.
Tender to palpation in RLQ and periumbilical area. Some rebound
tenderness, minimal voluntary guarding.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: No rashes or lesions noted in area of discomfort.
Neuro: CN II-XII grossly intact. Moving all four limbs. Normal
speech.
DISCHARGE:
VS: 97.9 115/60 88 18 99%RA
Gen: Young female in NAD. Oriented x3. Pleasant, bright affect.
HEENT: Sclera anicteric. MM moist, OP benign.
Neck: JVP not elevated. No concerning cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes, or rhonchi.
Abd: Active bowel sounds. Soft, ND. No organomegaly or masses.
Tender to palpation in RLQ and periumbilical area but improved
from yesterday. no rebound or guarding. psoas, obturatory, and
___ signs negative
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, ___ 2+.
Skin: No rashes or lesions noted in area of discomfort.
Neuro: CN II-XII grossly intact. Moving all four limbs. Normal
speech.
Pertinent Results:
ADMISSION;
___ 06:10PM BLOOD WBC-17.6*# RBC-4.55# Hgb-14.0 Hct-42.2
MCV-93 MCH-30.9 MCHC-33.3 RDW-12.7 Plt ___
___ 06:10PM BLOOD Neuts-86.4* Lymphs-8.4* Monos-4.2 Eos-0.5
Baso-0.5
___ 06:10PM BLOOD Plt ___
___ 08:10AM BLOOD ___ PTT-27.2 ___
___ 06:10PM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-139
K-3.4 Cl-104 HCO3-21* AnGap-17
___ 06:10PM BLOOD ALT-19 AST-21 AlkPhos-60 TotBili-0.4
___ 06:10PM BLOOD Albumin-4.6 Calcium-9.5 Phos-2.9 Mg-1.9
OTHER PERTINENT:
___ 08:10AM BLOOD WBC-7.3# RBC-4.04* Hgb-12.4 Hct-38.1
MCV-94 MCH-30.8 MCHC-32.6 RDW-13.0 Plt ___
___ 08:10AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-141
K-4.1 Cl-111* HCO3-20* AnGap-14
___ 08:10AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.8
___ 05:04PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:04PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 05:04PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE
Epi-18
MICRO:
___ 5:04 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O YERSINIA (Final ___: NO
YERSINIA FOUND.
DISCHARGE:
___ 07:59AM BLOOD WBC-8.7 RBC-3.89* Hgb-12.1 Hct-36.4
MCV-94 MCH-31.1 MCHC-33.3 RDW-12.9 Plt ___
___ 07:59AM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-138
K-4.2 Cl-108 HCO3-22 AnGap-12
___ 07:59AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
IMAGING:
___ CT ABD/PELVIS:
IMPRESSION:
1. Enteritis involving several loops of small bowel located in
the right
lower quadrant of the abdomen and within the pelvis.
Differential diagnosis
includes infectious, inflammatory, and ischemic etiology.
2. The appendix is 5-6 mm in diameter, and given the diffuse
inflammatory
findings, appendicitis is not likely the cause of the patient's
symptoms.
___ CXR:
FINDINGS: The lung volumes are normal. No pleural effusions.
No parenchymal
abnormalities. Normal size of the cardiac silhouette.
Brief Hospital Course:
The patient is a ___ year old female with a history of GERD and
prior C.diff infecion ___ years ago who presents with right lower
quadrant abdominal pain and watery diarrhea.
ACTIVE ISSUES:
# Enteritis/Abdominal Pain: Most likely represents a viral
enteritis given her associated URI symptoms of voice hoarseness
and sinus congestion, though her recent cruise to ___ raises
traveler's diarrhea as also possible but unlikely due to late
presentation. Appendicitis was considered very unlikely based on
imaging and prominence of diarrhea. Fortunately C-diff PCR is
negative. Campylobacter and otther stool studies also negative.
IBD very unlikely given the acute presentation and lack of alarm
or systemic symptoms. She receivedI IV fluids, bismuth, and an
empiric 3-day course of po ciprofloxacin. Her pain was managed
with tylenol, opioids, and dicyclomine for cramping. She was
tolerating a light diet prior to time of discharge.
# Leukocytosis: Resolved after IV fluids overnight after
admission. She had elevated WBC 17.6 with N 86.4% on admission.
Most likely this is multifactorial from enteritis along with
hypovolemia and hemoconcentration. Resolved with fluids alone
without any initial empiric antibiotic coverage.
CHRONIC ISSUES:
# GERD: She takes Omeprazole 40 mg PO BID for GERD symptoms.
Given her Cdiff history, tapering her PPI as an outpatient would
be reasonable to consider. Continued Omeprazole 40 mg PO BID for
now
# Anxiety: Continued home fluoxetine.
TRANSITIONAL ISSUES:
- consider tapering omeprazole as outpatient if able given
history of c-diiff
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN SOB
3. Fluoxetine 20 mg PO DAILY
4. Lorazepam 0.5-1 mg PO BID:PRN anxiety
5. acetaminophn-isometh-dichloral *NF* 325-65-100 mg Oral
Q1H:PRN migraine
up to maximum of 5 tabs in 12 hours
6. Microgestin Fe ___ (28) *NF*
(norethindrone-e.estradiol-iron) 1.5-30 mg-mcg Oral DAILY
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Microgestin Fe ___ (28) *NF*
(norethindrone-e.estradiol-iron) 1.5-30 mg-mcg Oral DAILY
3. Omeprazole 40 mg PO BID
4. Acetaminophen 1000 mg PO Q8H
5. DiCYCLOmine 20 mg PO QID
RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp
#*10 Tablet Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not take if drowsy or driving. Take only if pain persists
despite taking acetaminophen.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN SOB
8. Lorazepam 0.5-1 mg PO BID:PRN anxiety
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*10 Tablet Refills:*0
10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses
take through end of ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with diarrhea and
abdominal pain. We treated you with antibiotics, fluids and
pain medications, and your symptoms improved. You were able to
eat and drink by the time of discharge.
You will need to continue treatment with antibiotics for a
further 1 day. We also gave you medications to contorl pain and
cramping. Please followup with your primary care practitioner.
Followup Instructions:
___
|
10005024-DS-4 | 10,005,024 | 25,023,471 | DS | 4 | 2138-04-19 00:00:00 | 2138-04-19 13:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
-Flexible sigmoidoscopy ___
-Colonic stent placement ___
History of Present Illness:
Mr. ___ is a ___ with history of HCV, etOH use, and
hypertension who presents upon transfer from ___
with abdominal pain and found to have likely metastatic colon
cancer on CT imaging. The patient reports that he has had dark,
liquid bowel movements for the past several weeks. He also
reports crampy lower abdominal pain for the past several days
which has been worsening. His symptoms have been associated with
weight loss; the patient reports 40-lbs over just a few weeks.
Lately, the patient has also noticed some lightheadedness with
rising with unsteadiness while walking. At ___,
the patient was noted to have a hematocrit of 34% and sodium of
118. A CT abdomen showed a rectosigmoid mass with likely
metastases to the liver and lungs. Given concern for a RLL
infiltrate, he was given antibiotics for a community-acquired
pneumonia. Upon transfer to ___ ED, he was found to have a
further reduced hematocrit after IV fluids.
Past Medical History:
Hypertension
Alcohol dependence
Hepatitis C infection
Social History:
___
Family History:
Mother without significant illnesses. Father with heart
condition.
Physical Exam:
ADMISSION:
Vitals: 97.4 134/95 104 22 71.2kg
General: Disheveled appearing, drowsy. No acute distress.
HEENT: Sclera anicteric. Pale conjunctiva. Pupils equal and
reactive to light. Poor dentition. Oropharynx clear. Dry mucous
membranes.
NECK: Supple.
Heart: Tachycardic. Regular rate and rhythm. Normal S1, S2. No
murmurs.
Lungs: Decreased breath sounds at the bases bilaterally. No
wheezes, crackles, or rhonchi.
Abdomen: +BS, soft, nondistended. Tender to palpation diffusely.
+Hepatomegaly.
Genitourinary: No foley.
Extremities: Warm and well perfused. Pulses 2+. No peripheral
edema.
DISCHARGE:
Vitals: none
GENERAL: Pale appearing not moving. Not arousable to sternal rub
HEENT: No pupilary or corneal reflex. Pale conjunctiva
CARDIAC: no heart sounds
PULMONARY: No breath sounds
EXTREMITIES: Cool, no pulses.
NEURO: no corneal, pupilary, gag reflexes. No withdrawal to
painful stimulus.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:30AM BLOOD WBC-8.0 RBC-3.83* Hgb-10.8* Hct-31.0*
MCV-81* MCH-28.1 MCHC-34.7 RDW-15.3 Plt ___
___ 06:19AM BLOOD ___ PTT-30.5 ___
___ 01:30AM BLOOD Glucose-93 UreaN-7 Creat-0.4* Na-123*
K-3.5 Cl-90* HCO3-19* AnGap-18
___ 01:30AM BLOOD ALT-30 AST-64* AlkPhos-364* TotBili-0.7
___ 01:30AM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.6*
Mg-1.9
IMAGING:
========
CT ABD PLV w/oral Contrast (___)
IMPRESSION:
1. Interval (since ___ placement of a colonic stent,
2. Circumscribed 10.4 x 7.4mm anterior pelvic fluid collection
containing small locules of gas, likely an abscess from sigmoid
tumor perforation. This is amenable to drainage.
2a. Moderate/large amount of free air, and small amount of free
fluid within the peritoneum.
3. Extensive lymphadenopathy in the retroperitoneum and porta
hepatis, which results in narrowing of the origin of the left
renal vein. Encasement of the splenic vein-SMV confluence and
bilateral renal arteries is also demonstrated, without
significant intraluminal narrowing in these vessels. Normally
enhancing kidneys on today's study.
4. Innumerable hepatic metastases.
5. Innumerable pulmonary metastases, lungs only partially
imaged.
6. Moderately-sized bilateral non-hemorrhagic pleural effusions.
___ Flexible sigmoidoscopy
A circumferential mass was encountered at the rectosigmoid
junction around 15 cm from the anal verge highly suspcious for
primary colorectal cancer. The colonoscope was unable to
traverse the stricture which was estimated at around 9mm in
diameter.The mass was very friable. (biopsy)
Otherwise normal sigmoidoscopy to distal sigmoid colon.
Sigmoidoscopy ___:
Contents: Solid green stool was found in the rectum. No fresh or
old blood was noted. A metal stent was found in the rectum.
There is mild tumor ingrowth into the mid-portion of the stent.
This area is friable with some bleeding from passage of the
endoscope - likely source of bleeding.
Impression: Stent in the rectum
Stool in the rectum
Otherwise normal sigmoidoscopy to splenic flexure
Recommendations: Stool softners and laxatives as d/w inpatient
team.
Oral iron
CXR ___:
IMPRESSION:
There is no clear radiographic change over the past 11 days.
Bilateral
pleural effusions moderate on the right small on the left and
callus pulmonary nodules are unchanged. Extent of central
adenopathy is better revealed by the chest CT scan.
Confluent opacification at the base of the right lung is
probably atelectasis, pleural mild pneumonia is difficult to
exclude. In all other locations there no findings that would
raise the possibility of pneumonia.
___ ___:
FINDINGS:
There is normal compressibility, flow and augmentation of the
bilateral common femoral, proximal, mid, distal femoral, and
popliteal veins. Normal color flow and compressibility are
demonstrated in the posterior tibial and peroneal veins. There
is normal respiratory variation in the common femoral veins
bilaterally. No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilaterallower
extremity veins.
EKG ___:
Narrow complex tachycardia. Probably sinus tachycardia. Compared
to the
previous tracing of ___ the rate has increased.
CXR ___:
FINDINGS:
Numerous nodular opacities compatible the patient's metastatic
disease are again appreciated. In addition, there is worsening
pulmonary edema as well as a worsening right lower lobe
infiltrate which could represent pneumonia in the correct
clinical setting. A right pleural effusion is also increased in
size.
IMPRESSION:
Worsening combination of pleural effusion, pulmonary edema and
possibly
pneumonia particularly in the right lower lobe.
CTA CHEST W/ CONTRAST ___:
IMPRESSION:
1. Partially limited evaluation of the subsegmental pulmonary
arteries,
however no evidence of central, lobar, or segmental pulmonary
embolism.
2. Since ___, increase in size and number of
innumerable pulmonary metastases, as well as enlargement of
bilateral pleural effusions, large on the right and moderate on
the left.
3. Partially imaged upper abdomen demonstrates diffuse
intrahepatic metastasis and considerable upper abdominal
lymphadenopathy.
KUB ___:
IMPRESSION:
1. Rectal stent overlying the sacrum.
2. No bowel obstruction.
3. Likely interval decrease of small right pleural effusion.
CT ABDOMEN PELVIS W/ CONTRAST ___:
IMPRESSION:
1. Interval (since ___ placement of a colonic stent,
2. Circumscribed 10.4 x 7.4mm anterior pelvic fluid collection
containing small locules of gas, likely an abscess from sigmoid
tumor perforation. This is amenable to drainage.
2a. Moderate/large amount of free air, and small amount of free
fluid within the peritoneum.
3. Extensive lymphadenopathy in the retroperitoneum and porta
hepatis, which results in narrowing of the origin of the left
renal vein. Encasement of the splenic vein-SMV confluence and
bilateral renal arteries is also demonstrated, without
significant intraluminal narrowing in these vessels. Normally
enhancing kidneys on today's study.
4. Innumerable hepatic metastases.
5. Innumerable pulmonary metastases, lungs only partially
imaged.
6. Moderately-sized bilateral non-hemorrhagic pleural effusions
PATHOLOGY:
==========
___ GI mucosa
PATHOLOGIC DIAGNOSIS:
Sigmoid mass biopsy: Adenocarcinoma, low grade
Brief Hospital Course:
Mr. ___ was a ___ with history of HCV and EtOH abuse who
presented with abdominal pain and melena with imaging concerning
for metastatic colon cancer.
ACUTE ISSUES:
=============
# Metastatic colon cancer: Patient presented with weight loss
for several months with anemia and abdominal pain. Patient
without prior preventative health care. Imaging from outside
hospital demonstrated rectosigmoid mass with metastases to the
liver and lungs. Patient underwent flexible sigmoidoscopy with
biopsy demonstrating adenocarcinoma. Given near complete
obstruction Advanced Endoscopy placed a palliative stent. He
developed diffuse abdominal pain on ___ CT abd showed
colonic stent perforation. He was not deemed a surgical
candidate due to his widely metastatic disease. He wished to
become CMO/DNR/DNI, and expired peacefully on ___. Family
was notified and declined autopsy.
# Abdominal Stent Perforation: Experienced diffuse abdominal
pain on ___, CT abdomen showed perforation ___ stent. He was
not felt to be a good surgical candidate due to metastatic
cancer and poor functional status. He wished to become CMO.
Vancomycin, Ceftriaxone, and Metronidazole were prescribed to
improve his abdominal pain and discomfort.
# Hyponatremia, chronic: Patient presented with sodium of 118 at
outside hospital The patient was given IV fluids until stable
sodium level reached at 127. SIADH was thought to be a
significant component of his hyponatremia, given his extensive
metastatic disease to his lungs.
# Septicemia: Met sepsis criteria on ___. Thought to be due to
either hospital-associated pneumonia or GI translocation in the
setting of stent perforation. He was treated with antibiotics
until his family was able to visit, then discontinued.
# Hospital-Associated Pneumonia: He developed increased sputum
production and shortness of breath, and a chest x-ray was
suggestive of right lower lobe pneumonia. He was treated with
vancomycin and ceftriaxone.
CHRONIC ISSUES:
===============
# Microcytic anemia: Patient found to have anemia with MCV 79.
Iron studies demonstrated anemia of chronic disease and also
likely iron deficient in setting of chronic bleeding from GI
malignancy. He was started on iron supplementation.
# Transaminitis: Likely secondary to metastatic liver
involvement vs. EtOH use given elevated AST:ALT ratio.
# Alcohol abuse: Patient reports chronic use of alcohol,
multiple beers and at least two shots of brandy daily. Has
continued to drink despite lack of appetite prior to
hospitalization. During his admission, he had no evidence of
withdrawal.
# Melena: Patient had melena after stent placement.
Sigmoidoscopy on ___ showed tumor infiltration into the stent
with friable, bleeding tissue, which was the likely source of
his bleeding.
# Hypertension: Held home lisinopril in the setting of low blood
pressures.
# Hepatitis C: untreated.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
=======
Metastatic colon (adenocarcinoma) cancer
Colonic perforation
Hospital associated pneumonia
Septicemia
Secondary:
==========
Anemia
Hypertension
Hyponatremia
Hepatitis C
Discharge Condition:
expired
Discharge Instructions:
Dear loved ones of Mr. ___,
It was as pleasure taking part in his care during your
hospitalization at ___. He wastransferred from ___
___ after a CT scan was concerning for colon cancer. A
biopsy revealed colon cancer with metastases to his liver and
his lung. He had a stent placed in his colon to relieve his
abdominal pain. He wasseen by the Oncologists who felt he was
not a candidate for chemotherapy given his weakness/poor
functional status. Over his hospitalization he had pneumonia,
which was treated with antibiotics. He developed worsening
abdominal pain and was found to have a perforated colon from the
stent that was placed. It was a pleasure taking part in his
care!
Followup Instructions:
___
|
10005308-DS-20 | 10,005,308 | 20,445,854 | DS | 20 | 2178-04-20 00:00:00 | 2178-04-20 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right ankle fracture dislocation
Major Surgical or Invasive Procedure:
right ankle surgical fixation
History of Present Illness:
___ healthy female who sustained a right ankle injury
following a mechanical slip and fall down stairs. She states
she was packing to fly home tomorrow morning when she was going
to load up her suitcase down stairs, slipped on the last step,
twisting and injuring her ankle. Denied head strike or loss of
consciousness. She is not currently on anticoagulation. She
denies any numbness or paresthesias in the right foot. She
denies any previous injury to the right ankle. Notably she is
currently in town visiting her son. She lives in ___
currently. She is here with her husband and son.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
Right lower exam
-splint c/d/I
-grossly moves exposed toes
-silt in exposed toes
-toes WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fracture dislocation and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation of
right ankle fracture, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity in a splint, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. Alternatively,
since she is from ___ she may choose to follow-up
with an orthopedic provider ___. She was instructed to
follow-up in 2 weeks. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
don't drink or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
PRN Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
right ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity in splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Followup Instructions:
___
|
10005606-DS-17 | 10,005,606 | 29,646,384 | DS | 17 | 2143-12-16 00:00:00 | 2143-12-16 09:33:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck fracture
Major Surgical or Invasive Procedure:
___ C5/6 corpectomy, C4-C7 ACDF
___ C2-T2 posterior cervical fusion, C4-6 cervical
laminectomy
History of Present Illness:
___ year-old male who presents s/p intoxicated fall from ___
story balcony. He denies LOC, but sustained a laceration to his
face. He complaining of neck, chest and right shoulder pain. CT
of the cervical spine demonstrated comminuted C5-C7 fractures,
T2
superior endplate fracture. He also sustained a sternal
fracture.
He denies numbness, tingling, weakness, or loss of bowel or
bladder function.
Past Medical History:
ETOH abuse
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION:
General: laceration/abrasions to face, Alert and interacting,
but
appears intoxicated
nl resp effort
RRR
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT
T2-L1 (Trunk)
SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)
R 2 2 2 2 2
L 2 2 2 2 2
___: Negative
Babinski: Downgoing
Clonus: No beats
Postop:
gen: awake, pleasant, Dressings with staining
skin: warm and dry, incision are intact
___: normal breathing
abd: soft, nt
extr: no c/c/e
Neurologic:
Motor Strength:
Delt Bi Tri BR WF/WE HI
Right 5 5 5 5 5 5
Left 4+ 4+ 4- 4 4 4
IP Quad Ham TA Gas ___
Right 5 5 5 5 5 5
Left 5 5 5 5 5 5
Sensation: dyesthesia bilateral C7/C8 distribution
Pertinent Results:
Trauma Pelvis XR
___
IMPRESSION:
1. No acute cardiopulmonary process. No obvious rib fractures.
2. No fracture or dislocation involving the ___, hips, and
partially imaged
femurs.
___
C/A/P CT
IMPRESSION:
1. Comminuted and displaced sternal fracture with surrounding
hematoma and
underlying pulmonary contusion in the right middle lobe.
2. Subtle focal irregularity of the superior T12 vertebral body
with subtle
superior endplate depression, suspicious for T12 compression
fracture.
3. No additional acute fracture is identified.
4. Small amount of hyperdense material between the right kidney
and psoas
muscle most likely representing hematoma without active
extravasation.
Adjacent ureter appears patent but with short-segment luminal
narrowing.
Close follow-up is recommended.
5. No additional traumatic organ injury in the chest, abdomen,
or pelvis.
Ct c-spine ___
1. Multiple mildly displaced comminuted fractures through the
C5, C6, and C7
vertebral bodies as described above, with traumatic kyphotic
angulation at
C5-C6 and extension into the spinal canal with fractures
involving the C4, C5,
C6 spinous processes, lamina and multiple levels, and right
C5-C6 facet joint
and possibly right C6-C7 facet joint. Additional acute
anterosuperior
endplate fracture of T2 is also noted.
2. Extensive prevertebral edema from C2-C3 through T1-T2.
CT head ___
1. Large scalp hematoma over the vertex with skin laceration.
No underlying
calvarial fracture. No evidence of acute intracranial
hemorrhage.
CT Head angiogram ___
1. Patent intracranial and cervical vasculature without
high-grade stenosis,
occlusion, or dissection.
2. Numerous known comminuted fractures involving the mid to
lower cervical
spine are better delineated on the separately reported CT
cervical spine
examination.
3. For description of the intracranial parenchymal findings
please see the
separate CT head examination performed earlier on the same day.
Cervical spine MRI ___
. Redemonstrated acute to subacute compression deformities of
the C5, C6 and
C7 vertebral bodies with associated unchanged traumatic kyphotic
deformity at
C5-C6. There is also evidence of acute to subacute compression
deformities of
the superior endplates of the T2 and T3 vertebral bodies with
minimal loss of
vertebral body height.
2. Redemonstrated multilevel mildly displaced cervical spine
fractures
extending from C4 through C7, better described on the recent CT
cervical spine
study.
3. Evidence of increased interspinous interval and ligamentum
flavum
disruption at C4-C5 with findings suspicious for CSF leak at
this level.
4. Extensive edema of the posterior paraspinal musculature
extending from C2
through T1.
5. Unchanged traumatic kyphotic angulation at C5-C6.
6. Moderate prevertebral edema is likely trauma related.
7. Degenerative changes of the cervical spine most significant
at C5-C6 where
superimposed traumatic kyphotic deformity results in mild spinal
canal
narrowing and flattening of the ventral cord without evidence of
abnormal cord
signal.
pCXR ___
In comparison with the study of ___, the bilateral
layering pleural
effusions are no longer seen. However, this appearance could
merely reflect a
more upright position of the patient.
No pneumonia, vascular congestion, or other abnormality.
Cervical fusion device is again seen.
Brief Hospital Course:
Patient was admitted to Orthopedic Spine Service on ___ in
the trauma ICU for further management. He underwent the above
stated procedure on ___ and ___. Patient tolerated the
procedures well without complication. Please review dictated
operative report for details. Patient remained intubated
postoperative for respiratory failure and delirium tremens. He
was started on folate/thiamine IV and phenobarb for agitation
and DTs. His neuro exam was monitored closely.
His ICU course is as follows:
___- paresthesias in bilateral thumbs, consented to remain
intubated x2d for procedures if needed > to OR for ACDF EBL 2.2L
___, 2u pRBC, 4u FFP remained intubated (easy with
___, lactate downtrending. plan for OR likely ___. started
phenobarb load postop. BPs with MAPS in ___, UOP trending down >
gave albumin bolus, expect Hct to continue slow downtrend for
now but holding off on blood.
___-
Neuro exam improved, only mild numbness in left ___ digit.
Hct stable 23.7->24.
Sedation increased and phenobarb rescue dosed for
agitation/tremors.
Hypercarbic on ASV with increased sedation. Switched to CMV but
hypoxic with paO2 75-> PEEP increased to 8. CXR without
congestion or consolidation.
TTE: LVEF 74%. Grade I (mild) left ventricular diastolic
dysfunction.
___: pt intermittently agitated, will write midaz PRN; pt to go
to the OR today for posterior fusion, EBL 3.5 L, 6U PRBC, 2U
Plts, 1U FFP; post op Hct 28, pt HDS and has to be flat for CSF
leak. Pt anemic preop, got 1UPRBC. ankle XR showed ankle sprain,
can immobilize if uncomfortable/consult ortho.
___: Og tube replaced. stays flat for 24h, until ___ on ___.
wean propofol, add precedex. repeat CBC is 8.8/26.4. per spine,
SQH restarted. concern for ? CSF leak on the blanket, ortho
spine consulted- discussed with ___. will monitor. does not
think it is csf leak.
___:
Pt extubated in the AM, doing well from resp standpoint, good
O2 sat on RA. NGT out, A-line out, +gas, -BM, Still agitated on
precedex, being weaned off. HLIV, foley still in, Neurochecks
Q4H, lactulose added to bowel regimen, worked with ___:
recommending rehab
___: pt continues on dex intermittently, was interactive and
appropriate with friend today. will continue to monitor for
agitation
___: febrile with leukocytosis. plan is for fever workup with
Cdiff, UA, Blood culture, CXR. gabapentin TID. speech and
swallow consult. plan to transfer to spine, no longer has ICU
needs.
He was transferred to floor in stable condition on ___.
During the patient's course ___ were used for
postoperative DVT prophylaxis. Diet was advanced as tolerated.
Foley was removed in routine fashion and patient voided without
incident. Hemovac was removed in routine fashion once the
output per 8 hours became minimal.
He was complicated by diarrhea on ___ and CDIFF was sent.
On ___, patient + for CDIFF and was started on flagyl po for
10 days. His diarrhea improved as of ___. Neurologically he
had dysesthesia and numbness. He had LUE weakness secondary to
spinal cord injury and jumped facet. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Now, Day of Discharge, patient is afebrile, VSS, and neuro
stable s/p SCI. He had LUE weakness and bilateral ulnar
weaknessPatient tolerated a good oral diet and pain was
controlled on oral pain medications. Patient ambulated without
issues. Patient's wound is clean, dry and intact. Patient is
set for discharge to home in stable condition.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 650 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*120 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Gabapentin 300 mg PO Q8H
RX *gabapentin 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*90 Capsule Refills:*1
5. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*21 Tablet Refills:*0
6. OxycoDONE Liquid 5 mg PO Q3H:PRN Pain - Moderate
RX *oxycodone 5 mg 1 tab by mouth Q4-6h Disp #*40 Tablet
Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
c5 fx
C6 fx
jumped facet fx
CSF leak
Delirium Tremens
D-diff colitis
spinal cord injury
respiratory failure
alcohol abuse
respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent with Hard collar on at
all times
Discharge Instructions:
ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion.
1.When you are discharged from the hospital and settled at
home/rehab, if you do not have an appointment, please call to
schedule two appointments:
1.a wound check visit for 8 -14 days after surgery
2.a post-operative visit with your surgeon for ___ weeks after
surgery.
1.You can reach the office at ___ and ask to speak
with staff to schedule or confirm your appointments.
Wound Care
If not already done in the hospital, remove the incision
dressing on day 2 after surgery. Keep the incision dry for the
first two days after surgery.
There will often be small white strips of tape over the
incision (steri-strips). These should be left alone and may get
wet in the shower on day 3.
Starting on the third day, you should be washing your incision
DAILY. While holding the head and neck still, gently clean the
incision and surrounding area with mild soap and water, rinse
and then pat dry.
Do not put any lotion, ointments, alcohol, or peroxide on the
incision.
If you have a multi-level fusion and require a hard cervical
collar, this may be removed for showering, and often sleeping
and eating. The collar will typically be removed at the week 4
visit.
You may remove the compression stockings when you leave the
hospital
Have someone look at the incision daily for 2 weeks. Call the
surgeons office if you notice any of the following:
___ redness along the length of the incision
___ swelling of the area around your incision
___ from the incision
___ of your extremities greater than before surgery
___ of bowel or bladder control
___ of severe headache
___ swelling or calf tenderness
___ above 101.5
At your wound check visit, the Nurse Practitioner or ___
___, will check your wound and remove any sutures or
staples or steri-strips.
Do not soak or immerse your incision in water for 1 month. For
example, no tub baths, swimming pools or jacuzzi.
Medications
You will be given prescriptions for pain medications and stool
softeners upon discharge from the hospital.
Pain medications should be taken as prescribed by your surgeon
or nurse practitioner/ physician ___. You are allowed to
gradually reduce the number of pills you take when the pain
begins to subside.
If you are taking more than the recommended dose, please
contact the office to discuss this with a practitioner ___
medication may need to be increased or changed).
Constipation: Pain medications (narcotics) may cause
constipation (difficulty having a bowel movement). It is
important to be aware of your bowel habits so you ___ develop
severe constipation. Call the office if this occurs for more
than 3 days or if you have stomach pain.
Most prescription pain medications cannot be called into the
pharmacy for renewal.
The following are 2 options you may explore to obtain a
renewal of your narcotic medications:
1.Call the office ___ days before your prescription runs out and
speak with our office staff about mailing a prescription to your
home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS)
2.Call the office 24 hours in advance and speak with office
staff about coming into the office to pick up a prescription.
If you continue to require medications, you may be referred to
a pain management specialist or your medical doctor for ongoing
management of your pain medications.
Avoid NSAIDS for 12 weeks post-operative. These medications
include, but are not limited to the following:
Non-Steroidal Anti-Inflammatory Agents: Advil, Aleve, Cataflam,
Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin,
Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen,
Tolectin, Toradol, Trilisate, Voltarin
Activity Guidelines
If you have a multi-level cervical fusion, you will be asked to
wear a hard cervical collar. This is typically removed at week
4 after surgery. You may not drive while wearing the collar.
You may remove your cervical collar for eating, sleeping, and
when showering.
Avoid strenuous activity, bending, pushing, or reaching
overhead. For example, you should not vacuum, do large loads of
laundry, walk the dog, wash the car, etc. until your follow-up
visit with your surgeon.
Avoid heavy lifting. Do not lift anything over ___ pounds for
the first few weeks that you are home from the hospital.
Increase your activities a little each day. Walking is a form
of exercise. Exercise should not cause pain. Limit yourself to
things that you can do comfortably and plan rest periods
throughout the day.
You are not unless you are not taking narcotic medication and
are not required to wear a collar. You may ride in a car for
short distances and avoid sitting in one position for too long.
You may resume sexual activity ___ weeks after surgery,
avoiding stress on the neck and shoulders.
Physical Therapy
Outpatient Physical Therapy (if appropriate) will not begin
until after your post-operative visit with your surgeon. A
prescription is needed for formal outpatient therapy.
You may be given simple stretching exercises or a prescription
for formal outpatient physical therapy, based on what your needs
are after surgery.
Blood Clots in the Leg
1.It is not uncommon for patients who recently had surgery to
develop blood clots in leg veins.
Symptoms include low-grade fever, and/or redness, swelling,
tenderness, and/or an aching/cramping pain in your calf.
You should call your doctor immediately if you have these
symptoms.
To prevent blood clots in legs, try walking and/or pumping
ankles several times during the day.
If the blood clot breaks free from the leg vein, it can travel
to the lungs and cause severe breathing difficulty and/or chest
pain. If you experience this, call ___ immediately.
Questions
Any questions may be directed to your surgeon or nurse
practitioner/ physician ___.
1.During normal business hours (8:30am- 5:00pm), you can call
our office directly at ___. If no one picks up,
please leave a message and someone will get back to you.
If you are calling with an urgent medical issue, please go to
nearest emergency room (i.e. pain unrelieved with medications,
wound breakdown/infection, or new neurological symptoms).
Rigid Collar Instructions
How to put collar on:
___ collar is labeled front and back with arrows
indicating top and bottom.
___ the back section on your neck first. Apply the
front section placing your chin in the chin rest.
___ securing the Velcro, make sure the front overlaps
the back section. This allows more Velcro to be exposed giving
the collar a more secure fit.
___ the collar as tight as you can while remaining
comfortable. The tighter it is worn, the more immobilization of
your spine is obtained and the less likely you will move your
neck.
Care for/during use:
___ alert to pressures under your chin. Some pressure
is necessary but do not allow a blister or pressure sore to
develop.
___ provide comfort, you should wear the collar liners
provided between the brace and your chin to absorb perspiration
and lessen irritation. We recommend that these liners be hand
washed.
___ collar can be washed with mild soap and water, then
dried with a towel and/or hair dryer on the lowest setting.
Hand washing is recommended.
Posterior Cervical Fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 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 ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
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:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time.If you have an incision on your hip please follow the same
instructions in terms of wound care.
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 please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___ 2.We are not allowed to call in narcotic
prescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Followup Instructions:
___
|
10005749-DS-17 | 10,005,749 | 24,015,009 | DS | 17 | 2145-09-14 00:00:00 | 2145-09-16 20:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
High blood sugars, labs showing acute on chronic kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a h/o renal transplant, CHF, AFib on
Coumadin, DM who presented to the ED on ___ with
hyperglycemia (600s) and worsening kidney function on routine
tests at PCP. On ___, her blood glucose was 665, and her Hgb A1c
was found to be 12.7. Her creatinine was 2.1, up from 1.4 in
___ (most recent value). Had been taking her home
Glipizide as prescribed. She had been urinating frequently and
had a cold a few days prior to admission, but otherwise had no
symptomatic complaints.
Past Medical History:
ATRIAL FIBRILLATION
CHRONIC KIDNEY DISEASE
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
GALLSTONE PANCREATITIS S/P SPHINCTEROTOMY
S/P RENAL TRANSPANT
SYSTOLIC CONGESTIVE HEART FAILURE EF ___
SHINGLES - FOREHEAD
DIABETES MELLITUS
MITRAL REGURGITATION
URINARY TRACT INFECTION
RENAL TRANSPLANT ___
BILATERAL NEPHRECTOMIES ___
SPHINCTEROTOMY
BREAST AUGMENTATION
Social History:
___
Family History:
Sister RENAL TRANSPLANT
Daughter POLYCYSTIC KIDNEYS
Physical Exam:
PHYSICAL EXAM upon admission:
Vitals: 97.4 PO, 160 / 55, 71, 20, 97 Ra
Intake: 480, outs not recorded
General: alert, oriented, no acute distress
HEENT: sclera anicteric, slightly dry mucus membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
PHYSICAL EXAM upon discharge:
Vitals: 97.4 PO, 160 / 55, 71, 20, 97 Ra
Intake: 480, outs not recorded
General: alert, oriented, no acute distress
HEENT: sclera anicteric, slightly dry mucus membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
LABS UPON ADMISSION
___ 05:42PM BLOOD UreaN-46* Creat-2.1* Na-127* K-4.0 Cl-86*
HCO3-22 AnGap-23*
___ 05:42PM BLOOD Glucose-665*
___ 05:42PM BLOOD WBC-7.9 RBC-3.54* Hgb-9.8* Hct-29.1*
MCV-82 MCH-27.7 MCHC-33.7 RDW-14.1 RDWSD-41.6 Plt ___
___ 05:42PM BLOOD %HbA1c-12.7* eAG-318*
___ 12:15PM BLOOD Glucose-548* UreaN-47* Creat-1.9* Na-122*
K-3.8 Cl-85* HCO3-21* AnGap-20
___ 12:15PM BLOOD WBC-11.2* RBC-3.64* Hgb-10.1* Hct-30.0*
MCV-82 MCH-27.7 MCHC-33.7 RDW-14.1 RDWSD-41.8 Plt ___
___ 12:15PM BLOOD Neuts-90.2* Lymphs-6.1* Monos-2.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.14* AbsLymp-0.68*
AbsMono-0.24 AbsEos-0.02* AbsBaso-0.02
LABS UPON DISCHARGE:
___ 11:19AM BLOOD Glucose-221* UreaN-42* Creat-1.8* Na-130*
K-3.1* Cl-91* HCO3-22 AnGap-20
___ 05:56PM BLOOD Glucose-356* UreaN-43* Creat-1.9* Na-126*
K-4.0 Cl-89* HCO3-23 AnGap-18
___ 11:19AM BLOOD WBC-11.4* RBC-3.64* Hgb-10.1* Hct-30.1*
MCV-83 MCH-27.7 MCHC-33.6 RDW-14.1 RDWSD-41.7 Plt ___
___ 11:19AM BLOOD ___ PTT-35.5 ___
IMAGING:
RENAL US ___
IMPRESSION:
1. Patent renal transplant vasculature.
2. Borderline to minimally elevated intrarenal resistive
indices measuring up to 0.79 in the interpolar region.
CXR ___
IMPRESSION:
Persistent small left and trace right pleural effusions and
cardiomegaly. No pulmonary edema.
Brief Hospital Course:
___ with a history of renal transplant, CHF, AFib on Coumadin,
DM who was admitted on ___ after she was found to have
hyperglycemia (600s) and worsening renal function on routine lab
tests at PCP (Cr 2.1 on ___, up from most recent 1.4 on
___.
# Hyperglycemia / T2DM:
Pt presented with significant hyperglycemia with ___ and
elevated serum osms (but not meeting criteria for HHS). Treated
with insulin in ED and developed low K. Given her significantly
elevated glucose and HbA1c, the patient requires insulin therapy
for glucose control. ___ was consulted and recommended the
following regimen: NPH 10 Units fixed dose in the morning and
Humalog sliding scale at meals (see discharge paperwork for
scale). Her electrolyte abnormalities resolved with repletion
and intravenous fluids. Her home glipizide was held.
# Acute on chronic kidney disease s/p renal transplant: She
presented with Cr 2.1, though her Cr has been baseline 1.2-1.3
for many years. Her acute presentation is likely due to
hypovolemia in setting of hyperglycemia and gradual decline in
kidney function. She was given intravenous fluids, and her
creatinine was followed closely. Her Lasix and Losartan were
held during admission due to her dehydration and ___. Her home
cyclosporine, prednisone, and MMF were continued. Cr was not
back to baseline upon discharge. Losartan and Lasix held at
discharge.
# UTI: She was also found to have a urinalysis suggestive of
UTI, culture pending. This infection likely developed in setting
of acute on chronic hyperglycemia. Endorsed urinary sx. She was
treated with ceftriaxone 1g IV once daily and transitioned to
cefpoxodime 500mg twice a day for a 7 day course (last dose
___. Urine cultures were pending at the time of discharge.
#Extensive discussions were had with patient and husband
regarding discharge plan. We requested that the patient stay
overnight given the elevated Cr, pending urine cultures,
electrolyte abnormalities, and need for additional fluid
repletion and patient education. Patient insisted on discharge
and agreed to help ensure very close follow-up.
CHRONIC:
# A-fib
Continued home warfarin at 0.5 and 1mg alternating (note was
just changed on ___ per ___ clinic because INR was high.
Continued diltiazem, metoprolol and digoxin.
# CHF
ECHO ___ with normal regional/global systolic function.
Mild-to-moderate mitral regurgitation. Moderate pulmonary
hypertension. EF >55%. Per hx and exam, she was volume down.
Lasix was held.
# Anxiety
Continued home lorazepam
# HTN
Losartan held in setting of ___. Furosemide held in setting of
___.
# HLD
Continued home atorvastatin and zetia.
**TRANSITIONAL ISSUES**
NEW MEDICATIONS:
Insulin NPH 10 units at breakfast
Insulin sliding scale Humalog (see discharge medications)
Cefpodoxime 100 mg PO BID, end date ___
STOPPED MEDICATIONS:
Glipizide
Furosemide (Lasix)
Losartan
-Pt needs close f/u with PCP, ___, and ___. PCP is
___. Discussed with patient and family
-Pt should have repeat labs on ___, chem 10 and INR. If her
creatinine is improved and she does not appear hypovolemic,
please restart her losartan and furosemide.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. LORazepam 0.5 mg PO QHS:PRN anxiety
4. Metoprolol Succinate XL 100 mg PO BID
5. Diltiazem Extended-Release 120 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Warfarin 1 mg PO EVERY OTHER DAY
8. Atorvastatin 10 mg PO QPM
9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
10. Mycophenolate Mofetil 250 mg PO BID
11. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
12. Furosemide 60 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. GlipiZIDE XL 5 mg PO DAILY
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
16. Warfarin 0.5 mg PO EVERY OTHER DAY
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 10 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice per day Disp
#*18 Tablet Refills:*0
2. NPH 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Atorvastatin 10 mg PO QPM
4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
9. LORazepam 0.5 mg PO QHS:PRN anxiety
10. Metoprolol Succinate XL 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Mycophenolate Mofetil 250 mg PO BID
13. PredniSONE 5 mg PO DAILY
14. Warfarin 1 mg PO EVERY OTHER DAY
15. Warfarin 0.5 mg PO EVERY OTHER DAY
16. HELD- Furosemide 60 mg PO BID This medication was held. Do
not restart Furosemide until you see your PCP or your kidney
doctor
17. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you see your PCP
or kidney doctor
18.Outpatient Lab Work
Chem 10, ___
fax to:
___, MD
___, MD
___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
HYPERGLYCEMIA
Acute kidney injury on chronic kidney injury
Complicated urinary tract infection
Hyponatremia
Hypokalemia
SECONDARY DIAGNOSIS:
Atrial fibrillation
Renal transplant
Congestive heart failure
Anxiety
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you had very high blood sugar
and bloodwork showing that your kidneys were not working as
well.
While you were in the hospital, you were given insulin and
intravenous fluids. Your Lasix and Losartan medications were
held because you were very dehydrated. Your electrolyte levels
were abnormal, which were repleted. You were also found to have
a urinary tract infection, which was treated with antibiotics.
Since your blood sugars were so high, it is very important that
you take insulin every day, as prescribed. When you leave the
hospital, you will also need to continue taking antibiotics
(cefpodoxime 100 mg PO twice per day for 10 days) with last dose
on ___.
NEW MEDICATIONS:
Insulin NPH 10 units at breakfast
Insulin sliding scale Humalog (see discharge medications)(we
have provided you with a chart that)
Cefpodoxime 100 mg PO twice a day through ___
STOPPED MEDICATIONS:
Glipizide
Furosemide (Lasix)
Losartan
MAKE AN APPOINTMENT WITH YOUR NEPHROLOGIST FOR WITHIN ONE WEEK -
Dr. ___ AN APPOINTMENT WITH YOUR PRIMARY CARE DOCTOR - Call
___
PLEASE ATTEND YOUR ___ APPOINTMENT
Please get your labs checked next ___.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
10005858-DS-13 | 10,005,858 | 22,585,238 | DS | 13 | 2172-07-20 00:00:00 | 2172-07-20 09:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee
Sting Kit / adhesive bandage / Caffeine
Attending: ___.
Chief Complaint:
Left leg weakness with multiple falls
Major Surgical or Invasive Procedure:
Lumbar laminectomy L2-5 with L3-5 fusion
History of Present Illness:
___ with pmhx of chronic LBP ___ steroid injections), sp bl TKR,
cerebral aneurysm sp clipping, hypothyroidism (sp L
hemithyroidectomy), sp ccy, sp tonsillectomy, sp TAH (fibroids),
sp R oopheretomy), sp appy, sp CTS release who presents with LBP
and "knee buckling".
Pt underwent massage on ___, and on ___ (4d ago),
developed severe, sharp, sudden onset LBP in area of lower
lumbar spine, radiating to left side of lower back. She had
another massage last night and subsequently developed feeling of
weakness in ___. She also reports numbness on medial aspect of
LLE. Due to these sx she has had ___ falls (no head strike, no
LOC) during the past day. She was referred by her PCP.
In the ED, initial vs were: 97 75 161/76 18 97%. Pt had MRI
spine which showed no acute changes. Patient seen by
orthopedics who recommended outapatient evaluation for steroid
injections, since patient did not want surgery.
Labs were unremarkable. Patient was given tramadol, and
dexamethasone. She was seen by ___ and case management who felt
that she was unable to ambulate and would need further
evaluation prior to placement in a rehab facility.
Past Medical History:
1. Hypertension
2. Hypothyroidism, status post partial thyroidectomy for
multinodular goiter
3. Arthritis
4. Spinal stenosis
5. Chronic low back pain
6. Mitral valve prolapse
7. Irritable bowel syndrome
8. Cerebral Aneurysm
Social History:
___
Family History:
Positive for breast cancer in the patient's mother. Brother and
father both status post CABG. Brother with type ___ diabetes.
Physical Exam:
Vitals: 98.6, 144/77, 72, 22, 97RA
General: Alert, obese, oriented, tearful about impending surgery
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ttp in lumbar spine and R flank, R leg, some numbness in
medial L shin
Pertinent Results:
___ 06:38PM BLOOD WBC-11.0 RBC-5.13 Hgb-14.0 Hct-44.8
MCV-87 MCH-27.3 MCHC-31.2 RDW-13.8 Plt ___
___ 06:38PM BLOOD Neuts-69.3 ___ Monos-6.3 Eos-1.9
Baso-1.0
___ 05:55AM BLOOD ___ PTT-28.6 ___
___ 06:38PM BLOOD Glucose-91 UreaN-20 Creat-0.9 Na-142
K-3.8 Cl-102 HCO3-33* AnGap-11
___ 05:55AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2
IMAGING:
MRI L spine
No signficant change since the prior study. Severe degenerative
changes with grade 1 anterolisthesis of L3-L4 and severe spinal
stenosis and neural foraminal narrowing at that level. Clumbing
of the nerve roots is also stable, likely arachnoiditis. At
L4-L5 stable grade 1 anterolisthesis with clumping of nerve
roots, moderate canal stenosis and neural foraminal stenosis. No
fractures.
LUMBO SACRAL X RAY:
Marked multilevel degenerative changes with no definite evidence
of new malalignment or fracture. If there is high clinical
concern for fracture, CT of the lumbar spine could be obtained.
If there are worsening neurological symptoms, MR of the lumbar
spine could be obtained. ___ discussed with ___ at
10:30 a.m. on ___, at the time of discovery.
B/L KNEE X RAY:
IMPRESSION: Bilateral knee arthroplasties without evidence of
hardware failure or fracture.
HIP/FEMUR X RAY:
No acute fracture or traumatic malalignment. Moderate
degenerative changes.
Brief Hospital Course:
Ms. ___ is a ___ yo F with a history of spinal stenosis,
chronic lower back pain, HTN, hypothyroidism presenting with
worsening lower back pain, found to have severe spinal stenosis
now s/p L2-L5 fusion laminectomy with Dr. ___.
#Lower Back Pain: Came to ED with pain that was consistent with
patient's prior lower back pain. Ortho spine was consulted in
the ED and felt that although surgical intervention was
possible, patient initially refused. They therefore recommended
pain control, patient received steroids in the ED, and was
admitted for pain control and placement with rehab facility.
However, the patient changed her mind and Dr. ___ was able to
take Ms. ___ to the OR for the procedure. She did not require
pain control with anything on the medicine floor and refused
narcotics based on the side effect of nightmares.
#HTN: History of hypertension, elevated to 140s on admission,
however patient is not currently on any antihypretensive regimen
#Hypothyroidism: History of multinodular goiter, currently
stable. Synthroid 50mcg daily was continued.
Ms. ___ was taken to the OR for a lumbar laminectomy and
fusion L2-5. She tolerated the procedure well and was able to
work with ___. She was discharged in good condition and will
follow up with Dr. ___ in 10 days.
Medications on Admission:
LEVOTHYROXINE [LEVOXYL] - Levoxyl 50 mcg tablet. 1 Tablet(s) by
mouth once a day
MODAFINIL - modafinil 100 mg tablet. 1 Tablet(s) by mouth qam
and
one at lunch
NITROFURANTOIN MONOHYD/M-CRYST [MACROBID] - Macrobid ___ mg
capsule. 1 capsule(s) by mouth twice daily x 7 days
PRAMIPEXOLE - pramipexole 0.25 mg tablet. 1 tablet(s) by mouth
three times a day
SEQUENTIAL COMPRESSION STOCKINGS - . thigh high daily
SOLIFENACIN [VESICARE] - Vesicare 5 mg tablet. 1 tablet(s) by
mouth once a day
SULINDAC - Dosage uncertain - (Prescribed by Other Provider)
TRAZODONE - trazodone 100 mg tablet. 2 (Two) Tablet(s) by mouth
at bedtime
VENLAFAXINE - venlafaxine 100 mg tablet. 2 Tablet(s) by mouth at
bedtime
Medications - OTC
B COMPLEX-VITAMIN C-FOLIC ACID - Dosage uncertain - (OTC)
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - Citracal + D 315
mg-200 unit tablet. 2 Tablet(s) by mouth twice daily
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000
unit capsule. 1 Capsule(s) by mouth daily - (Prescribed by
Other
Provider)
FERROUS GLUCONATE [FERGON] - Dosage uncertain - (Prescribed by
Other Provider)
LACTOBACILLUS ACIDOPHILUS [PROBIOTIC] - Dosage uncertain -
(Prescribed by Other Provider)
LYSINE [L-LYSINE] - L-Lysine 500 mg capsule. 1 Capsule(s) by
mouth twice daily - (OTC)
MAGNESIUM - Dosage uncertain - (Prescribed by Other Provider:
PCP)
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth DAILY
(Daily) - (Prescribed by Other Provider)
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*100 Tablet Refills:*0
2. Levothyroxine Sodium 50 mcg PO DAILY
3. TraZODone 100 mg PO HS:PRN insomnia
4. Venlafaxine 200 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar stenosis L2-5
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Lumbar laminectomy
and fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
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.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
As tolerated
Treatment Frequency:
Please continue to change the dressing daily
Followup Instructions:
___
|
10005858-DS-14 | 10,005,858 | 29,352,282 | DS | 14 | 2172-08-17 00:00:00 | 2172-08-17 09:34:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee
Sting Kit / adhesive bandage / Caffeine
Attending: ___.
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
Washout of lumbar incision
History of Present Illness:
___ with pmhx of chronic LBP ___ steroid injections), sp bl TKR,
cerebral aneurysm sp clipping, hypothyroidism (sp L
hemithyroidectomy), sp ccy, sp tonsillectomy, sp TAH (fibroids),
sp R oopheretomy), sp appy, sp CTS release with recent lumbar
laminectomy L2-5 with L3-5 fusion on ___ by Dr. ___
presents with fever. Patient states that for the past two days
she has had worsening pain and redness at her operative site.
She denies any new lower extremity weakness, parasthesias or
anesthesia. She does endorse occasional urinary incontinence she
attributes to difficulty reaching commode in time. Denies fecal
incontinence, saddle anesthesia. Denies CP, dyspnea, cough, abd
pain, dysuria.
Past Medical History:
1. Hypertension
2. Hypothyroidism, status post partial thyroidectomy for
multinodular goiter
3. Arthritis
4. Spinal stenosis
5. Chronic low back pain
6. Mitral valve prolapse
7. Irritable bowel syndrome
8. Cerebral Aneurysm
Social History:
___
Family History:
Positive for breast cancer in the patient's mother. Brother and
father both status post CABG. Brother with type ___ diabetes.
Physical Exam:
In general, the patient is a
Vitals: T 102.7dF Hr 93 BP 127/77 RR 18 SpO2 96% RA
Spine exam:
Wound: Midline lumbar spine wound from L1-L5 has surrounding
blanching erthema and induration, no clear fluctuance. No
discharge.
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L ___ 5
R ___ 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L ___ 2 2
R ___ 2 2
Plantar response was extensor bilaterally.
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
Pertinent Results:
___ 06:50PM BLOOD WBC-11.5* RBC-3.75* Hgb-10.3* Hct-32.9*
MCV-88 MCH-27.4 MCHC-31.3 RDW-14.4 Plt ___
___ 10:10AM BLOOD WBC-13.3* RBC-3.54* Hgb-9.9* Hct-31.4*
MCV-89 MCH-28.0 MCHC-31.6 RDW-14.2 Plt ___
___ 03:27PM BLOOD WBC-14.2* RBC-4.03* Hgb-10.9* Hct-35.0*
MCV-87 MCH-27.0 MCHC-31.1 RDW-14.2 Plt ___
___ 03:27PM BLOOD Neuts-82.2* Lymphs-11.1* Monos-5.9
Eos-0.4 Baso-0.3
___ 06:50PM BLOOD ESR-128*
___ 03:27PM BLOOD ESR-92*
___ 06:50PM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-145
K-4.5 Cl-99 HCO3-31 AnGap-20
___ 10:10AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
___ 03:27PM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-139
K-4.3 Cl-98 HCO3-29 AnGap-16
___ 09:55AM BLOOD Vanco-15.2
___ 08:45PM BLOOD Genta-4.0* Vanco-14.0
Brief Hospital Course:
Ms. ___ underwent a washout of her posterior lumbar incision.
She had a PICC line placed and will receive 10 weeks of IV
vancomycin. She will follow up with both the ___ clinic and Dr.
___.
Medications on Admission:
Trazodone
Venlafaxine
Pramipexole
Synthroid
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*100 Tablet Refills:*0
3. Levothyroxine Sodium 50 mcg PO DAILY
4. pramipexole 0.25 mg oral TID restless leg
5. TraZODone 100 mg PO HS:PRN insomnia
6. Venlafaxine 200 mg PO QHS
7. Vancomycin 1000 mg IV Q 12H X 10 weeks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar incision infection
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Washout lumbar
incision
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
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.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity as tolerated
Treatments Frequency:
Please continue to change the dressing daily
Followup Instructions:
___
|
10005866-DS-16 | 10,005,866 | 22,589,518 | DS | 16 | 2149-02-14 00:00:00 | 2149-02-16 09:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / Neurontin
Attending: ___
Chief Complaint:
RUQ abdominal pain, vomiting, diarrhea
Major Surgical or Invasive Procedure:
-diagnostic para ___
History of Present Illness:
Mr ___ is a ___ year old man with cirrhosis (EtOH/HCV
untreated, genotype 3)Child Class C, complicated by esophageal
varices, ascites, and encephalopathy, chronic abdominal pain and
multiple prior abdominal surgeries, presenting with 3 days of
more severe RUQ pain, vomiting, and diarrhea.
After a several month stay in rehab in ___ following his
last ___ hospitalization in ___, the patient has been doing
well at home. In his usual state of health, he has chronic RUQ
abdominal pain, and is followed by his PCP and hepatologist;
patient states that his pain has been attributed to possibly
scar tissue from his several abdominal surgeries. He was
previously on fentanyl patch for this but is now on oxycodone
10mg QID. ___ checked ___. Last filled oxycodone 10mg 30
day supply (120 pills) ___.
He has Child's class C cirrhosis but overall his ascites and
hepatic encephalopathy are well controlled with
Lasix/spironolactone and lactulose. Prior paracentesis was
"Several years ago."
He developed his present symptoms 3 days ago, with the subacute
onset of worsening RUQ pain (stabbing, constant with waves of
more severe pain, worse with vomiting, no change with
eating/position/movement). For the past 3 days he has also had
___ episodes per day of vomiting (clear/yellow fluid, no blood
or coffee-ground emesis), and has been unable to tolerate food,
or fluids, and thinks he has also vomited pills (although has
been trying to stay compliant with his regimen). He has also
been having multiple episodes per day of watery/yellow fluid
diarrhea (no blood or melena).
His ROS is positive for chills/sweats, and fatigue. His
abdominal distention is moderate but stable. But he denies
fevers, myalgia/arthralgias, HA, URI symptoms, visual complaint,
chest pain/pressure, dyspnea, cough, rash, bruising, lower
extremity edema. No recent travel, sick contacts, or recent
raw/uncooked/spoiled food.
He presented to the ED for further evaluation.
In the ED, initial vitals were: Temp. 98.0, HR 82, BP 157/82, RR
22, 100% RA
- Exam notable for: RUQ tenderness to palpitation, abdomen
distended but soft
--Bedside abdominal ultrasound showed small volume of ascites
without a pocket amenable to paracentesis.
- Labs notable for:
--WBC 5.4, Hgb 14.0, plt 181
--Na 130, K 4.8, HCO3 15, creatinine 0.8, glucose 144, BUN 9
--ALT 32, AST 127, alk phos 145, Tbili 4.7, albumin 2.8
--lactate 2.6, repeat lactate 1.7
--INR 1.4, PTT 38.7
- Imaging was notable for:
CT abdomen ___:
1. Cirrhosis with evidence of portal hypertension with moderate
volume ascites partially loculated in the right upper quadrant,
extensive portosystemic varices. ***Partially occlusive thrombus
in the main portal vein. ***
2. Small bowel distention without obstruction may reflect ileus.
Mild thickening of the proximal colon may reflect portal
colopathy.
3. Trace right pleural effusion with chronic appearing
atelectasis in the right lower lung.
4. Extensive atherosclerotic disease of the aorta.
Liver US ___:
1. There is a new nonocclusive thrombus within the main portal
vein with extension into the left and right portal vein
branches. There is normal hepatopetal flow within the main
portable vein and evidence of sluggish flow within the left and
right portal vein branches.
2. Large volume ascites.
3. Worsening splenomegaly measuring 13.7 cm today, previously
measuring 12 cm ___.
4. New 1.6 cm focus within the right hepatic lobe is
incompletely characterized. Follow-up MR for further evaluation
is recommended.
- Patient was given:
--morphine 4mg IV x2
--ondansetron 4mg IV
--1L normal saline
--started on heparin drip
Upon arrival to the floor, patient reports continued abdominal
pain in the RUQ, and being very thirsty and a little hungry.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Hepatitis C (genotype 3)
- Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic
encephalopathy, portal hypertension with ascites and esophageal
varices, portal hypertensive gastropathy
- Gastric & Duodenal ulcers
- Insomnia
- Umbilical hernia
- Sacral osteoarthritis
Past Surgical History:
- Umbilical hernia repair (___)
-SBO requiring Ex lap & repair of ruptured umbilical hernia
with lysis of adhesions (___)
- Abdominal Hematoma evacuation (___)
- Abdominal incision opened, wound vac placed (___)
Social History:
___
Family History:
Sister and brother both with "collapsed lungs." No family
history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
VITAL SIGNS: BP 115 / 77 hr 64 RR18 SPO2 98 Ra
GENERAL: chronically ill appearing man, resting in bed in
moderate discomfort. Able to move around in bed without obvious
increase in pain. Alert, fully conversant, very pleasant.
HEENT: NCAT. Dry oral mucosa. No scleral icterus. Conjunctivae
white. No JVD.
NECK: full ROM, no masses
CARDIAC: RRR, no murmurs, no lower extremity edema
LUNGS: CTAB, unlabored breathing on ambient air
ABDOMEN: moderately distended, but soft. Moderately tender in
RUQ. Umbilical hernia site intact, non-tender. Dull to
percussion, no fluid wave. Normal bowel sounds. Collateral
vessels faintly visible in abdominal wall
EXTREMITIES: warm, no edema. No asterixis
NEUROLOGIC: alert, fully oriented. CN exam normal.
Strength/sensation intact. Gait not tested. No asterixis or
tremor.
SKIN: no rashes, no jaundice
DISCHARGE PHYSICAL EXAM:
==============================
VS: 98.1 PO 106 / 68 R Lying 68 18 96 Ra
GENERAL: chronically ill appearing man, resting in bed in
moderate discomfort.
HEENT: NCAT. MMM. No scleral icterus
CARDIAC: RRR, no murmurs, no lower extremity edema
LUNGS: CTAB, unlabored breathing on ambient air
ABDOMEN: moderately distended, but soft. Moderately tender in
RUQ. Umbilical hernia site intact, non-tender. Normal bowel
sounds. Collateral vessels faintly visible in abdominal wall
EXTREMITIES: warm, no edema. No asterixis
NEUROLOGIC: alert, fully oriented. CN exam normal.
Strength/sensation intact. Gait not tested. No asterixis or
tremor.
SKIN: no rashes, no jaundice
Pertinent Results:
ADMISSION LABS:
==========================
___ 09:36AM BLOOD WBC-5.4 RBC-3.97* Hgb-14.0 Hct-42.2
MCV-106* MCH-35.3* MCHC-33.2 RDW-14.2 RDWSD-56.4* Plt ___
___ 09:36AM BLOOD Neuts-65.3 ___ Monos-10.4 Eos-1.9
Baso-1.7* Im ___ AbsNeut-3.51 AbsLymp-1.08* AbsMono-0.56
AbsEos-0.10 AbsBaso-0.09*
___ 11:21AM BLOOD ___ PTT-38.7* ___
___ 09:36AM BLOOD Glucose-144* UreaN-9 Creat-0.8 Na-130*
K-4.8 Cl-101 HCO3-15* AnGap-19
___ 09:36AM BLOOD ALT-32 AST-127* AlkPhos-145* TotBili-4.7*
___ 09:36AM BLOOD Albumin-2.8*
___ 05:00AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.4*
___ 09:44AM BLOOD Lactate-2.6*
DISCHARGE LABS:
==========================
___ 04:46AM BLOOD WBC-5.1 RBC-3.46* Hgb-12.3* Hct-37.0*
MCV-107* MCH-35.5* MCHC-33.2 RDW-14.2 RDWSD-55.5* Plt ___
___ 04:46AM BLOOD ___ PTT-36.8* ___
___ 04:46AM BLOOD Glucose-93 UreaN-9 Creat-0.9 Na-133 K-4.2
Cl-99 HCO3-26 AnGap-12
___ 04:46AM BLOOD ALT-21 AST-63* AlkPhos-159* TotBili-2.3*
___ 04:46AM BLOOD Albumin-2.4* Calcium-8.0* Phos-3.6 Mg-1.6
PERTINENT RESULTS:
==========================
___ 01:55PM ASCITES TNC-64* RBC-650* Polys-1* Lymphs-48*
Monos-6* Mesothe-2* Macroph-43* Other-0
___ 01:55PM ASCITES TotPro-1.7 Glucose-103 LD(LDH)-104
Albumin-0.7 Cholest-19
___ 08:58PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE
MICROBIOLOGY:
==========================
___ 1:55 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
___ 1:48 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
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.
IMAGING:
==========================
___
IMPRESSION:
1. Cirrhosis with new partially occlusive thrombus within the
main portal
vein.
2. Large volume ascites.
3. Worsening splenomegaly measuring 13.7 cm today, previously
measuring 12 cm ___.
4. New 1.6 cm focus within the right hepatic lobe is
incompletely characterized. Follow-up MR for further evaluation
is recommended.
___
IMPRESSION:
Tiny right pleural effusion, otherwise unremarkable exam.
___
IMPRESSION:
1. Cirrhosis with evidence of portal hypertension with moderate
volume ascites partially loculated in the right upper quadrant,
extensive portosystemic varices. Partially occlusive thrombus
in the main portal vein.
2. Small bowel distention without obstruction may reflect ileus.
Mild thickening of the proximal colon may reflect portal
colopathy.
3. Trace right pleural effusion with chronic appearing
atelectasis in the right lower lung.
4. Extensive atherosclerotic disease of the aorta.
Brief Hospital Course:
___ year old man with cirrhosis (EtOH/HCV untreated, genotype 3)
Child Class C, complicated by esophageal varices, ascites, and
encephalopathy, chronic abdominal pain and multiple prior
abdominal surgeries, presenting with 3 days of acute on chronic
RUQ pain, vomiting, and diarrhea likely ___ viral
gastroenteritis. C.diff negative, norovorius negative.
Diagnostic para w/ no e/o SBP. Stool Cx pending at time of
discharge. Patient was given IV fluids with spontaneous
resolution (though persistent chronic RUQ pain).
Hospital course complicated by new non-occlusive PVT, lactate
slightly elevated on initial presentation normalized with IVF
less c/f ischemia. Outpatient hepatologist (Dr. ___ was
contacted who recommended against anticoagulation given
non-occlusive, and concerns with patient compliance.
Otherwise no changes to home medications.
======================
ACUTE ISSUES
======================
#Abdominal pain, vomiting, diarrhea: presented with 3 days of
acute on chronic RUQ pain, vomiting, and diarrhea likely ___
viral gastroenteritis. C.diff negative, norovorius negative.
Diagnostic para w/ no e/o SBP. Stool Cx pending at time of
discharge. Patient was given IV fluids with spontaneous
resolution (though persistent chronic RUQ pain). Of note RUQ U/S
and CT A/P w/ e/o non-occlusive PVT, though unlikely explanation
for presentation as non-occlusive w/ down-trending lactate.
#Partially occlusive portal vein thrombosis: iso decompensated
cirrhosis; RUQ ultrasound and CT abdomen with contrast
demonstrated partially occlusive portal vein thrombus, new since
___ ultrasound. Lactate slightly elevated on initial
presentation normalized with IVF less c/f ischemia. Outpatient
hepatologist (Dr. ___ was contacted who recommended against
anticoagulation given non-occlusive, and concerns with patient
compliance.
#Hyponatremia : Admitted w/ serum sodium 130. Per history,
multiple days of low fluid intake, diarrhea, vomiting, while
continuing to take diuretics suggested he was intravascularly
depleted. Resolved s/p 1L IVF, and resolution of gastroenteritis
w/ improved PO intake. Home diuretics restarted upon discharge.
#Cirrhosis: Child's Class C, complicated by ascites, hepatic
encephalopathy, prior SBP, esophageal varices.
-volume: home Lasix/spironolactone initially held iso n/v/d,
resumed upon discharge.
-hepatic encephalopathy - cont home lactulose after resolution
of diarrhea
-SBP ppx - cont home Bactrim
-esophageal varices - last EGD in ___ no evidence of bleeding
on this presentation;
Transitional Issues:
==========================
-On RUQ U/S: There is a 1.6 cm echogenic focus within the mid
right hepatic lobe, peripherally, for which follow-up MR for
further evaluation is recommended.
-Patient w/ new non-occlusive PVT. Would recommend f/u CT in 3
months to eval for progression of PVT thrombus.
-Stool cultures pending at time of discharge, please follow up
# CODE: full
# CONTACT: sister/HCP ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Spironolactone 50 mg PO DAILY
4. Famotidine 20 mg PO Q12H
5. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
6. Multivitamins 1 TAB PO DAILY
7. Potassium Chloride 10 mEq PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
2. Famotidine 20 mg PO Q12H
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth every six (6) hours
Disp #*8 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Potassium Chloride 10 mEq PO DAILY
Hold for K >
9. Spironolactone 50 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
=======================
-viral gastroenteritis
Secondary Diagnosis:
======================
-ETOH/HCV Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure being involved in your care.
Why you were here:
-You came in for nausea/vomiting/diarrhea.
What we did while you were here :
-We gave you some fluids through your IV because you were
dehydrated. We believe that you had a viral illness, which
cleared on its own.
-We also took some fluid out of your abdomen to make sure you
were not having an infection, and this was negative for any
infection.
Your next steps:
-please take all your medications as indicated below
-please keep all of your appointments
We wish you well,
Your ___ Care Team
Followup Instructions:
___
|
10006029-DS-16 | 10,006,029 | 27,104,518 | DS | 16 | 2169-10-05 00:00:00 | 2169-10-06 14:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
___: ERCP and EUS
History of Present Illness:
Mr. ___ is a ___ male with IDDM, HTN, BPH,
and clear cell RCC s/p radical L nephrectomy (___) metastatic
to
the lungs, mediastinum, and hilum currently on chemotherapy
(experimental trial; on sunitinib), with recent admission
(___) for biliary stricture s/p ERCP with plastic stent
placement (CBD brushing cytology non-diagnostic) and
non-occlusive portal vein thrombus started on enoxaparin who
presented to the ED with fever, jaundice, and confusion.
The CBD brushing cytology from his prior admission was
non-diagnostic. His imaging was reviewed at multidisciplinary
pancreas conference and no mass lesion was visualized in the
head
of the pancreas but there was some peripancreatic stranding
around the head of the pancreas noted. There was some concern
for
a potential primary pancreatobiliary tumor (rather than rare RCC
metastasis to pancreas), so he was planned for a repeat ERCP and
EUS in ___ weeks (planned for the week of ___ off sunatinib).
He last followed up in ___ clinic with Dr. ___ on
___.
He was complaining of a week of increased fatigue, nausea, and
poor PO intake. His sunatinib was held due to concern for side
effects. Over the past week since then, he has had worsening
jaundice and fatigue. Last night, he developed chills,
restlessness, mild confusion, and fevers to 101, which prompted
his wife to bring him to ___. He was
transferred from there to the ___ ED.
Right now, he feels ok, just a little tired. He feels like his
thinking is foggy. No fevers/chills since he presented to the
hospital. No nausea, vomiting, abdominal pain. He has had loose
stools, which he associates with the sunatinib. No bloody,
black,
or ___ stools. His urine has been "tea colored." He has
had poor appetite. No chest pain, shortness of breath, or
palpitations.
ED COURSE:
VS: Tmax 98.6, HR ___, BP 100s-110s/60s, RR 16, SpO2 98-100%
on RA
Labs: WBC 3.4, AST/ALT 71/97, AP 214, Tbili 7.6, lipase 148,
lactate 1.4
Exam: jaundiced, abdomen benign, guaiac negative brown stool
Imaging: RUQ US: persistent left intrahepatic biliary dilation,
persistent GB sludge
Interventions: None
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___: presented with acute onset of gross hematuria
accompanied with some mild flank pain. During his workup, he was
found to have a 4.8 cm mass on a CAT scan dated ___,
specifically the scan describes a left renal mass with internal
enhancement measuring 4.1 x 4.8 cm in size in the mid and upper
pole of the left kidney. Also described was the fat-containing
left inguinal hernia and left perinephric stranding. There was
no
adenopathy or other suspicious lesions. There is also an old
sclerotic right ilial lesion and left sacral lesion.
-___: underwent a laparoscopic hand assisted radical right
nephrectomy by Dr. ___ pathology showed a
renal
cell carcinoma, clear cell type, ___ grade II/IV measuring 4
cm extending but not invading through the renal capsule or
Gerota's fascia margins were questionably positive at the renal
vein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the
renal
vein margin. A background of global glomerulosclerosis is
described. Overall, this was a T3bNxMx lesion. Postoperative
imaging on ___ which was a CT torso showed no evidence of
recurrent or metastatic disease.
-___: CT chest showed interval increase in prominence of
mediastinal lymph nodes and minimal interval increase in
multiple
b/l pulmonary nodules, concerning for progression
-___: Fine needle aspirate of 11R and 11L lymph nodes, which
was consistent with metastatic RCC
-___: CT Torso - mediastinal and hilar nodes and pulmonary
lesions increased in size. No definite intra-abdominal sites of
disease
-___: C1D1 ___, randomized to sunitinib
-___: Multiple grade ___ adverse events including
thrombocytopenia (grade 2; platelet 52,000), leukopenia (grade
2;
WBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1;
elevated at baseline), elevated ALT (grade 1), and
hypothyroidism
(grade 1). Mild symptoms with treatment. Continued sunitinib at
50mg daily per protocol.
-___: CT Torso: Response of mediastinal lymphadenopathy,
bilateral hilar lymphadenopathy, and numerous parenchymal
metastases. Stable disease by RECIST (decrease 19.1% from
baseline).
-___: Sunitinib reduced to 37.5 mg daily due to erythematous
rash and blistering on palms and sole of right foot.
-___: CT Torso: Decrease in pulmonary and mediastinal
lesions. Stable disease by RECIST 1.1 (decrease 22.5% from
baseline).
-___: CT Torso: Partial response by RECIST 1.1 (decrease
39.8% from baseline).
-___: CT Torso: Partial response by RECIST 1.1 (decrease
46.3% from baseline).
-___: CT Torso: Partial response by RECIST 1.1 (decrease
40.3%
from baseline).
-___: CT Torso: Partial response by RECIST 1.1 (decrease
42.6% from baseline).
-___: CT Torso: Partial response by RECIST 1.1 (decrease
47.7% from baseline).
-___: CT torso: Ongoing partial response comments: No
significant change compared to prior scan. No new lesions.
-___: CT Torso: PR by RECIST 1.1
-___: CT Torso: PR by RECIST 1.1: -54.22% change from
baseline and -10.29% change from last scan.
-___: CT Torso: partial response: -57.79% from baseline,
-7.79% from nadir
-___: CT Torso shows continued partial response, no
significant change compared to prior
PAST MEDICAL HISTORY (per OMR):
1. Clear cell kidney cancer as above.
2. Benign prostatic hypertrophy.
3. Diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. History of anxiety.
Social History:
___
Family History:
Colorectal cancer - mother
___ cancer - sister (dx at age ___
Liver cancer - brother
___ cell leukemia - brother
___ - father
Physical ___:
ADMISSION EXAM:
VITALS: T 97.6, HR 68, BP 115/76, RR 16, SpO2 98% on RA
___: Alert, NAD, breathing room air comfortably
EYES: Icteric sclera, PERRL
ENT: MMM, sublingual jaundice, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Jaundiced
NEURO: Alert, oriented to hospital, city, date; able to recite
the days of the week backwards, face symmetric, gaze conjugate
with EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
T 97.9, HR 70, BP 143/79, RR 18, SpO2 97% on RA
___: Alert, NAD, breathing room air comfortably
EYES: Icteric sclera
ENT: MMM, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Jaundiced (but improved)
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 05:43AM BLOOD WBC-3.4* RBC-2.48* Hgb-8.4* Hct-24.9*
MCV-100* MCH-33.9* MCHC-33.7 RDW-16.8* RDWSD-61.6* Plt ___
___ 05:43AM BLOOD Glucose-95 UreaN-24* Creat-1.5* Na-138
K-4.4 Cl-106 HCO3-18* AnGap-14
___ 05:55AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.5 Mg-1.9
Iron-18*
___ 05:43AM BLOOD Albumin-2.8*
___ 05:55AM BLOOD calTIBC-160* Hapto-230* Ferritn-990*
TRF-123*
___ 05:43AM BLOOD ALT-97* AST-71* AlkPhos-214* TotBili-7.6*
DirBili-5.6* IndBili-2.0
MICRO:
BCx ___: NGTD
Blood culture (___):
STREPTOCOCCUS ANGINOSUS (___) GROUP
|
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
PATHOLOGY/CYTOLOGY:
Biliary mass biopsy (___): Minute fragment of highly
atypical cells with sclerotic stroma consistent with
adenocarcinoma
Common bile duct stricture brushings (___):
POSITIVE FOR MALIGNANT CELLS. - Adenocarcinoma.
IMAGING:
RUQ US (___):
IMPRESSION:
1. Persistent mild left intrahepatic biliary dilation in
presence
of a partially visualized CBD stent raises concern for stent
malfunction. Compared to the prior ultrasound, the degree of
intrahepatic biliary dilation has not changed significantly.
2. Persistent gallbladder sludge.
ERCP ___:
removal of the old stent and placement of a new stent over a 2cm
malignant-appearing stricture
of the distal CBD. Cytology brushings were sampled.
EUS ___:
1.8 x 1.1 cm ill-defined hypoechoic area around the distal CBD.
FNB was performed x3
CT torso ___:
IMPRESSION:
Non obstructive pneumonia, left upper lobe.
Minimal residual pulmonary edema and pleural effusions
attributable to heart failure.
Atherosclerotic coronary calcification.
Left PICC line ends just above the superior cavoatrial junction.
IMPRESSION:
1. No evidence of local recurrence or metastatic disease in the
abdomen and
pelvis.
2. Mild intrahepatic and extrahepatic biliary ductal dilatation,
with CBD
stent in place.
3. Known nonocclusive main portal vein thrombus appears
increased in size,
though difficult to directly compare to MR due to differences in
imaging
technique.
ERCP ___: Biliary plastic stent removed with a snare. A
metal stent was placed over 2cm long malignant appearing
stricture in the distal CBD.
TTE ___:
IMPRESSION: Adequate image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global left ventricular systolic function. No 2D
echocardiographic evidence for endocarditis. If clinically
suggested, the absence of a discrete vegetation on
echocardiography does not exclude the diagnosis of endocarditis.
Brief Hospital Course:
SUMMARY/ASSESSMENT:
Mr. ___ is a ___ male with IDDM, HTN, BPH, and
metastatic clear cell RCC s/p radical L nephrectomy (___) on
chemotherapy (sunitinib), with recent admission (___) for
biliary stricture s/p ERCP with plastic stent placement (CBD
brushing cytology non-diagnostic) and non-occlusive portal vein
thrombus started on enoxaparin who presented to the ED with
fever, jaundice, and confusion, found to have persistent
intrahepatic biliary dilation and gallbladder sludge on ___ US
s/p ERCP x2 with placement of plastic, then metal biliary stent
and EUS with pathology from FNB of CBD mass consistent with new
pancreatobiliary adenocardinoma.
ACUTE/ACTIVE PROBLEMS:
# Cholangitis
# Strep spp. (likely Enterococcus) bacteremia
# Adenocarcinoma pancreaticobiliary origin
He presented with fever, jaundice, and mental status changes.
RUQ US also showed persistent left intrahepatic biliary dilation
and gallbladder sludge despite the presence of CBD stent,
suggesting that the stent was non-functioning/occluded or there
was some other source of obstruction. The CBD brushing cytology
from his prior ERCP was non-diagnostic. He had no apparent mass
in the head of the pancreas on imaging but there remained some
concern for a primary pancreatobiliary tumor so he was planned
to have a repeat ERCP and EUS the week he was admitted.
Blood culture at ___ is growing Strep spp. He was treated with
Unasyn for cholangitis as well as Strep bacteremia. BCx here
grew Strep anginosus. He had an ERCP on ___ with removal of the
old stent and placement of a new stent over a 2cm
malignant-appearing stricture of the distal CBD. Cytology
brushings were sampled. EUS was completed on which they
visualized a 1.8 x 1.1 cm ill-defined hypoechoic area around the
distal CBD. FNB was performed x3. Pathology was consistent with
adenocarcinoma.
After the plastic stent placement, his LFTs did not improve and
bilirubin continued to rise. A repeat ERCP was done on ___ with
removal of the plastic stent and placement of a metal stent.
After this, his LFTs started to improve. His Unasyn was changed
to ceftriaxone and metronidazole for ease of dosing to complete
a 2 week course ___ - ___. A PICC was placed prior to
discharge. TTE did not show evidence of endocarditis.
# ___ on CKD
Cr peaked at 1.8 from baseline 1.2. Most likely this was
prerenal in the setting of cholangitis. It improved after ERCP,
antibiotics, and fluid resuscitation.
# PVT
He was found to have a non-occlusive portal vein thrombus on
MRCP during his recent hospital admission and was started on
enoxaparin. HIs home enoxaparin was initially held for ERCP,
then resumed.
# Macrocytic anemia
Macrocytic anemia is chronic. Baseline H/H appears to be ___,
so he is lower than baseline. He had no signs of bleeding.
Recent TSH, folate, B12, ferritin, and TIBC were wnl. Bilirubin
is predominantly direct, so less likely hemolysis. Other
hemolysis labs were not consistent with hemolysis. Acute on
chronic anemia is perhaps ___ bone marrow suppression from
sepsis. He was given 1 unit pRBCs for Hgb 7.6.
# Metastatic clear cell RCC on chemotherapy
He is followed at ___ by Dr. ___. He was diagnosed in
___ in workup of gross hematuria and flank pain. He underwent a
laparoscopic radical right nephrectomy in ___. He was found
to have metastases to the lungs, mediastinal lymph nodes, and
hilar lymph nodes in ___. In ___ he was enrolled in an
experimental trial and started on sunatinib. His most recent CT
showed clinical response. He is currently in his regularly
scheduled two weeks off on sunatinib. He had a surveillance CT
on ___ which showed no evidence of local recurrence of
metastatic disease in the abdomen/pelvis.
# LUL pneumonia
He was found to have LUL opacity on CT chest ordered for
surveillance. He was also complaining of cough. He was on Unasyn
while inpatient, then transitioned to ceftriaxone and
metronidazole for 2 weeks total, which should cover him for
pneumonia.
# HTN
Initially his home atenolol dose was halved due to concern for
cholangitis/impending sepsis. His home amlodipine 10 mg and
lisinopril 40 mg daily were also initially held. These were
resumed prior to or at discharge.
# Insulin-dependent DM type II
At home he takes glargine 16 units qhs if his FSBG is <170 and
he takes 18 units qhs if his FBSG is >170. While inpatient, he
was given glaring 8 units qhs as he was not taking much PO as
well as lispro SSI.
CHRONIC/STABLE PROBLEMS:
# Hypothyroidism - continued home levothyroxine
# Depression and anxiety - continued home fluoxetine; held home
cariprazine as it is non-formulary
Mr. ___ is clinically stable for discharge. The total time
spent today on discharge planning, counseling and coordination
of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
2. amLODIPine 10 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. cariprazine 1.5 mg oral DAILY
6. FLUoxetine 20 mg PO DAILY
7. Gabapentin 100 mg PO BID
8. GlipiZIDE 2.5 mg PO BID
9. Glargine 16 Units Bedtime
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. LORazepam 0.5 mg PO DAILY:PRN anxiety
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Prochlorperazine 5 mg PO Q8H:PRN nausea
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D 5000 UNIT PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Fenofibrate 48 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV once a
day Disp #*9 Intravenous Bag Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*27 Tablet Refills:*0
3. Glargine 16 Units Bedtime
4. amLODIPine 10 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Atenolol 100 mg PO DAILY
7. cariprazine 1.5 mg oral DAILY
8. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
9. Fenofibrate 48 mg PO DAILY
10. FLUoxetine 20 mg PO DAILY
11. Gabapentin 100 mg PO BID
12. GlipiZIDE 2.5 mg PO BID
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Lisinopril 40 mg PO DAILY
15. LORazepam 0.5 mg PO DAILY:PRN anxiety
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO DAILY
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. Prochlorperazine 5 mg PO Q8H:PRN nausea
20. Tamsulosin 0.4 mg PO QHS
21. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Cholangitis
Bacteremia
Adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after you were found to have a
blockage of your bile ducts causing a serious infection called
cholangitis. You were also found to have bacteria in your blood
stream. You underwent an ERCP with a plastic stent placed.
After the procedure your bilirubin continued to rise and you
underwent a second ERCP to place a metal stent.
For your serious infection you were started on IV antibiotics
and will need to continue this for two weeks.
This blockage in the bile duct was caused by a stricture.
Samples of the stricture were taken and found to be cancer
(adenocarcinoma). You were seen by the oncology team and have
follow up with them in a few days to talk about treatment
options.
It was a pleasure caring for you,
Your ___ Team
Followup Instructions:
___
|
10006269-DS-16 | 10,006,269 | 27,357,430 | DS | 16 | 2124-07-05 00:00:00 | 2124-07-06 07:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Biopsy during colonoscopy
Lumbar puncture
attach
Pertinent Results:
ADMISSION LABS:
___ 11:00AM WBC-10.0 RBC-4.66 HGB-8.4* HCT-30.9* MCV-66*
MCH-18.0* MCHC-27.2* RDW-20.1* RDWSD-45.3
___ 11:00AM NEUTS-85.1* LYMPHS-6.6* MONOS-7.7 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-8.47* AbsLymp-0.66* AbsMono-0.77
AbsEos-0.00* AbsBaso-0.02
___ 11:00AM PLT COUNT-225
___ 11:00AM GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-128*
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-18* ANION GAP-15
___ 11:00AM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-80 TOT
BILI-1.0
___ 11:00AM ALBUMIN-4.9
___ 07:20AM BLOOD Hypochr-1+* Anisocy-1+* Macrocy-1+*
Microcy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI
___ 11:42AM BLOOD Ret Aut-3.1* Abs Ret-0.13*
___ 07:20AM BLOOD calTIBC-371 VitB12-293 Folate-8
Ferritn-5.6* TRF-285
___ 11:42AM BLOOD Hapto-208*
___ 07:20AM BLOOD TSH-1.1
___ 07:20AM BLOOD 25VitD-17*
___ 03:30AM BLOOD IgA-162
___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-146* RBC-7*
POLYS-1 ___ MONOS-12 BASOS-1 OTHER-0
___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-141* RBC-2
POLYS-1 ___ MONOS-3 OTHER-0
___ 03:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-100*
GLUCOSE-57
___ 11:00AM Lyme Ab-NEG
___ 04:45PM BLOOD Trep Ab-NEG
___ 07:20AM BLOOD HIV Ab-NEG
___ 03:05PM BLOOD Parst S-NEGATIVE
MICRO:
___ 3:40 pm CSF;SPINAL FLUID
Site: LUMBAR PUNCTURE
TUBE #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
HSV CSF HSV2 + low positive
IMAGING:
CT head w/o acute intracranial process
Discharge Labs:
___ 06:00AM BLOOD WBC-5.6 RBC-3.79* Hgb-7.2* Hct-27.1*
MCV-72* MCH-19.0* MCHC-26.6* RDW-22.1* RDWSD-56.4* Plt ___
___ 06:00AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-143
K-3.9 Cl-111* HCO3-21* AnGap-11
___ 06:00AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7
___ 05:45AM BLOOD Hapto-126
___ 07:20AM BLOOD TSH-1.1
___ 05:50AM BLOOD CEA-1.9
___ 03:30AM BLOOD IgA-162
Colonoscopy:
Circumferential mass of malignant appearance was found in the
distal rectum completely encircling the rectal verge. There were
local ulcerations in the 12 o'clock position. Multiple cold
forceps biopsies were performed for histology in the rectal
mass.
EGD:
Normal erythema in the whole esophagus. Erythema in the antrum
with gastritis. Erythema in the duodenum compatible with
duodenitis.
Brief Hospital Course:
Hospital Medicine Attending Progress Note
Time patient seen and examined today
HPI on Admission:
Mr. ___ is a ___ male with a PMHX of partial aortic
dissection, HTN, who presents w/ HA & fever x2d concerning for
meningitis.
Patient reports that 3 days ago, he developed malaise and
terrible headache: constant, dull, diffuse. The following day,
headache was relenting ___ pain. Also had fever of 102 and
took tylenol/ibuprofen without relief of symptoms. He reports
nausea and decreased PO intake. Denies vision changes,
sensitivity to light, syncope, URI sx, chest pain, shortness of
breath, abd pain, diarrhea/constipation, sick contacts. Has mild
neck stiffness as well. He lives in ___, does a lot of
yardwork. Has had exposure to ticks, mosquitoes, but none he
memorably recalls recently. No recent travel hx. No rash. He was
feeling entirely well prior to onset of these symptoms. Given
terrible headache and fever, he presented to the ED.
Hospital Course to Date:
The pt was admitted for acute onset headache and fever. LP
showed a cell count of 141 with lymphocytic predominance and
elevated protein to 100. He was initially started on bacterial
meningitis coverage, then narrowed to acyclovir based on
negative CSF stain and cultures. Doxycycline was added to cover
potential lyme
meningitis. The pt's CSF came back positive for HSV PCR. Per ID
recommendations from ___: "Would recommend continuing on
Acyclovir for now but when safe for discharge can change to
Valtrex 1 gram po three times per day to complete 14 day course.
In setting of only low positive HSV 2 PCR and extensive outdoor
activity would also complete 14 day course of doxycycline even
though lyme is less likely." The pt improved dramatically. His
headache resolved. Throughout his hospitalization, he had no
confusion or neurologic deficits. He was transitioned to oral
acyclovir the day before discharge and discharged on PO
acyclovir + PO doxycycline for a total 14 day course.
Of note, the pt was incidentally found to have an abnormally low
Hb on admission. He required 1u PRBC transfusion ___. He denies
any known bleeding. GI was consulted and recommended EGD +
colonoscopy, performed ___. EGD showed diffuse erythema of
the mucosa with no bleeding noted in the antrum, consistent with
gastritis. Colonoscopy showed a circumferential mass of
malignant appearance in the distal rectum completely encircling
the rectal verge. There were local ulcerations in the 12:00
position. Colorectal surgery was consulted. They recommended
follow up at the colorectal cancer clinic. Follow up was
arranged prior to discharge and the pt was aware of the
diagnosis and need for follow up. The clinic and colorectal
surgery asked for a baseline CEA which was normal. They asked
for a staging MRI pelvis which did not show any spread of the
presumed cancer. Pathology was sent by GI. Initial pathology
showed superficial fragments of tubulovillous adenoma. This was
pending at the time of discharge, though initial reports had
shown the same diagnosis, so the pt was instructed to follow up
with GI. The GI phone number was shared with the patient and he
was instructed to call them directly if he did not hear from the
clinic within 24 hours. The pt received a total of 2u PRBCs this
hospitalization. Hb was 7.2 on the morning of discharge and the
pt received 1u PRBCs (the second unit this stay) on the day of
discharge after the Hb of 7.2 in order to ensure that his Hb did
not drop below 7.0 at home. Close follow up was arranged prior
to discharge. The pt had no active bleeding at the time of
discharge. Return to ER precautions such as dizziness and
increased bleeding were reviewed with the patient.
The pt's BP meds were held on admission but restarted prior to
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS:PRN insomnia
2. Citalopram 20 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*12 Capsule Refills:*0
3. Pantoprazole 40 mg PO DAILY
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. ValACYclovir 1000 mg PO TID
RX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth three
times a day Disp #*18 Tablet Refills:*0
5. Citalopram 20 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Viral meningitis ___ HSV
Iron deficiency anemia
Rectal cancer
Discharge Condition:
Stable for outpatient follow up
Discharge Instructions:
Dear ___,
You came to the hospital with severe headache and fevers. You
were found to have a viral meningitis with testing showing
herpes simplex virus to be the cause. Please continue taking
Valtrex and doxycycline until ___ to treat this infection.
When you were in the hospital, you were found to have iron
deficiency anemia. You were seen by the Gastroenterologists.
You underwent an EGD and a colonoscopy. The EGD showed a little
stomach irritation. Avoid ibuprofen, higher dose aspirin, and
naproxen. Take pantoprazole to help with the irritation. There
was no cancer found in the stomach. The colonoscopy showed a
rectal cancer. Please follow up as instructed with
gastroenterology for a better pathology sample and with the
multi-disciplinary colorectal cancer team as instructed.
Your appointment with the multi-disciplinary team has already
been set up.
Call the ___ clinic to set up an appointment
with them, in order for them to get a better sample of the
tumor. This is needed for the pathologists and oncologists. If
you do not hear from the office within 48 hours, call them at:
___.
We wish you the best in your recovery.
-- Your medical team
Followup Instructions:
___
|
10006431-DS-22 | 10,006,431 | 27,715,811 | DS | 22 | 2128-03-07 00:00:00 | 2128-03-16 02:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ w/ HTN, DL, congenital
deafness, and recently diagnosed borderline resectable
pancreatic
head adenocarcinoma, on neoadjuvant C1D21 Folfirinox who
presents
for diarrhea for two days.
She had ERCP with stent placement done yesterday. No
complications with that. She reports multiple episodes of watery
brown non-bloody diarrhea for the past two days. She reports not
eating or drinking as much over the past several months. Also
some nausea on and off over the same time period. She reports
mild gas pain but denies abdominal pain and vomiting.
In ED, initial vitals were Temp 97.7, HR 91, BP 102/65, RR 15,
O2
sat 98% RA. She received 1L NS. CXR was negative for infection.
Vitals prior to transfer were Temp 98.1, HR 77, BP 106/66, RR
16,
O2 sat 100% RA.
On arrival to the floor, she reports that she is feeling well.
She denies fevers/chills, headache, dizziness/lightheadedness,
shortness of breath, cough, chest pain, palpitations, abdominal
pain, vomiting, constipation, dysuria, and rashes.
Past Medical History:
HTN
congenital deafness
GERD
Goiter
Social History:
___
Family History:
Father passed away from complications of gangrenous colitis.
Mother with T2DM.
Sister with colon CA.
Sister deceased, ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.3, BP 125/89, HR 69, RR 18, O2 sat 100% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: Alert, oriented, good attention and linear thought, CN
II-XII intact. Strength full throughout.
SKIN: No significant rashes.
Brief Hospital Course:
___ is a pleasant ___ w/ HTN, DL, congenital deafness, and
recently diagnosed borderline resectable pancreatic head
adenocarcinoma, on neoadjuvant C1D21
Folfirinox who presents for diarrhea for two days.
Diarrhea- She has 2 loose watery diarrhea everyday mostly at AM.
Her stool c diff was negative. She was started on Imodium and
the dose was titrated up to 4mg TID but she still continued to
have loose watery diarrhea. Her diarrhea is most likely from
Irinotecan. She was also started on peptobismol to help her
diarrhea
Elevated Lipase- She had a mild elevation of lipase levels but
this is likely from her having a ERCP on the day prior to
admission. She does not have any epigastric abdominal pain or
lipase levels high enough to suspect pancreatitis.
Her blood and urine cultures were negative during this
admission. She was discharged home in a stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. LORazepam 0.5 mg PO BID:PRN anxiety,nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
6. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
7. Dexamethasone 4 mg PO BID
Discharge Medications:
1. Bismuth Subsalicylate 30 mL PO TID
___ cause black discoloration of stool
RX *bismuth subsalicylate [Bismatrol] 525 mg/15 mL 15 ml by
mouth three times daily Refills:*0
2. LOPERamide 4 mg PO Q8H
RX *loperamide 2 mg 2 tablets by mouth three times daily Disp
#*50 Capsule Refills:*1
3. Dexamethasone 4 mg PO BID
take for 2 days after chemotherapy
4. Lisinopril 20 mg PO DAILY
5. LORazepam 0.5 mg PO BID:PRN anxiety,nausea
RX *lorazepam 0.5 mg 1 tablet by mouth twice daily Disp #*30
Tablet Refills:*1
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
9. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea-likely from Irinotecan.
Pancreatic cancer
Discharge Condition:
stable
alert and oriented to time place and person
independent ambulation
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you. You were admitted since
you developed loose stools. We found out that you had no
infections causing the diarrhea. It is likely a adverse reaction
from chemotherapy agent.
Please take Imodium and Peptobismol as directed until your
diarrhea is controlled.
Please follow up for your appointment with ___ on
___.
Sincerely,
___ MD
Followup Instructions:
___
|
10006431-DS-23 | 10,006,431 | 28,771,670 | DS | 23 | 2128-03-30 00:00:00 | 2128-03-30 16:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Nausea/vomting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with with HTN, DL,
congenital deafness, and borderline resectable pancreatic head
adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with
nausea/vomiting, diarrhea, and inability to tolerate POs.
Patient reports continued diarrhea as well as nausea/vomiting
that has not been controlled with home medications. She was seen
in clinic on ___ where she noted diarrhea for one week and
was given immodium, Zofran, and 1L NS. She had been taking Pepto
Bismal. Stool studies were ordered however patient unable to
give
a sample and attempted to be done at outside facility but not
processed. She continued to have diarrhea and poor PO intake due
to nausea and poor appetite. She tried immodium without
significant improvement. She wants to stop chemo due to the side
effects.
Of note, she was recently admitted ___ to ___ with
diarrhea. Stool studies were negative. She was started on
immodium and pepto bismal.
On arrival to the ED, initial vitals were 97.9 80 118/71 16 100%
RA. Labs were notable for WBC 3.0, H/H 13.0/39.8, Plt 248, Na
134, K 3.5, BUN/Cr ___, LFTs wnl, INR 1.2, and UA bland. CT
abdomen was negative for acute process. Patient was given Zofran
4mg IV x 2 and 1L Ns at 100 cc/hr. Vitals prior to transfer were
98.0 99 117/90 18 99% RA.
On arrival to the floor, patient reports that she is feeling
better. She is able to drink without nausea. She denies
fevers/chills, headache, dizziness/lightheadedness, vision
changes, weakness/numbness, shortness of breath, cough, chest
pain, palpitations, and dysuria.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ has a history of hypertension, congenital
deafness, and GERD, and presented in early ___ to ___ with painless jaundice. At the time, she also
noted several weeks of nausea, vomiting, postprandial abdominal
pain and a 20-pound weight loss. She was referred to ___ where
she underwent ERCP. This study identified a stricture in the
common bile duct due to external compression. Brushings were
atypical. Her CA ___ was elevated at 180 U/mL. She underwent
endoscopic ultrasound ___. This study identified a
1.8
x 1.6 cm pancreatic head mass without vascular involvement.
Biopsy by ___ showed adenocarcinoma. CT angiogram also
showed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding
but no definite involvement at the SMA and SMV. There was no
evidence of distant metastases. Ms. ___ was diagnosed with
borderline resectable PDA and initiated chemotherapy with
neoadjuvant FOLFIRINOX ___. C1D15 dose reduced for N/V/D.
She underwent biliary stent change and was then hospitalized
___ with persistent diarrhea and leukocytosis.
PAST MEDICAL HISTORY:
1. Hypertension
2. Congenital deafness
3. GERD
4. Goiter
5. History of nephrolithiasis
6. Hypercholesterolemia
7. Status post C-section x 2
Social History:
___
Family History:
The patient's father died of an MI at ___ years.
Her mother died with type 2 diabetes mellitus. A sister died
with
colon cancer at ___ years. Another sister died of ___
disease. She has two sons without health concerns.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.2, BP 154/84, HR 99, RR 18, O2 sat 98% RA.
___: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: Alert, oriented, good attention and linear thought, CN
II-XII intact. Strength full throughout.
SKIN: No significant rashes.
Discharge PE:
97.7 142 / 80 82 18 97 RA
___: Well appearing, lying in bed in NAD
Eyes: PERLL, EOMI, sclera anicteric
ENT: MMM, oropharynx clear without exudate or lesions
Respiratory: CTAB without crackles, wheeze, rhonchi, though
breath sounds reduced at bases.
Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or
gallops
Gastrointestinal: Soft, nontender, nondistended, +BS, no masses
or HSM
Extremities: Warm and well perfused, no peripheral edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert and oriented x3
Pertinent Results:
ADMISSION LABS:
___ 10:35AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:35AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 04:29AM GLUCOSE-103* UREA N-10 CREAT-0.5 SODIUM-134
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19
___ 04:29AM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-60 TOT
BILI-0.4
___ 04:29AM LIPASE-33
___ 04:29AM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-2.3*
MAGNESIUM-1.6
___ 04:29AM WBC-3.0*# RBC-4.66 HGB-13.0 HCT-39.8 MCV-85
MCH-27.9 MCHC-32.7 RDW-15.0 RDWSD-45.9
___ 04:29AM NEUTS-41 BANDS-3 ___ MONOS-21* EOS-2
BASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-1.32* AbsLymp-0.99*
AbsMono-0.63 AbsEos-0.06 AbsBaso-0.00*
___ 04:29AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-3+ TEARDROP-OCCASIONAL
___ 04:29AM ___ PTT-22.7* ___
DISCHARGE LABS:
___ 06:17AM BLOOD WBC-7.6 RBC-4.35 Hgb-12.0 Hct-36.5 MCV-84
MCH-27.6 MCHC-32.9 RDW-15.4 RDWSD-46.3 Plt ___
___ 06:17AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-137 K-4.0
Cl-99 HCO3-29 AnGap-13
___ 06:17AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ C diff, stool studies negative
IMAGING:
___ CXR
IMPRESSION:
In comparison with the study of ___, there is little
interval change. The cardiac silhouette remains within normal
limits with no evidence of vascular congestion or acute focal
pneumonia. There is blunting of the left costophrenic angle on
the lateral view, suggesting small interval pleural effusion.
The right Port-A-Cath again extends to the lower SVC.
___ CT A/P
IMPRESSION:
1. No evidence of acute intra-abdominal process.
2. Pancreatic head hypodensity is unchanged and associated
peripancreatic soft
tissue density is less conspicuous, potentially due to interval
improvement or
differences in technique.
3. Left pelvic vein engorgement and left gonadal vein
enlargement are
nonspecific findings but may be seen in the setting of pelvic
congestion
syndrome.
Brief Hospital Course:
___ female with with HTN, congenital deafness, and
borderline resectable pancreatic head adenocarcinoma on
neoadjuvant C2D12 Folfirinox who presents with nausea/vomiting,
diarrhea, and inability to tolerate POs.
# Diarrhea/Nausea/Vomiting: Most likely due to side effects of
FOLFIRINOX. Abdominal CT without acute process and exam benign.
Similar symptoms in past after chemotherapy. Less likely
infection especially given negative stool studies. C. diff
negative so after consultation with outpatient oncologist,
treated with typical antidiarrheal regimen of loperamide and
lomotil with resolution of diarrhea. Beginning to improve,
mildly increased PO intake but solid foods still limited.
Diarrhea largely resolved. After discussion with patient and
outpatient oncologist was started on Decadron 2 mg PO daily to
help improve appetite/reduce nausea in order to allow adequate
PO intake for safe discharge.
- Continue 2mg dexamethasone daily, likely will stop after 7 day
course if continued improvement
- Continue anti-emetic regimen
- Continue PPI
#Cough: Having cough intermittently productive of yellow sputum.
Lung exam reassuring, CXR shows no evidence of pneumonia,
afebrile without leukocytosis.
-Monitor off antibiotics, if symptoms worsening consider repeat
chest imaging
-Cont IS
-Encourage ambulation
# Pancreatic Cancer/neutropenia: s/p FOLFIRINOX cycle 2 on ___.
GI sx likely ___ further plans
for
administration of this drug. Neutropenic with ANC ___,
likely ___ recent chemotx, no fevers to date, WBC now improved
with ANC >2800. Will follow with Dr. ___.
- Continue tramadol for pain
# HTN:
- Lisinopril was held initially, restarted on discharge
# Anxiety: She reports having anxiety about leaving the hospital
as after multiple recent discharges she quickly went to a local
ED. She was counseled extensively that she had made gradual
improvement and there was no further treatment recommended in
the hospital at this time.
-Consider outpatient social work or palliative care referral to
help with anxiety and symptom management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO BID:PRN anxiety,nausea
2. Omeprazole 20 mg PO DAILY
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
5. Bismuth Subsalicylate 30 mL PO TID:PRN
diarrhea/nausea/abdominal pain
6. LOPERamide 4 mg PO TID:PRN diarrhea
7. Dexamethasone 4 mg PO BID
8. Lisinopril 20 mg PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
10. ___ ___ UNIT PO QID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Dexamethasone 2 mg PO DAILY Duration: 7 Days
RX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
4. Bismuth Subsalicylate 30 mL PO TID:PRN
diarrhea/nausea/abdominal pain
5. Lisinopril 20 mg PO DAILY
6. LOPERamide 4 mg PO TID:PRN diarrhea
7. LORazepam 0.5 mg PO BID:PRN anxiety,nausea
8. ___ ___ UNIT PO QID
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary: Chemotherapy-related nausea
Secondary: Pancreatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for nausea/vomiting/diarrhea and
inability to tolerate food after your recent chemotherapy. You
were given medicine which resolved your diarrhea and helped with
nausea. Since you continued to have difficulty eating, you were
started on a course of steroids.
Please follow up with your oncologist to determine your ongoing
chemotherapy plans.
It was a pleasure caring for you,
Your ___ Healthcare Team
Followup Instructions:
___
|
10006457-DS-13 | 10,006,457 | 27,894,366 | DS | 13 | 2147-12-17 00:00:00 | 2147-12-17 14:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine Sulfate / Codeine / Dilaudid (PF)
Attending: ___.
Chief Complaint:
Dizziness, fatigue, and possible syncopal episode x 2 weeks.
Major Surgical or Invasive Procedure:
Carotid endarterectomy (CEA)
History of Present Illness:
___ is a ___ right handed woman with PMH of HTN, HL,
DM II c/b peripheral neuropathy, current smoking, an episode of
pericarditis, family history of early MI, and poor previous
medical care (has not seen a physician in over ___ years), who
initially presented with HTN (SBP 190-210) and nonspecific
symptoms of postural lightheadedness, bilateral hand numbness
and tingling, left retro-orbital headaches, some transient
visual blurring, and a possible syncopal episode.
Past Medical History:
PmHX:
DMII - ___ years, complicated with neuropathy and retinopathy.
pericarditis
HTN
Hyperlipidemia
abd pain, s/p x-lap ___, unrevealing; appendectomy
ETT ___ with small anterior defect (likely artifact). EF 73%.
Nephrolithiasis
ALL: Codeine, morphine, dilaudid - all cause nausea, vomiting,
itching
Social History:
___
Family History:
No family history of neurologic disease including stroke,
seizures, movement disorders, demyelinating diseases, or
migraines.
# Mother: ___
# Father: Fatal MI at age ___.
# Siblings: Three sisters and one brother, all well.
Physical Exam:
PER OMR on ___
T 98.8 BP 115/74 (110-150s) HR 79 RR 18 O2 100% RA
Blood glucose ranging from 200-252
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, soft bruit in left neck, high by the angle of jaw.
Pulmonary: CTABL
Cardiac: RRR, III/VI murmur in mitral area
Abdomen: soft, nontender, nondistended
Extremities: no edema, warm to palpation
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, ___ and ___.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL briskly, L>R by <1mm. VFF to confrontation.
III, IV, VI: Some difficulty with smooth pursuit but EOMI
without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: R NLF, symmetric activation
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. Mild atrophy of small
muscles of hand/feet. +R pronator drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+ 5 4+ 5 5 4 4
R 4+ 5 4+ ___ 4+ 4+ 5 4 5 5 4 4
-Sensory: No deficits to light touch throughout. Decreased
vibration at the toes bilaterally. Decreased pinprick to just
below the knees bilaterally. Decreased proprioception at the
toes
> fingers.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was tonically extensor.
-Coordination: Mild dysmetria on FNF on R, worse when eyes
closed
?related to proprioceptive loss. Somewhat slow/clumsier on R
hand
with finger tapping and rapid alternating movement.
-Gait: +Romberg. Somewhat unsteady gait but not broad based.
Pertinent Results:
ADMISSION LABS
___ 07:53PM BLOOD WBC-8.5 RBC-4.82 Hgb-14.7 Hct-42.0 MCV-87
MCH-30.5 MCHC-35.1* RDW-12.3 Plt ___
___ 07:53PM BLOOD Neuts-63.0 ___ Monos-3.9 Eos-2.1
Baso-1.1
___ 06:10AM BLOOD ___ PTT-29.5 ___
___ 07:53PM BLOOD Glucose-152* UreaN-17 Creat-0.8 Na-138
K-3.7 Cl-98 HCO3-28 AnGap-16
PERTINENT LABS
___ 07:53PM BLOOD ALT-19 AST-24 CK(CPK)-212* AlkPhos-81
TotBili-1.1
___ 07:53PM BLOOD Calcium-9.9 Phos-3.3 Mg-1.6
___ 07:53PM BLOOD Lipase-53
___ 07:53PM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:10AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:10AM BLOOD VitB12-PND
___ 06:10AM BLOOD %HbA1c-9.3* eAG-220*
___ 06:10AM BLOOD Triglyc-PND HDL-PND LDLmeas-PND
DISCHARGE LABS
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
___ 9.6 4.13* 12.3 35.7* 87 29.7 34.3 12.6 256
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:15 173 9 0.6 138 3.9 ___
Calcium Phos Mg
___ 8.6 3.9 2.0
MICRO
__________________________________________________________
___ 6:10 am SEROLOGY/BLOOD CHEM # ___ ___.
RAPID PLASMA REAGIN TEST (Pending): NON-REACTIVE
__________________________________________________________
___ 9:00 pm URINE 802S.
URINE CULTURE (Pending): MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 8:32 pm BLOOD CULTURE
Blood Culture, Routine (Pending): NO GROWTH.
__________________________________________________________
___ 7:53 pm BLOOD CULTURE
Blood Culture, Routine (Pending): NO GROWTH.
STUDIES
___: CTA NECK W&W/OC & RECONS
IMPRESSION:
Increase in size of hypodensities in the left basal ganglia and
left
frontal lobe compared to the previous MR, which could represent
evolution of the infarct; however, new infarcts are also
possible. Consider MRI to
evaluate for acute or progressive infarct if clinically
indicated. The left common carotid artery is widely patent
status post endarterectomy.
Patent right carotid arterie, vertebral arteries and major
branches.
___: MR HEAD W/O CONTRAST
IMPRESSION: Multiple, predominantly left infarctions as above,
with interval increase in the size of infarctions seen
previously, as well as multiple new foci of infarction,
including a right paramedian focus. A small amount of interval
susceptibility artifact in the confluent left frontal infarction
suggests minimal interval intracranial blood.
___: MR HEAD W/O CONTRAST
IMPRESSION: Redemonstration of numerous bilateral cerebral foci
of abnormally slow diffusion consistent with infarction, overall
unchanged from the most recent comparison. A small amount of
left frontal hypointensity on gradient-echo imaging suggesting
blood products seen on the most recent examination is no longer
apparent.
Brief Hospital Course:
___ woman h/o HTN, DMII c/b neuropathy and retinopathy, daily
tobacco abuse, alcohol dependence, presented with postural
lightheadedness, visual obscurations, bilateral hand tingling
and numbness. She also had fluctuating inattentiveness. Was
initially admitted to medicine, but MRI showed scattered
punctate left hemisphere deep ___ infarctions as well as one in
the splenium of the CC. MRA shows what looks like critical
stenosis of the left carotid bifurcation
___:
- Patient presented to ED with dizziness and subtle left-sided
weakness with high BP (194/95). In the ED, she remained quite
hypertensive (SBP 190-210), and all parts
of neurological examination were normal except for a mild distal
symmetric peripheral neuropathy in a stocking distribution.
Overnight, her blood pressures were improved, remaining in the
130-140s, with blood sugars in the 200-250 range. She spiked one
low grade fever to 100.2 while in house, but this spontaneously
resolved. On my examination, she had a delayed reaction time and
was quite indifferent and dysprosodic. There was a paucity of
emotionality and facial expressions. She had no aphasia or
dysarthria, and followed commands well. There was no neglect.
The remainder of the examination was unremarkable.
___: With the nonspecific findings on examination, the
patient was admitted to the medicine service for a presumed
hypertensive emergency. She was started on a baby aspirin. An
MRI was recommended, and identified multiple small areas of
restricted diffusion in the left hemisphere and splenium all
consistent with a shower of emboli from a proximal embolic
source. An MRA done at that time showed the presence of a
stenosed left carotid bifurcation. Labs showed hyperglycemia and
an elevated A1c to 9.3, consistent with poorly controlled DM.
Her lipid panel returned showing an elevated TC (277), elevated
LDL (169) and normal HDL(46). Her UA showed a urinary tract
infection, and so she was started on ceftriaxone. Upon discovery
of the stroke, the patient has been transferred to the neurology
stroke service for continued work up and care.
Echo on ___ showed:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function
(LVEF >55%). No valvular pathology or pathologic flow
identified.
No structural cardiac cause of syncope identified.
Carotid Duplex on ___ showed:
IMPRESSION:
Significant stenosis at the origin of the left internal carotid
artery, estimated between 80 and 99%. On the right, there is
also significant stenosis at the origin of the ICA, with
estimated 40-59% narrowing.
___: In light of discovering significant stenosis at the
origin of the left internal carotid artery, estimated between 80
and 99%, urgent vascular surgery consult was initiated and
heparin gtt was started (goal 50-70, PTT q6h).
- Will stop ASA 325mg daily while on heparin drip
- HOB down and allow BP autoregulation.
- Continue atorvastatin 40mg daily
- Supportive care with insulin sliding scale, PRN tylenol, CIWA
scale, nicotine patch, etc.
- Continue ceftriaxone for UTI
- ___ consult
- Placed SW consults in light of poor previous medical care, new
diagnosis.
The patient underwent emergent left CEA on ___ (see
operative note for details). The patient tolerated the procedure
well, was extubated in the OR and was taken to the recovery room
in stable condition.
Overnight on ___, the patient experienced confusion and
weakness of the right upper extremity; anisocria was seen on
examination. Neurology was consulted who recommended avoidance
of hypotension with goal SBP 120-160, continue aspirin/statin
and repeat MRI of head to look for additional infarcts. A CTA of
the head and neck was performed on ___ that showed increase
in size of hypodensities in the left basal ganglia and left
frontal lobe compared to the previous MR with possibility of new
infarcts. This was followed by a MR1 Head that confirmed the
presence of multiple, predominantly left infarctions as above,
with interval increase in the size of infarctions, as well as
multiple new foci of infarction, including a right paramedian
focus. There was also concern for a left frontal hypointensity
on gradient-echo imaging suggesting blood products.
The next day on ___ the patient complained of headache so
Neurology was consulted again who recommended obtaining a repeat
CT brain to document stability of
the left frontal lobe petechial hemorrhage. The patient's
aspirin and SQH were held and an MRI Head w/o contrast was
performed on ___. The repeat MRI confirmed resolution of
hemorrhage seen the previous day. That same day the patient
underwent a speech/swallowing evaluation the next day following
which her diet was progressed. ___ were on board throughout
the ___ hospital stay.
On ___, the patient's motor function appeared to be stable
(barring some fluctuation due to difficulty with cooperating)
and there was improvement in
speech so the goal was to achieve normotension with a SBP <150,
avoid hypotension, continue aspirin/statin, re-start heparin SQ
TID for DVT prophylaxis, diabetic diet/heart healthy diet, and
insulin sliding scale for goal normoglycemia.
___ was consulted, given the patient's
uncontrolled blood sugar levels and HBA1C of 9%, following which
she was started on oral hyperglycemics and
Humalog sliding scale.
Over ___, the patient has continued to make excellent
progress. Her medical issues are well under control and after
soliciting re-evaluation from Neurology and ___
___ she was deemed stable for discharge to an acute rehab
facility of her family's choice in ___. There the patient
will continue to receive extensive ___ and speech therapy and
will follow up with Vascualr Surgery, Neurology and ___
___ in the coming weeks.
Medications on Admission:
None.
Discharge Medications:
1. Senna 1 TAB PO BID:PRN constipation
2. Acetaminophen 1000 mg PO Q6H:PRN pain
3. Aspirin EC 325 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
5. Heparin 5000 UNIT SC TID
6. Metoprolol Tartrate 12.5 mg PO TID
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
7. GlipiZIDE 5 mg PO DAILY
RX *glipizide 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin [Glucophage] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
9. Insulin SC
Sliding Scale
Fingerstick QID
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog] 100 unit/mL As per attached
schedule Up to 10 Units QID per sliding scale Disp #*2 Cartridge
Refills:*0
10. Nicotine Patch 7 mg TD DAILY
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
Duration: 1 Weeks
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-325 mg-40 mg
___ tablet(s) by mouth three times a day Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left-sided carotid stenosis s/p Left Carotid Endarterectomy
(___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires supervision because of
some motor weakness on the right upper extremity.
Discharge Instructions:
Please monitor your blood glucose levels frequently and alter
insulin dose according to the attached Insulin Sliding Scale
guidleines.
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR: ___
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
10006513-DS-13 | 10,006,513 | 28,504,108 | DS | 13 | 2125-05-07 00:00:00 | 2125-05-09 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nephrolithiasis, acute kidney injury
Major Surgical or Invasive Procedure:
Cystoscopy, left ureteral stent placement.
History of Present Illness:
___ yo diabetic male, found to have at least 2 separate left
ureteral stones, 4 mm at left UVJ and 6 mm at proximal ureter.
His UA is unremarkable and he is without fevers. His creatinine
is elevated to 1.4 on arrival and 1.5 on recheck after fluids.
Discussed this with the patient, and ultimately recommended
cystoscopy and placement of left ureteral stent for
decompression given his elevated creatinine.
Past Medical History:
Problems (Last Verified - None on file):
DIABETES TYPE II
NEPHROLITHIASIS
Surgical History (Last Verified - None on file):
No Surgical History currently on file.
Social History:
___
Family History:
No Family History currently on file.
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 10:36PM BLOOD WBC-10.1* RBC-5.54 Hgb-14.2 Hct-44.0
MCV-79* MCH-25.6* MCHC-32.3 RDW-12.9 RDWSD-36.7 Plt ___
___ 10:36PM BLOOD Neuts-64.3 ___ Monos-6.9 Eos-2.9
Baso-0.4 Im ___ AbsNeut-6.50* AbsLymp-2.49 AbsMono-0.70
AbsEos-0.29 AbsBaso-0.04
___ 06:28AM BLOOD Glucose-193* UreaN-13 Creat-1.4* Na-143
K-4.9 Cl-107 HCO3-24 AnGap-12
___ 05:39AM BLOOD Glucose-91 UreaN-15 Creat-1.5* Na-139
K-4.8 Cl-102 HCO3-24 AnGap-13
___ 10:36PM BLOOD Glucose-260* UreaN-18 Creat-1.4* Na-135
K-4.6 Cl-99 HCO3-18* AnGap-18
___ 10:36PM BLOOD ALT-23 AST-14 AlkPhos-93 TotBili-0.2
___ 06:28AM BLOOD Calcium-8.8 Mg-2.0
___ 10:36PM BLOOD Albumin-4.0
___ 03:16AM BLOOD Lactate-1.6
___ 12:35AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:35AM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 12:35AM URINE RBC-14* WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 12:35AM URINE Mucous-RARE*
___ 01:05PM OTHER BODY FLUID STONE ANALYSIS-PND
___ 12:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. ___ is known to Dr. ___ previous treatment of
uric acid renal stones. He has had ___ days of vomiting and left
flank pain and came to the emergency room last night. CT scan
revealed proximal and distal left ureteral stones. His
creatinine was elevated from baseline of ___. Based on his
constellation of
symptoms and the acute kidney injury, we decided to bring him to
the operating room today for left ureteral stent placement. He
was taken urgently for obstructing left ureteral stones with
acute kidney injury and underwent cystoscopy, left ureteral
stent placement. He tolerated the procedure well and recovered
in the PACU before transfer to the general surgical floor. See
the dictated operative note for full details. Overnight, the
patient was hydrated with intravenous fluids and received
appropriate perioperative prophylactic antibiotics. Intravenous
fluids and Flomax were given to help facilitate passage of
stones but toradol was held given his acute kidney injury. On
POD1 his creatinine bumped to 1.6 from 1.4. At discharge on
POD1, patients pain was controlled with oral pain medications,
tolerating regular diet, ambulating without assistance, and
voiding without difficulty. He was explicitly advised to follow
up for future procedures to include ureteral stent
removal/exchange, definitive stone management. He was
discharged with antibiotics and sodium bicarb tablets and
advised to have a recheck of his lab work in ___ days after
discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlipiZIDE 20 mg PO DAILY
3. Januvia (SITagliptin) 100 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cephalexin 250 mg PO Q6H Duration: 7 Days
RX *cephalexin 250 mg ONE tablet(s) by mouth Q6hrs Disp #*28
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #*10 Tablet
Refills:*0
5. Pravastatin 80 mg PO DAILY
6. Sodium Bicarbonate 650 mg PO TID
RX *sodium bicarbonate 650 mg ONE tablet(s) by mouth three times
a day Disp #*28 Tablet Refills:*0
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg ONE capsule(s) by mouth DAILY Disp #*30
Capsule Refills:*0
8. amLODIPine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. GlipiZIDE 20 mg PO DAILY
11. Januvia (SITagliptin) 100 mg oral DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13.Outpatient Lab Work
Please have repeat lab work (Chem 7) through your PCP ___ ___
days after discharge (to check your kidney function). Call to
arrange when you get home today.
Discharge Disposition:
Home
Discharge Diagnosis:
nephrolithiasis; Obstructing left ureteral stones
acute kidney injury
urinary tract infection (E.Coli)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-For pain control, try TYLENOL FIRST, then ibuprofen, and then
take the narcotic pain medication as prescribed if additional
pain relief is needed.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
Followup Instructions:
___
|
10006692-DS-5 | 10,006,692 | 29,746,536 | DS | 5 | 2165-05-13 00:00:00 | 2165-05-14 07:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
CHIEF COMPLAINT: Headache, RLE cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Pt is a ___ year old ___ speaking M w/ PMH of CAD s/p CABG,
HTN and HLD presenting to the ED with hypertension recorded at
home, found to have RLE cellulitis. Per pt, on the day prior to
admission, he began to experience RLE leg pain that was
described as more discomfort. This was followed one hour later
by an acute onset of headache, chills, shivering/shaking and
felt feverish. Pt felt warm to the touch but Temp taken at home
was not elevated. Pt took Excedrin at the time of symptom onset,
checked his BP at home which showed a reading of 211/110. Pt
took 2 doses of Captopril 25mg tablets, and came into the ___
ED for further evaluation. Of note, pt reports that he has had
well controlled BP on a beta blocker (trade name: ___ 25mg
x1 a day, a Bblocker not available in the US), with baseline BPs
in the 120s/50s per home readings. Pt had been fasting for
___ in the day-light hours, but of note, he has been fasting
for ___ but states he has been taking his BP meds, as well
as his Aspirin 81mg and Lipitor 40mg.
In the ED, initial vitals were: 97.7 98 ___
- Labs were significant for Labs were significant for initial
Wbc of 9.6 which increased to 17.8 (initial Diff 93.2%N), low
Phos at 1.4, low Mg of 1.5 but otherwise normal Mg and lactate
of 1.6. Pt received ___, CT head, and Chest CXR were negative
for acute process.
- The patient was given 500NS bolus, 125ml/hr maintenance.
Cefazolin, Vanc, Ceftriaxone, Tylenol and , IV Mag, IV Phos + 3
packets NeutraPhos, Potassium Chloride 40 mEq
- EKG was notable for 1mm STD V3-V4 and TWI when BP was in 200's
systolic. First trop neg and second value .02. Repeat ECG after
control of BP shows sub-1mm STD in V3-V4. Trop resolved.
- Cards was consulted who believed patient had demand ischemia
in setting of febrile cellulitis and hypertensive emergency
which resolved. They had no suspicion of plaque rupture and no
need for anticoagulation.
While in the ED he spiked to T100.5 HR 81 BP 103/50 RR 24 SpO2
96% RA. Pt continued to improve on IV Abx therapy, with vitals
prior to transfer T 97.8 HR 73 BP 106/53 RR 24 SpO2 97% RA.
Upon arrival to the floor, pt was afebrile with stable VS:
T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA. Pt was
comfortable sitting in bed, with no pain in the LLE, resolution
of his headache symptoms and no chills or shakes. Pt did endorse
feeling subjectively warm, and endorsed 2x episodes of diarrhea.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
HLD
HTN
CAD s/p CABG
Social History:
___
Family History:
Denies family history of CAD
Physical Exam:
PHYSICAL EXAM:
Vitals: VS: T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA
General: Alert, oriented, sitting upright in bed, in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Systolic murmur, regular rate and rhythm, audible S1 S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Full ROM of RLE at knee and ankle.
Skin: Warm, smooth, erythematous area extending from ankle to
upper calf just below knee. Area marked. Warm to touch, with
minimal tenderness to palpation
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
Admission
==========
___ 05:10PM GLUCOSE-106* UREA N-15 CREAT-1.0 SODIUM-134
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16
___ 05:10PM CALCIUM-8.7 PHOSPHATE-3.2# MAGNESIUM-2.0
___ 01:00PM cTropnT-<0.01
___ 06:45AM cTropnT-0.02*
___ 10:30AM ALT(SGPT)-28 AST(SGOT)-30 LD(LDH)-146
CK(CPK)-50 ALK PHOS-47 TOT BILI-2.4* DIR BILI-0.2 INDIR BIL-2.2
___ 10:30AM WBC-17.8*# RBC-4.95 HGB-14.4 HCT-41.6 MCV-84
MCH-29.1 MCHC-34.6 RDW-12.9 RDWSD-39.2
___ 01:09AM URINE HOURS-RANDOM
___ 01:09AM URINE UHOLD-HOLD
___ 01:09AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Discharge
===========
___ 07:17AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-135
K-3.8 Cl-102 HCO3-22 AnGap-15
___ 07:17AM BLOOD Calcium-8.4 Phos-1.5*# Mg-1.8
___ 07:17AM BLOOD ALT-28 AST-37 AlkPhos-49 TotBili-1.4
___ 07:17AM BLOOD WBC-11.9* RBC-4.73 Hgb-13.9 Hct-40.0
MCV-85 MCH-29.4 MCHC-34.8 RDW-13.2 RDWSD-40.7 Plt ___
Imaging
==========
Chest Xray ___
IMPRESSION:
No acute cardiopulmonary abnormality.
CT Head ___
IMPRESSION:
Mild involutional change. No evidence of hemorrhage.
___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins. The peroneal veins are not visualized.
Brief Hospital Course:
This is a ___ year old ___ male recently immigrated
to ___ with past medical history of CAD s/p CABG presenting
___ with headache, chills, and subjective fever in setting
of fasting for ___, as well as hypertension on check at
home, in ED found to have RLE cellulitis and hypertensive
emergency (SBP 211mmHg with EKG changes concerning for demand
ischemia), with quick normalization of blood pressures on oral
regimen (and normalization of EKG changes), treated with
antibiotics with significant improvement, discharged home with
scheduled appointment to establish care at ___.
# Acute Cellulitis right leg: patient presented after acute
onset of RLE pain, swelling and progressively worsening
erythema; exam consistent with acute cellulitis; otherwise
notable for leukocytosis WBC 17.9, afebrile. He was started on
Cefazolin 2G IV Q8H with rapid improvement, receding from the
area marked in the ED, WBC downtrending to 11.9. He was
transitioned to PO Cephalexin 2GM Q8H prior to discharge with an
expected ___nding on ___.
# Malignant Hypertensive / Accelerated Hypertension - patient
admitted with SBP 211mmHg; during that time he had nonspecific
ST/Twave changes noted and troponin peaking at 0.02. His blood
pressures rapidly improved with oral metoprolol. Repeat EKG
improved, troponins downtrended. Underlying etiology felt to
relate to possible missed doses of home antihypertensive. On
day of discharge BP ranged 110s-120s/60s-70s. Patient on
nabivolol from ___ (not available here), declined transition
to blood pressure agent sold here, but willing to discuss when
establishing with PCP.
# Hyponatremia / Hypokalemia / Hypophosphatemia / Hypomagnesemia
- Na of 132, K of 3.4, Phos 1.0 and Mg 1.5 on presentation, all
thought to related to insensible losses from infection as well
as ongoing fasting during ___. He was repleted with
improvement. Counseled patient that due to his acute illness,
team advised against additional fasting which could pose a risk
to his health.
#CAD s/p 3 vessel CABG - as above, he had evidence of cardiac
strain in setting of hypertension that resolved with blood
pressure control; while inpatient he was given metoprolol (as
nabivolol is not available here), home Aspirin and Atorvastatin.
See above re: blood pressure management medications.
Transitional
-------------
- In setting of fasting for ___, he was noted to have some
electrolyte deficiencies - he was counseled that, given his
illness, would avoid fasting
- To complete a 10 day course of antibiotics end date ___
- Noted to have mild thrombocytopenia during this admission,
stable; could consider outpatient workup
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. nebivolol 25 ng oral DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Acetaminophen 325-650 mg PO Q6H:PRN fever
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
3. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*33 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. nebivolol 25 ng oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Cellulitis
Hypertensive emergency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was our pleasure caring for you in ___
___. You came to the hospital because you were
feeling unwell and had high blood pressure. You were found to
have a skin infection and we gave you antibiotics and you
improved. Your blood pressure improved as well. You were doing
better so you were able to go home.
Followup Instructions:
___
|
10007058-DS-2 | 10,007,058 | 22,954,658 | DS | 2 | 2167-11-11 00:00:00 | 2167-11-12 11:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Percutaneous coronary intervention with thrombectomy
and no stent
History of Present Illness:
Mr. ___ is a healthy ___ year-old male who presented with
back pain and chest pain following a crossfit work-out and was
found to have a dissection of the abdominal aorta in addition to
new q waves on EKG and a mildly elevated troponin. The patient
reports that he had a strenuous work-out the morning of
admission. At home, shortly following the work-out, he
experienced acute onset back pain across his back below the
clavicle. This was associated with a cold sweat. The pain did
not subside and when the patient tried to climb his stairs at
home, he felt extremely week and thus presented to the ___ at
___. Upon presentation his back pain began to subside
but he did begin to experience some mild central chest pain.
At the ___, he was hemodynamically stable. An EKG was
obtained which demonstrated new inferior q waves and a troponin
was measured at 0.04. A CTA was obtained which demonstrated an
abdominal aortic dissection of the infrarenal aorta. He was
therefore transferred to ___ for further care.
Here CT repeated â still no ascending dissection. Overnight
echocardiogram poor quality, no obvious WMA. This morningâs
echo showed slight inferior HK. Cardiac biomarkers rising and
pt noted to have Q waves with slight STEs inferiorly.
He went to cath and was found to have a RCA lesion. He had a
thrombectomy with no stent and has a 50% residual distal RCA
stenosis. Admitted to the CCU for further monitoring.
Vitals on transfer were: T 98.2, HR 63, BP 123/71, RR 21, 99%
RA.
On the floor, patient reports that he feels "great" with no
chest pain, back pain, shoulder pain or SOB. Only complaint is
of mild lower abdominal dull pain.
Past Medical History:
PCP ___ ___ EKG with first-degree heart block sinus
bradycardia, pt is asymptomatic, no further actions
GERD
L4/L5 microdiscectomy
Otherwise healthy
Social History:
___
Family History:
Father: angioplasty, afib
Mother: afib
___ grandfather may have had MI
Otherwise mainly history of cancer (lung)
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.2, HR 63, BP 123/71, RR 21, 99% RA
Gen: Pleasant gentleman, NAD
HEENT: MMM
NECK: no JVP elevation
CV: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes
ABD: soft, +BS, mild tenderness in mid lower quadrant
EXT: warm, well-perfused, +pulses
SKIN: warm, dry, no rashes or lesions
NEURO: A&Ox3, CNII-XII grossly intact
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.2, HR 60-70s, BP 120s/70s, RR ___, 97-99% RA
Gen: Pleasant gentleman, NAD
HEENT: MMM
NECK: no JVP elevation
CV: RRR, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes
ABD: soft, +BS, mild tenderness in mid lower quadrant
EXT: warm, well-perfused, +pulses
SKIN: warm, dry, no rashes or lesions
NEURO: A&Ox3, CNII-XII grossly intact
Pertinent Results:
Admission Labs:
===============
___ 06:15PM BLOOD WBC-11.3* RBC-4.61 Hgb-13.4* Hct-40.5
MCV-88 MCH-29.1 MCHC-33.1 RDW-12.9 RDWSD-41.2 Plt ___
___ 06:15PM BLOOD Neuts-76.8* Lymphs-15.5* Monos-7.2
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.67* AbsLymp-1.75
AbsMono-0.81* AbsEos-0.00* AbsBaso-0.02
___ 06:15PM BLOOD ___ PTT-27.9 ___
___ 06:15PM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-137
K-4.1 Cl-102 HCO3-27 AnGap-12
___ 12:19AM BLOOD CK(CPK)-2278*
___ 06:15PM BLOOD CK-MB-52*
___ 12:19AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0
Discharge Labs:
===============
___ 06:40AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.9* Hct-37.3*
MCV-90 MCH-28.7 MCHC-31.9* RDW-12.8 RDWSD-42.0 Plt ___
___ 06:40AM BLOOD ___ PTT-28.4 ___
___ 06:40AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-101 HCO3-26 AnGap-15
___ 10:45AM BLOOD CK(CPK)-713*
___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0
___ 04:55AM BLOOD %HbA1c-5.2 eAG-103
___ 11:26AM BLOOD Triglyc-627* HDL-65 CHOL/HD-2.6
LDLmeas-73
___ 04:24AM BLOOD CRP-2.8
Troponin Trend:
===============
___ 06:15PM BLOOD cTropnT-0.21*
___ 12:19AM BLOOD CK-MB-157* MB Indx-6.9* cTropnT-0.70*
___ 03:58AM BLOOD CK-MB-178* MB Indx-7.3* cTropnT-1.37*
___ 09:58AM BLOOD CK-MB-171* MB Indx-6.7* cTropnT-1.82*
___ 04:24AM BLOOD cTropnT-2.77*
___ 11:26AM BLOOD CK-MB-3 cTropnT-<0.01
CK Trend:
=========
___ 12:19AM BLOOD CK(CPK)-2278*
___ 03:58AM BLOOD CK(CPK)-2432*
___ 09:58AM BLOOD CK(CPK)-2562*
___ 11:26AM BLOOD CK(CPK)-74
Micro:
=======
RPR:
Imaging:
=========
CTA ___:
1. Infrarenal abdominal aortic aneurysm as detailed above
originating at the level of the ___ and extending into the
proximal right common iliac artery. No significant change
compared to recent CT.
2. Normal thoracic aorta without dissection.
CXR ___:
Lungs are fully expanded and clear. Cardiomediastinal and hilar
silhouettes and pleural surfaces are normal.
EKG (___):
NSR, nl axis, no ST changes
TTE (___):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. An
aortic dissection cannot be excluded. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
CARDIAC CATH (___): RCA occluded with thrombus in mid- to
distal-vessel. LAD and circumflex free of disease.
Brief Hospital Course:
___ y/o previously healthy gentleman presenting with a type B
aortic dissection complicated by an NSTEMI in the context of a
cross-fit workout.
# CORONARIES: 50% distal RCA occlusion, LAD and circumflex
clean
# PUMP: EF > 55%
# RHYTHM: normal
#) TYPE B AORTIC DISSECTION: Mr. ___ is a healthy ___
year-old male who presented with back pain and chest pain
following a crossfit work-out and was found to have a dissection
of the abdominal aorta. The dissection was located just beneath
the takeoff of the ___, and terminating at the proximal most
aspect of the right
common iliac artery. Although he is a male he has no other clear
risk factors, including HTN, age, CAD, vasculitis, bicuspid
aortic valve, family history, h/o AVR, or cocaine use. We
continued tight BP control - SBP<140 with IV/PO BB. He had no
evidence on exam or imaging of end-organ or lower extremity
ischemia. Therefore, the is no indication for emergent vascular
surgery intervention. He will need f/u imaging in 6 months and
will follow up with ___. His ESR and CRP were
within normal limits and his RPR was not reactive.
#) ACUTE CORONARY SYNDROME:
He went to cath and was found to have a RCA lesion. He had a
thrombectomy with no stent and has a 50% residual distal RCA
stenosis. Admitted to the CCU for further monitoring after
thrombectomy and we continued heparin 24h after procedure
(starting
it 4 hours after procedure). The patient is a Killip Class I
indicating 6% mortality based on an updated study in JAMA
performed at ___ and ___ published in
___. We continued aspirin 81mg daily, ticagrelor 90 BID,
atorvastatin 10mg daily.
TRANSITIONAL ISSUES:
=========================
[] f/u aortic imaging in 6 months
Medications on Admission:
None.
Discharge Medications:
1. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*6
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*6
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
4. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*6
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- TYPE B AORTIC DISSECTION
- ACUTE CORONARY SYNDROME
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were having chest pain. We
found that you were having a heart attack and we broke down a
clot from one of your hearts blood vessels to treat that. Other
imaging found that the wall of your large blood vessel, the
aorta had formed a slit called a dissection. The vascular
surgeons and did not think you needed to have a surgical repair
at this time. It will be very important for you to keep good
control of your blood pressure, and follow-up with the vascular
surgeons, your PCP, and your new cardiologist (Drs. ___
and ___.
Should you have any chest pain, please use the nitroglycerin
pills we have prescribed for you. Take up to three pills, spaced
5 minutes apart. If the pain does not go away after this, call
___. If your pain does go away, call either Dr. ___ Dr.
___ an appointment.
Finally, we have started you on several new medications because
of your heart attack. These are very important, and must be
taken every day. They are:
1) Ticagrelor (Brillinta) 90 mg twice a day. This will be
continued for at least 3 months, and potentially as long as 9
months. The duration of this will be decided in follow-up
appointments with Dr. ___
2) Aspirin 81 mg daily, likely for the forseeable future
3) Metoprolol succinate 12.5 mg daily, on an ongoing basis
4) Atorvastatin 80 mg daily, on an ongoing basis
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
10007134-DS-16 | 10,007,134 | 29,356,606 | DS | 16 | 2140-05-24 00:00:00 | 2140-05-24 15:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Left chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man who was sleeping lying on a
driveway and was run over by backing out car, causing 3 left
ribs fracture.
Past Medical History:
DM (not treated)
? head aneurysm ___ years ago, seen in ___
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSISCAL EXAM ON ADIMSSION (___)
Constitutional: Comfortable, intoxicated
HEENT: Pupils equal, round and reactive to light,
Normocephalic, atraumatic
Ccollar in place
Chest: Clear to auscultation, diffuse tenderness, L crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: No cyanosis, clubbing or edema
Skin: abrasions to anterior chest wall
Neuro: GCS 14 ( -1 for spont eye opening), otherwise intact
Psych: Normal mood
PHYSISCAL EXAM ON DISCHARGE (___)
Constitutional: Comfortable, AAOX3
HEENT: Pupils equal, round and reactive to light, normocephalic
Chest: Clear to auscultation, mild diffuse tenderness on
anterior chest wall
Cardiovascular: Regular Rate and Rhythm, no m/r/g
Abdominal: Soft, Nontender, non-distended, no organomegaly
Extr/Back: No cyanosis, clubbing or edema
Skin: abrasions to anterior chest wall
Neuro: GCS 15, strength ___
Psych: Normal mood
Pertinent Results:
LAB RESULTS
___ 08:45AM BLOOD WBC-7.6 RBC-4.12* Hgb-13.3* Hct-40.4
MCV-98 MCH-32.3* MCHC-32.9 RDW-15.5 RDWSD-55.6* Plt ___
___ 06:02AM BLOOD WBC-7.9 RBC-4.02* Hgb-13.1* Hct-38.1*
MCV-95 MCH-32.6* MCHC-34.4 RDW-14.7 RDWSD-51.2* Plt ___
___ 08:47AM BLOOD WBC-7.2 RBC-4.13* Hgb-13.3* Hct-39.5*
MCV-96 MCH-32.2* MCHC-33.7 RDW-14.8 RDWSD-51.8* Plt ___
___ 05:35AM BLOOD WBC-7.8 RBC-3.99* Hgb-12.9* Hct-38.7*
MCV-97 MCH-32.3* MCHC-33.3 RDW-14.6 RDWSD-52.1* Plt ___
___ 05:35AM BLOOD Plt ___
___ 08:47AM BLOOD Plt ___
___ 08:45AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-159* UreaN-5* Creat-0.6 Na-132*
K-3.5 Cl-94* HCO3-26 AnGap-16
___ 08:47AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-130*
K-3.9 Cl-91* HCO3-22 AnGap-21*
___ 06:02AM BLOOD Glucose-149* UreaN-8 Creat-0.6 Na-132*
K-3.7 Cl-92* HCO3-26 AnGap-18
___ 05:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8
___ 08:47AM BLOOD Calcium-8.9 Phos-1.2* Mg-2.0
___ 08:45AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
IMAGING
CXR (___)
IMPRESSION:
Small amount of subcutaneous emphysema along the mid left
lateral chest wall with concern for nondisplaced fracture of the
left sixth and seventh ribs. CT pending
CT SPINE (___)
1. No acute traumatic abnormality.
2. Severe paraseptal emphysema.
3. Small left thyroid nodule could be further evaluate dedicated
ultrasound, if clinically indicated.
CT HEAD (___)
IMPRESSION:
1. Left lamina papyracea probable chronic fracture.
2. No intracranial hemorrhage.
CT TORSO (___)
IMPRESSION:
1. Small left pneumothorax with adjacent anterolateral left
fifth through
seventh rib fractures and small amount of adjacent subcutaneous
emphysema.
2. Small foci of cortical regularity in the anterior right ribs
may reflect a nutrient foramen. If pain is present in this
location, however, subtle nondisplaced fractures could be
considered.
3. Severe paraseptal emphysema with a significant component of
centrilobular emphysema.
4. Scattered calcified pulmonary granulomas likely reflect prior
granulomatous infection.
CXR (___)
IMPRESSION:
Small left pneumothorax, more fully assessed by recent CT.
CXR (___)
IMPRESSION:
Resolution of pneumothorax. Unchanged left sixth and seventh
rib fractures.
No other acute cardiopulmonary process.
Brief Hospital Course:
The patient presented to Emergency Department on ___. Upon
arrival to ED the patient was evaluated for anterior chest pain.
Several imaging studies were done including CXR, CT scan of
Torson, spine and head showing only left ___ ribs fracture and
a small apical pneumothorax which did not need placement of a
chest tube. He was admitted to the floor for pain control.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a dilaudid PCA
and then transitioned to oral oxycodone, ketorolac and a
lidocaine patch.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient was always on a regular diet and with
bathroom privileges.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
OxyCODONE (Immediate Release) ___ mg PO/NG Q3H:PRN Pain -
Moderate
Lidocaine 5% Patch 1 PTCH TD QAM
Ketorolac 30 mg IV Q8H
Docusate Sodium 100 mg PO/NG BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left ___ rib fracture
Left small apical pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
rib fractures and were treated conservatively. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
* Your injury caused 3 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10007174-DS-11 | 10,007,174 | 20,280,072 | DS | 11 | 2164-03-04 00:00:00 | 2164-03-06 14:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / vancomycin /
levofloxacin / acyclovir / Lipitor / lisinopril / amlodipine
Attending: ___.
Chief Complaint:
abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with history of DVT and PE on
coumadin, T2DM, HTN, large smoking history, Crohn's, multiple
SBOs and abdominal surgeries who presents with right side
abdominal pain and diarrhea. 2 weeks prior to admission Mr.
___ was in his usual state of health when he began
experiencing watery diarrhea ___ times per day which consisted
mostly of water with small pieces of stool as well as what he
describes as "rectal pain" and diffuse pain across his entire
abdomen. His watery diarrhea continued when 4 days prior to
admission he began noticing bright red blood on the toilet
tissue and occasional blood mixed in with his stool. 2 days
prior to admission, Mr. ___ developed sharp episodic
non-radiating right side abdominal pain which came every ___
minutes then gradually dissipated. Of note, he admits to
experiencing nightsweats, increased satiety, increased belching
and increased flatulence for the past 2 weeks, and 50lb weight
loss over the past year. He also notes one episode of hematuria
2 weeks ago with the onset of his symptoms, rhinorrhea, and
increased urinary frequency of late which is consistent with his
past UTIs. He denies any fever, chills, vomiting, sick contacts,
recent travel, change in diet, change in his pain with eating,
dysuria, shortness of breath, or chest pain. Also of note, Mr.
___ had 7 sessile polyps removed during colonoscopy on
___, and was found to have multiple colonic diverticula at
this time. On ___ multiple biopsies were taken without any
evidence of colitis.
In the ED, initial vitals were: 98.7 74 145/99 18 100%
ED Labs: significant for INR 2.6, lipase 108, CRP 2.1, positive
UA
ED Studies:
CT Abdomen and pelvis with contrast - showed no acute
intraabdominal process, small bowel containing hernia adjacing
to surgical scarring in the RLQ without evidence of obstruction
UA - Lg leuk, 68 WBC, few bacteria, trace protein
ED Course: The patient was given morphine 5mg x1 and zofran 4mg
x1. He was admitted for further workup of abdmominal pain and
bloody diarrhea.
Vitals prior to transfer were: 98.9 69 125/66 17 100% RA.
Upon transfer, Mr. ___ continued to complain of R sided
abdominal pain.
Past Medical History:
-Diabetes mellitus with renal manifestation
-Hyperlipidemia
-Colon adenomas
-Hypertension, essential, benign
-PANIC DISORDER W/O AGORAPHOBIA
-DEPRESSIVE DISORDER
-Pulmonary nodule/lesion, solitary
-Crohn's disease
-NEUROPATHY, UNSPEC
-History of pulmonary embolism
-Coronary artery disease
-History of obesity
-COPD, moderate
-___ disease
-CKD (chronic kidney disease) stage 1, GFR 90 ml/min or greater
-PUD c/b perforation, s/p laparotomy, colostomy and reversal
-multiple hernia surgeries
-open cholecystectomy
Social History:
___
Family History:
No family GI history
Father - had emphysema
Mother - had CAD, PVD, and RA
Sister - had TTP
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.8 BP 112/58 HR 58 RR 18 Sat 96%RA Wt 74.7kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear of
erythema and exudate
Neck: supple, no LAD or masses.
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, Moderately tender at border
between RUQ and RLQ. Bowel sounds present in all quadrants, no
rebound tenderness or guarding. Multiple large ~1cm external
hemorrhoids and erythema on rectal exam.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Dry. Normal texure and temperature. Few echymmoses on
right wrist.
Neuro: CN II-XII intact. Full ___ strength in UE and ___
bilaterally. Sensation to light touch grossly intact in face,
UE, and ___ bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.5 Tc 98.3 BP 127/60 (106-130/45-60) HR 68 (55-68)
RR 20 Sat 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear of
erythema and exudate
Neck: supple, no LAD or masses.
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, Moderately tender at border
between RUQ and RLQ. Bowel sounds present in all quadrants, no
rebound tenderness or guarding. Multiple large ~1cm external
hemorrhoids and erythema on rectal exam.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Dry. Normal texure and temperature. Few echymmoses on
right wrist.
Neuro: CN II-XII intact. Full ___ strength in UE and ___
bilaterally. Sensation to light touch grossly intact in face,
UE, and ___ bilaterally.
Pertinent Results:
ADMISSION LABS
___ 04:20PM GLUCOSE-91 UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
___ 04:20PM WBC-9.8 RBC-5.31 HGB-11.2* HCT-37.9* MCV-71*
MCH-21.1* MCHC-29.6* RDW-18.4* RDWSD-44.9
___ 04:20PM PLT COUNT-231
___ 04:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:20PM URINE RBC-0 WBC-68* BACTERIA-FEW YEAST-NONE
EPI-1
MICROBIOLOGY
___ Blood cx pending
Urine culture
___ 4:39 pm URINE Site: NOT SPECIFIED
ADDED TO CHEM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS
___ 05:43AM BLOOD WBC-6.5 RBC-4.80 Hgb-10.1* Hct-34.2*
MCV-71* MCH-21.0* MCHC-29.5* RDW-18.0* RDWSD-44.7 Plt ___
___ 05:43AM BLOOD ___ PTT-38.6* ___
___ 05:43AM BLOOD Glucose-112* UreaN-9 Creat-0.9 Na-142
K-4.0 Cl-106 HCO3-27 AnGap-13
___ 05:43AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of DVT and PE on
coumadin, T2DM, HTN, large smoking history, Crohn's, multiple
SBOs and abdominal surgeries who presented with right side
abdominal pain and diarrhea.
#Abdominal pain and diarrhea/brbpr: Likely secondary to external
hemorrhoids and infectious enteritis. Mr. ___ reported
sharp episodic non-radiating right side abdominal pain which
came every ___ minutes then gradually dissipated before
returning again. He had one loose, non-bloody bowel movement
while in the ED but had no diarrhea during his hospitalization
despite reporting a two week history of watery, non-bloody bowel
movements ___ times per day which became tinged with blood 4
days prior to admission. CRP was wnl, CT A/P showed a hernia
containing bowel but was negative for fat stranding, mesenteric
lymphadenopathy, and bowel obstruction. Rectal exam revealed
multiple large external hemorrhoids. He was given Tylenol for
pain and tolerated a clear liquids diet. He was started on a
topical hydrocortisone BID for external hemorrhoids. He was
evaluated by the surgical team given his hx of multiple
abdominal surgeries and hernia, however no surgical intervention
was advised.
#Complicated Urinary Tract Infection: On admission Mr. ___
reported increased urinary frequency consistent with past UTIs.
UA done in the ED was positive, so he was started on a 7 day
course of Ceftriaxone 1g IV in the ED, and completed ___ days of
the course during his hospital stay. Urine culture grew
pan-sensitive E. coli. He was switched to PO Cefpodoxime for
continuation of the remaining 5 days of this antibiotic course
upon discharge. Given his history of multiple UTIs, Mr.
___ complicated UTI was believed to be secondary to
urinary tract structural abnormality vs. prostatic enlargement.
#Microcytic Anemia: Mr. ___ had low H/H with low MCV in
the ED that persisted throughout his hospital stay. Iron studies
showed iron deficiency anemia. He was started on Ferrous
gluconate 324mg daily. His microcytic anemia was believed to be
secondary to chronic bleeding from hemorrhoids vs. nutritional
deficiency. Slow bleeding from occult GI malignancy is also
possible.
#Hypomagnesemia: On admission Mr. ___ was found to have
low magnesium. He was given Magnesium Oxide, after which his
magnesium level normalized. This hypomagnesemia was believed to
be secondary to diarrhea in the setting of infectious enteritis
vs. colitis.
#Weight loss/Fe deficiency anemia: Mr. ___ reported
unintentional 50lb weight loss over the past year. PSA sent on
admission was within normal limits. Serum TSH level was sent as
further workup of his weight loss, and will be followed up after
discharge. Further workup for malignancy should be considered in
the outpatient setting.
#T2DM: Mr. ___ was started on Humalog sliding scale upon
admission. His blood glucose remained stable throughout the
admission. He will be restarted on his diabetes regimen of
Glipizide and Metformin upon discharge.
#History of PE and DVT: Mr. ___ was continued on his home
dose of warfarin during his hospitalization and his INR remained
therapeutic. He should continue this warfarin dosage after
discharge, with periodic f/u by PCP to test INR.
#Coronary artery disease: Mr. ___ was continued on his
home dosages of ASA and
Rosuvastatin during this hospitalization given his history of
coronary artery disease.
#Peptic Ulcer Disease: Continued on his home dosage of
Omeprazole during this hospitalization given his history of
peptic ulcer disease.
#HTN: Continued on his home dosage of Metoprolol tartrate for
HTN during this hospitalization with good blood pressure
control.
#HLD: Continued on his home dosage of Rosuvastatin during this
hospitalization.
#Insomnia: Continued on his home dosage of Trazodone for
insomnia during this hospitalization.
#Panic Disorder with Agoraphobia: Continued on his home dosage
of Lorazepam PRN for panic disorder during this hospitalization.
He did not require any administrations of the Lorazepam during
his stay.
====================
TRANSITIONAL ISSUES:
====================
-Continue topical hydrocortisone 0.2% ointment for one week only
given risk for thinning of skin with prolonged steroid use.
-Continue Cefpodoxime 400mg PO BID to be started on ___ and
continue until ___ (Day ___.
-Follow-up urine culture sensitivities
-Continue Ferrous gluconate 324mg PO q24h for iron deficiency
anemia and consider further w/u for etiology. Consider w/u of
malignancy in the setting of iron deficiency anemia, night
sweats, and weight loss.
-Followup TSH after discharge and notify PCP for further workup
if necessary.
#CODE STATUS: Full code.
#CONTACT: ___ (niece) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. GlipiZIDE 10 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Warfarin 3 mg PO DAILY16
8. Rosuvastatin Calcium 20 mg PO QPM
9. TraZODone 100 mg PO DAILY
10. Lorazepam 1 mg PO Q6H:PRN anxiety
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lorazepam 1 mg PO Q6H:PRN anxiety
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Rosuvastatin Calcium 20 mg PO QPM
7. Warfarin 3 mg PO DAILY16
8. Acetaminophen 1000 mg PO Q8H:PRN abdominal pain
RX *acetaminophen [Pain Reliever] 500 mg 2 capsule(s) by mouth
every 8 hours Disp #*30 Capsule Refills:*0
9. Cefpodoxime Proxetil 400 mg PO Q12H
Last dose should be administered ___
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
10. GlipiZIDE 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. TraZODone 100 mg PO DAILY
13. Ferrous GLUCONATE 324 mg PO DAILY
RX *ferrous gluconate 324 mg (37.5 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
14. Outpatient Lab Work
ICD9: V12.51
Please check INR ___.
Please fax results to:
___, RN - ___
Please fax results to ___
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea
Bleeding Hemorrhoids
Discharge Condition:
Stable
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you had a 2 week course of
diarrhea, abdominal pain and nausea. A CT Scan of your abdomen
showed a hernia but showed no signs of a small bowel
obstruction. We performed a rectal exam and identified multiple
external hemorrhoids which likely caused the bleeding you
noticed recently with your diarrhea. You were also found to have
a urinary tract infection for which we gave you antibiotics that
you will continue to take (by mouth) for another 4 days through
___. You were also found to have iron deficiency,
for which you will take an iron supplement daily. You should
continue to take the Tylenol that we prescribed for your
abdominal pain until it resolves, and should apply the
hydrocortisone cream for one week we prescribed for your
hemorrhoids as needed. Lastly, we recommend that you eat a diet
high in fiber to prevent future development or worsening of your
hemorrhoids.
It is very important that you follow up with your primary care
physician and take your medications as prescribed. Please have
your INR checked on ___.
We wish you the best!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10007795-DS-16 | 10,007,795 | 20,285,402 | DS | 16 | 2136-08-11 00:00:00 | 2136-08-11 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ciprofloxacin / fluconazole
Attending: ___.
Chief Complaint:
Elevated WBC, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ETOH hepatitis and pancreatitis episode ___ with
prolonged hospitalization at ___ c/b PNA,
sepsis, respiratory failure, and pancreatic pseudocyst s/p
endoscopic cystogastrostomy ___ and ___ drainage of R flank
collection ___ c/b infection of pseudocyst (___),
___ fungemia, & severe necrotizing pancreatitis s/p
laparoscopic
drainage and debridement ___, on home tube feeds and
outpatient micafungin therapy, now presents at the behest of her
outpatient caregiver due to an elevated WBC to 18 on routine
outpatient labs. She does endorse some malaise, myalgias, and
mild SOB for the past ___s a change in character of
her drain output from a purulent yellowish color to a purulent
brown/tan color, however drain quantity has remained unchanged
at about 40cc per day. Has had some non-radiating LLQ pain
around her ostomy for the past couple weeks that is dull and not
exacerbated by palpation or tube feeds (via dobhoff) and has
been stable, but she does feel that oral intake occasionally
makes this pain increase. Denies nausea or emesis and continues
to pass stool and gas from her ostomy, has lost ___ lbs over the
past month. She continues to have intermittent low-grade fevers
at home, but no fevers of 101 or higher, no chills or sweats.
RUE ___ site is cared for by home RN's and the cap is changed
weekly, last changed today, and she has not noticed any swelling
or redness or drainage from this site. No pain with urination,
urinary frequency, or discharge. No dizziness, lightheadedness,
chest pain, cough. Surgery is now consulted regarding her
elevated WBC and generalized malaise.
Past Medical History:
Per ___ and ___ discharge summary ___.
Hypertension.
Hypercholesterolemia.
Diabetes ___ pancreatitis.
Metabolic toxic encephalopathy
Depression.
Diverticulitis s/p sigmoid resection and end colostomy unable to
be reversed b/c severe scarring and fibrosis.
Anemia of chronic disease.
Breast Ca s/p bl mastectomy and chemotherapy ___ years ago.
ETOH abuse.
Bowel obstruction.
Pancreatic pseudocyst.
s/p appendectomy for ruptured appendix.
s/p laparoscopy - pelvic pain r/o endomitriosis
Social History:
___
Family History:
Cancer
Physical Exam:
Discharge physical exam:
Vital signs afebrile and stable
Gen: Alert and oriented, no acute distress
CV: RRR
Pulm: No respiratory distress
Abdomen: Soft, non-distended, mildly tender, ostomy with foul
smelling brown stool, R flank drainage with small amount of
brown liquid
Extremities: warm and well perfused
Pertinent Results:
___ 09:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-LG
___ 09:20PM URINE RBC-7* WBC-50* BACTERIA-FEW YEAST-NONE
EPI-11 TRANS EPI-<1
___ 09:20PM URINE MUCOUS-MANY
___ 05:20PM GLUCOSE-107* UREA N-12 CREAT-0.5 SODIUM-137
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19
___ 05:20PM estGFR-Using this
___ 05:20PM ALT(SGPT)-28 AST(SGOT)-22 ALK PHOS-129* TOT
BILI-0.3
___ 05:20PM LIPASE-11
___ 05:20PM ALBUMIN-4.3
___ 05:20PM WBC-20.4*# RBC-4.78 HGB-13.2 HCT-40.1 MCV-84
MCH-27.6 MCHC-32.8 RDW-15.6*
___ 05:20PM NEUTS-82.5* LYMPHS-9.3* MONOS-6.8 EOS-1.1
BASOS-0.4
___ 05:20PM PLT COUNT-295
US from ___:
Nonocclusive thrombus extending from the right subclavian vein
into the
axillary and central portion of the basilic vein. There is no
DVT in the
distal basilic vein, cephalic vein or paired brachial veins.
Brief Hospital Course:
Ms. ___ was admitted on ___ after being found to have an
elevated WBC in combination with malaise and some abdominal
pain. She was pan-cultured on admission. Her blood cultures
revealed negative cultures in those drawn from peripheral IV's,
however in the blood culture from the PICC, viridans strep,
coag-neg staph, and micrococcus grew. Her clostridium difficile
PCR test at the same time was positive. The infectious disease
service was then consulted. They recommended that she be on IV
vancomycin for 14 days for her gram positive bacteremia and po
vancomycin for 2 months. They planned to follow her in clinic
to gradually wean the dose of po vanc. On HOD1, she did note
some blood from her R flank drain however this never occurred
again during her hospitalization. On ___, IV nurse attempted
to place a R sided PICC line however follow chest xray revealed
it was curled up in the arm. She then went to interventional
radiology for placement of a PICC on ___. The radiology
placement was unsuccessful and it prompted for RUE US. US
revealed right subclavian vein thrombosis. Patient was started
on SC Lovenox. Her antibiotics were changed to Linezolid per ID.
Also per ID, her micafungin was stopped on ___. During her
hospitalization, her WBC was trended and was normalized at the
time of her discharge. Her electrolytes were also monitored and
repleted as necessary. At the time of discharge, she was
voiding, ambulatory, and mentating well. Her ostomy output was
brown and foul smelling. The output from the drain on the R
flank was decreasing in quantity and mostly liquid brown.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 60 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Gemfibrozil 600 mg PO BID
4. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain
5. Pancrelipase 5000 2 CAP PO TID W/MEALS
6. Lorazepam 1 mg PO Q8H:PRN anxiety
7. Micafungin 100 mg IV Q24H
8. Pantoprazole 40 mg PO Q24H
9. Tamoxifen Citrate 20 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Milk of Magnesia 30 mL PO HS:PRN constipation
12. Multivitamins 1 TAB PO DAILY
13. Senna 2 TAB PO HS:PRN constipation
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Duloxetine 60 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Gemfibrozil 600 mg PO BID
5. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain
6. Lorazepam 1 mg PO Q8H:PRN anxiety
7. Micafungin 100 mg IV Q24H
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Multivitamins 1 TAB PO DAILY
10. Pancrelipase 5000 2 CAP PO TID W/MEALS
11. Pantoprazole 40 mg PO Q12H
12. Senna 1 TAB PO BID:PRN constipation
13. Tamoxifen Citrate 20 mg PO DAILY
14. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Clostridium difficile colitis
2. Gram positive bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Note color, consistency, and amount of fluid in the drain.
___ the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
What to watch out for when you have a Dobhoff Feeding Tube:
1. Blocked tube: If the tube won't flush, try using 15 mL
carbonated cola or warm water. If it still will not flush, ___
your nurse or doctor. Always be sure to flush the tube with at
least 60 mL water after giving medicine or feedings.
2.Vomiting:
___ doctor if vomiting persists. Vomiting causes the loss of
body fluids, salts and nutrients.
*Give the feeding in an upright position.
*Try smaller, more frequent feedings. Be sure the total amount
for the day is the same though.
*Infection may cause vomiting. Clean and rinse equipment well
between feedings.
*Do not let formula in the feeding bag hang longer than 6 hours
unrefrigerated. After the formula can is opened, it should be
stored in refrigerator until used.
3. Diarrhea:
*This is frequent loose, watery stools.
*Can be caused by: giving too much feeding at once or running it
too quickly, decreased fiber in diet, impacted stool or
infection. Some medicines also cause diarrhea.
*Avoid hanging formula for longer than 6 hours.
*Give more water after each feeding to replace water lost in
diarrhea.
___ doctor if diarrhea does not stop after ___ days.
4. Dehydration:
*Due to diarrhea, vomiting, fever, sweating. (Loss of water and
fluids)
*Signs include: decreased or concentrated (dark) urine, crying
with no tears, dry skin, fatigue, irritability, dizziness, dry
mouth, weight loss, or headache.
*Give more water after each feeding to replace the water lost.
___ your doctor.
5. Constipation:
___ be caused by too little fiber in diet, not enough water or
side effects of some medicines.
*Take extra fruit juice or water between feedings.
*If constipation becomes chronic, ___ the doctor.
6. Gas, bloating or cramping: Be sure there is no air in the
tubing before attaching the feeding tube.
7.Tube is out of place: If the tube is no longer in your
stomach, tape it down and ___ your doctor or home health nurse.
Do not use the tube. You will need to have a new tube placed.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
Followup Instructions:
___
|
10007795-DS-17 | 10,007,795 | 22,051,341 | DS | 17 | 2136-09-24 00:00:00 | 2136-09-24 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ciprofloxacin / fluconazole
Attending: ___.
Chief Complaint:
dehydration, abdominal pain, and tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ with ETOH hepatitis and pancreatitis on
___ with a prolonged hospitalization at ___ c/b PNA, sepsis, respiratory failure, and pancreatic
pseudocyst, s/p endoscopic cystogastrostomy ___ and ___
drainage of R flank collection ___ c/b infection of
pseudocyst ___ fungemia, & severe necrotizing
pancreatitis s/p laparoscopic drainage and debridement ___.
She was most recently readmitted to ___ on ___ for
increased WBCs and malaise, and a work up was notable for blood
cultures from her PICC which grew viridans strep,
coag-neg staph, and micrococcus grew and clostridium difficile
PCR test at the same time was positive. She was treated with
Vancomycin and transitioned to Linezolid and started on
Micafungin per ID recomendations. She was ultimately discharged
to a rehab on ___ in stable condition.
Since discharge, the patient has been doing well, went from
rehab
to home two weeks prior to presenting and has been tolerating a
regular diet. One week prior to presentation, however, she
noticed a sharp burning pain at the site of her RLQ drain that
she reported was ___ in severity and has persisted. She also
noted that during this time, her RLQ drain, which had been
working its way out over the past few weeks, had withdrawn back
into her wound. Over the past few days, her RLQ pain has
persisted and radiates across her epigastrum and along her back
and increases to ___ in severity. Given the persistent
abdominal and back pain, she presented to clinic today for
evaluation. In addition to pain, she endorses poor po intake,
dark urine, and feeling dehdraded. She denies emesis or fevers
during this time, but does endorse having some nausea and night
sweats. She also reports feeling depressed and is upset that
she
continues to return to the hospital.
Past Medical History:
Per ___ and ___ discharge summary ___.
Hypertension.
Hypercholesterolemia.
Diabetes ___ pancreatitis.
Metabolic toxic encephalopathy
Depression.
Diverticulitis s/p sigmoid resection and end colostomy unable to
be reversed b/c severe scarring and fibrosis.
Anemia of chronic disease.
Breast Ca s/p bl mastectomy and chemotherapy ___ years ago.
ETOH abuse.
Bowel obstruction.
Pancreatic pseudocyst.
s/p appendectomy for ruptured appendix.
s/p laparoscopy - pelvic pain r/o endomitriosis
Social History:
___
Family History:
Cancer
Physical Exam:
Pertinent Results:
___ 09:15PM URINE HOURS-RANDOM
___ 09:15PM URINE UCG-NEGATIVE
___ 09:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 09:15PM URINE RBC-4* WBC-14* BACTERIA-FEW YEAST-NONE
EPI-4 TRANS EPI-<1
___ 09:15PM URINE MUCOUS-RARE
___ 06:36PM LACTATE-1.1
___ 06:30PM GLUCOSE-78 UREA N-13 CREAT-0.5 SODIUM-136
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
___ 06:30PM estGFR-Using this
___ 06:30PM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-116* TOT
BILI-0.2
___ 06:30PM LIPASE-14
___ 06:30PM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-3.3
MAGNESIUM-1.8
___ 06:30PM WBC-14.6*# RBC-4.97# HGB-13.7# HCT-42.3#
MCV-85 MCH-27.6 MCHC-32.3 RDW-14.2
___ 06:30PM NEUTS-81.4* LYMPHS-11.5* MONOS-4.3 EOS-2.2
BASOS-0.5
___ 06:30PM PLT COUNT-285
___ 06:30PM ___ PTT-31.8 ___
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ from clinic where she had presented with left abdominal
pain and tachycardia. Her drain had been removed in clinic and
silver nitrate was applied due to some bloody drainage at the
site. On admission, she was made NPO, put on IV pain medication,
and received IV fluid hydration. CT scan of her abdomen showed
an interval decrease in size of a prior peripancreatic fluid
collection with question of superinfection of the collection. CT
also showed question of a new splenic infarct, a high density in
the subcutaneous tissue of the right posterolateral drain tract
(which was correlated with the application of silver nitrate at
that site), and a destructive appearing right iliac lucency
concerning for a metastatic focus (given history of breast
cancer). Infectious work up was done that was unremarkable -
chest x-ray showed mild atelectasis and urinalaysis was
negative. Her labs were also within normal limits with no
leukocytosis.
On HD2, the patient showed improvement in her abdominal pain and
was advanced to a regular diet, which she tolerated well with no
nausea and vomiting. Her home medications were restarted, and
she was transitioned to PO pain control. Her wound remained
covered, and her ostomy was viable.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. We discussed with her the CT finding of possible
metastatic disease for which she was follow up with oncology.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Duloxetine 60 mg PO DAILY
3. Gemfibrozil 600 mg PO BID
4. Pancrelipase 5000 3 CAP PO TID W/MEALS
5. Lorazepam 1 mg PO Q8H:PRN anxiety
6. Pantoprazole 40 mg PO Q24H
7. Pregabalin 50 mg PO TID
8. Tamoxifen Citrate 20 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Senna 1 TAB PO BID:PRN constipation
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Duloxetine 60 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Gemfibrozil 600 mg PO BID
5. Lorazepam 1 mg PO Q8H:PRN anxiety
6. Multivitamins 1 TAB PO DAILY
7. Pancrelipase 5000 3 CAP PO TID W/MEALS
8. Pantoprazole 40 mg PO Q24H
9. Senna 1 TAB PO BID:PRN constipation
10. Tamoxifen Citrate 20 mg PO DAILY
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
12. Pregabalin 50 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Please change your dressing to your right abdomen wound daily
and as needed with dry gauze
Followup Instructions:
___
|
10007920-DS-20 | 10,007,920 | 26,693,451 | DS | 20 | 2136-08-30 00:00:00 | 2136-09-05 12:44:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Abacavir
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ with a history of HIV (last CD4 1236 ___
who was found to have gait instability and ?AMS by visiting
nurse. RN reports that patient had missed appointment, and per
protocol, case worker visited patient. Noted that patient was
unsteady on his feet, had difficulty concentrating and following
directions, could not sign a document they had brought for him.
They note a recent decline in his self-care over the past few
months, and that he has appeared more disheveled. He is
continuing to drink and it is unclear the extent to which he is
currently drinking. They were concerned about overmedication and
requested that he go to the hospital.
In the ED, VS: Temp: 97.8 HR: 64 BP: 115/78 Resp: 20 O(2)Sat:
100 Normal. He was comfortable, and exam was notable for mildly
surged speech and lethargy. Tox screen positive for methadone
and benzodiazopenes.
On admission to the floor, he reports that he was brought to the
hospital because his pills were missing and he was concerned
about the effects of BZD withdrawal because he is a substance
abuse counselor. He repeatedly brought up his concerns that he
has no way to organize his pills. He also says that he is in the
hospital because of worsening back pain over the past week
around his thoracic region that is exacerbated by walking and is
in the region around the spine. He is able to walk in his
building but after walking a few yards outdoords is he becomes
hunched over. He also says that he has been feeling confused
over the past week, losing track of what he is doing or where he
is.
ROS: Denies any headache, CP, dyspnea, abdominal pain,
f/c/n/v/d. Dizzy with standing, longstanding attributed to meds.
Denies HI, SI.
Past Medical History:
- HIV
- schizoaffective disorder
- Alcoholism
- psoriasis
- hypertension
- Hepatitis B, resolved per patient report
Social History:
___
Family History:
Mother: died of MI in ___
Father: died of ___ at 100.
Physical Exam:
VS: 98.3 164/98 67 20 100/RA
Gen: Slightly disheveled man in NAD.
HEENT: Anicteric sclerae. MMM. 2mm wart on tip of tongue, noted
on previous exams. Yellow-brown rough-appearing plaque on
posterior tongue.
Pulm: CTAB, no w/r/r
Abdomen: Soft, NTND. + BS
Back: No vertebral tenderness. Parapinal tenderness R > L.
Neuro: Alert, oriented to ___ at ___. PERRL. EOMI.
Biceps, triceps, deltoid strength intact. Hip flexor, hamstring,
gastroc, tib anterior strength intact. Left patellar reflex
difficult to elicit. R s/p repair. Achilles reflexes 1+
bilaterally.
Exam on discharge:
VS: 98.1 104/67 67 18 97/RA
Gen: Slightly disheveled man in NAD.
HEENT: Anicteric sclerae. Slightly dry MM. 2mm wart on tip of
tongue, noted on previous exams. Red rough-appearing plaque on
posterior tongue.
Pulm: CTAB, no w/r/r
Cor: RRR, no m/r/g
Abdomen: Soft, NTND. + BS
Neuro: Alert, oriented to conversation. Finger-nose-finger:
slow, but no dysmetria. Heel-shin - slow but no dysmetria.
Difficulty understanding instructions for assessing repetitive
movements. Mild orbiting of right around left. Intact
proprioception of big toe bilaterally. Romberg: Strongly
positive. Stable while standing, very unsteady with closing
eyes. Gait is wide-based, slight drift to right while walking,
but walked ___ yards without assistance.
Pertinent Results:
___ 02:50PM BLOOD WBC-9.7# RBC-4.06* Hgb-12.7* Hct-38.1*
MCV-94 MCH-31.4 MCHC-33.4 RDW-14.1 Plt ___
___ 06:00AM BLOOD WBC-8.4 RBC-3.73* Hgb-11.8* Hct-35.2*
MCV-94 MCH-31.6 MCHC-33.5 RDW-14.2 Plt ___
___ 07:24AM BLOOD WBC-6.3
___ 02:50PM BLOOD ___ PTT-29.2 ___
___ 02:50PM BLOOD Glucose-93 UreaN-17 Creat-1.3* Na-144
K-3.0* Cl-114* HCO3-19* AnGap-14
___ 07:24AM BLOOD Glucose-127* UreaN-15 Creat-0.9 Na-144
K-3.3 Cl-117* HCO3-19* AnGap-11
___ 06:00AM BLOOD ALT-15 AST-24 AlkPhos-62 TotBili-0.5
___ 07:24AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.7
___ 07:24AM BLOOD TSH-PND
___ 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 03:01PM BLOOD ___ pO2-28* pCO2-39 pH-7.30*
calTCO2-20* Base XS--7
___ 04:20PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:20PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
Blood cultures (sent ___: No growth to date
Urine cx: <10,000 colonies
CXR (___)
FINDINGS: PA and lateral views of the chest are compared to
previous exam from ___. As on prior, there are low
lung volumes. There are calcified pulmonary nodules seen in the
right upper lung stable dating back to ___. The
lungs are clear of consolidation, effusion or pneumothorax.
Cardiomediastinal silhouette is unchanged as are the osseous and
soft tissue structures.
IMPRESSION: No acute cardiopulmonary process.
Head CT (___):
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or large
territorial infarction. The ventricles and sulci are normal in
size and
caliber. The basal cisterns appear patent and there is
preservation of
gray-white matter differentiation. No fracture is identified.
The visualized
paranasal sinuses, middle ear cavities, and mastoid air cells
are clear.
IMPRESSION: No intracranial hemorrhage or mass effect.
EKG (___):
Sinus rhythm at lower limits of normal rate. Left axis
deviation.
Intraventricular conduction delay. ST-T wave abnormalities.
Since the
previous tracing of ___, the rate is slower. Axis is less
leftward
Brief Hospital Course:
Mr. ___ is a ___ with a history of well-controlled HIV,
schizoaffective disorder, EtOH abuse, polysubstance abuse, who
was sent to the ED by his case manager and RN with concern for
AMS and gait instability secondary to overmedication and not
taking medications as prescribed. He was lethargic and
dysarthric on presentation to the ED, but became increasingly
lucid during his admission. His gait instabilities improved
significantly over the course of his admission.
Active issues:
# ALTERED MENTAL STATUS
Mr. ___ was brought to the hospital with poor attention and
lethargy. Tox screen positive for benzos and methadone. He has a
complicated psychiatric history and is on several psychiatric
medications; per case manager, he manages his medications poorly
and they are all mixed together where he stores them in his
apartment. His medications as written prior to admission were
fluoxetine 60mg daily, seroquel 200mg qHS (patient reported
300mg), bupropion (patient reported 300mg bid), and Valium (not
recorded in our LMR, but verified by ___ RN - patient
reports 10mg tid).
Mr. ___ was oriented to time and place. Reported frequent
confusion and lapses of memory. Further mental status assessment
notable for deficits in attention and memory. He had intact
registration and recall and was able interpret metaphors. He
received Seroquel 200mg daily, fluoxetine 60mg daily, bupropion
XR 150mg daily while in the hospital. Given his history of
alcohol abuse and AMS, he received Valium 5mg once on the night
of admission, and then Valium was discontinued and he was
observed for signs of withdrawal. He reported insomnia on the
night of admission, but reported sleeping well on the second
night. He became increasingly alert over the course of the
admission, and was aroused from sleep more easily. His
dysarthria improved considerably with his improving alertness.
# GAIT INSTABILITY
Mr. ___ reports multiple falls in recent weeks, and his gait
was markedly unstable at the time of his presentation, with
considerable drift to the left. On the morning of his discharge,
he had a slightly wide-based gait and slight unsteadiness on
Romberg; discharge to ___ rehab was considered. He was
not dizzy and had no dysmetria, nystagmus on exam. His gait
continued to improve over the course of the day, and on repeat
evaluation, he was deemed safe to return to activity with home
___. These gait difficulties may reflect a combined effect of
overmedication and electrolyte abnormalities, in the context of
neuropathy secondary to alcohol abuse. B12 was low-normal and
given his symptoms we gave him a 1g dose IM. TSH and folate were
within normal limits.
# ELECTROLYTE ABNORMALITIES
Deficiencies of potassium, bicarb, calcium, magnesium, and
phosphate were noted on metabolic panel; these were not present
in labs as recent as ___, but were trending in this
direction in ___. The cause of these abnormalities is
unclear, but could reflect a combination of chronic alcohol use
and drug-induced Fanconi syndrome from tenofovir. These
deficiencies were repleted, but will warrant repeat evaluation.
# SUBSTANCE ABUSE
Patient denied any current drug use, and reported one drink
every other day, but prior use fifth/day one year ago per
patient report. He denies any other substance abuse. Blood
alcohol on presentation was less than assay. He received folate,
thiamine, MVI. He reports last abusing substances over ___ years
ago. He received 5mg Valium on the night of admission. Valium
was then discontinued and he was observed for signs of
withdrawal. His urine tox screen on presentation was positive
for methadone. Denies any current drug use, including methadone
or heroin use. Methadone assay is highly specific, but false
positive results have been reported for patients taking
Seroquel, so we sent urine sample for GC/MS confirmation, which
is pending.
#BACK PAIN - patient complained of back pain that seemed
primarily musculoskeletal in origin. Responded well to ibuprofen
600mg q6h prn.
Inactive issues:
#HIV - well controlled, last CD4 > 1200 and VL < assay on ___
- Continued home ARV
#Psoriasis - continued home clobetasol
#Nausea - continued metoclopramide 5mg ___ TAB q8h prn nausea,
not required
#Diarrhea - continued diphenoxylate-atropine 2.5mg-0.025mg 1 TAB
prn diarrhea, not required
#GERD - continued home omeprazole
Transitional issues:
# Psychiatric medications: Inpatient psychiatry recommended
against use of Valium in a patient with substance abuse history
and active alcohol use. His mental staus improved without Valium
and he did not request Valium after the night of his admission.
His Valium should be discontinued as an outpatient.
Further adjustments to his psychiatric medications may be
required.
# Medications: Continued concern for disorganized medications
reported by RN, case manager. Patient will benefit from home
health aide for managing meds (currently being set up by case
manager) and/or pre-packaged medications such as those offered
by Medicines on Time.
# Pending lab tests: Urine methadone GC/MS
# Electrolytes: Repleted while admitted, but etiology still not
clear; possibly Fanconi syndrome secondary to tenofovir. Will
require repeat lytes as outpatient.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Atenolol 50 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
5. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg
Oral qHS
6. Fluoxetine 60 mg PO DAILY
7. Ibuprofen 800 mg PO Q6H:PRN pain
8. Metoclopramide 5 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q24H
10. Quetiapine Fumarate 200 mg PO HS
11. Diazepam 10 mg PO Q 8H
10mg per patient report. Have attempted to contact Dr.
___ at ___ to verify correct dose.
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY
3. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 Tablet(s) by mouth
every six (6) hours Disp #*120 Tablet Refills:*5
4. Fluoxetine 60 mg PO DAILY
5. Metoclopramide 5 mg PO Q8H:PRN nausea
RX *metoclopramide 5 mg 1 tablet by mouth three times a day Disp
#*90 Tablet Refills:*5
6. Quetiapine Fumarate 200 mg PO HS
7. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg
Oral qHS
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*11
9. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*11
10. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*11
11. Ibuprofen 600 mg PO Q8H:PRN back pain
RX *ibuprofen 600 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*5
12. BuPROPion (Sustained Release) 300 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. Cyanocobalamin 1000 mcg IM/SC DAILY Duration: 6 Days
RX *cyanocobalamin (vitamin B-12) 1,000 mcg/mL Inject
Subcutaneously or Intramuscularly daily Disp #*6 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Pharmacologic/metabolic encephalopathy
Secondary diagnosis: Peripheral neuropathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
after your nurse and case worker were concerned that you were
confused. You were also concerned about back pain and difficulty
walking, and told us that you had several falls over the past
few weeks.
While you were admitted, you became less confused and you were
walking more comfortably. We believe some of these changes may
be due to an effect of your medicaitons, and are concerned that
you might have taken a medication at a higher dose than
prescribed by accident. We also think these symptoms were made
worse with Valium, and you should not take Valium anymore. We
think it is a very good idea for you to have someone help with
you with organizing your medications.
We also noticed some changes in several chemicals that are
normally in your blood. Some of these changes may be caused by
medicines you are taking at home, and others can be the result
of drinking alcohol. We corrected the changes while you were in
the hospital, but you should speak with Dr. ___
making any changes in your medication.
Your trouble with walking is likely caused by poor sensation in
your legs. This loss in sensation in your legs can be caused by
drinking alcohol. If you continue drinking alcohol, this damage
can become worse. It is also very dangerous to drink alcohol
while taking Valium. We recommend that you stop drinking
alcohol.
You should follow up with your psychiatrist, Dr. ___,
___ you have completed rehab about the correct doses of your
medications and to see if any of your medications could be
adjusted to lower the chance you may become confused.
Changes in medications:
1. STOP Valium - you should not take Valium until you speak with
your psychiatrist
2. START Vitamin B12 - Cyanocobalamin Injections daily for 6
days
3. START Thiamine daily
4. START Folate daily
5. START Mulivitamin daily
No other changes were made in your medications.
It was a pleasure participating in your care at ___.
Followup Instructions:
___
|
10007928-DS-2 | 10,007,928 | 20,338,077 | DS | 2 | 2129-04-11 00:00:00 | 2129-04-14 16:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ year old woman with no PMH presents with 5 days of abdominal
pain and nausea, and one day of nausea/hematemesis.
.
5 days ago patient experienced ___ loose non bloody bowel
movements per day, assocaiated with mild intermittent lower
abdominal pain. Three days ago, she noted shaking and felt hot
and sweaty, thought she hd a temperature, but did not have a
thermometer. This evening around 7:00 pm she became acutely
nauseous and vomiting with BRB. With her second emesis, she
vomited > 1 cup BRB. She then had 4 more episodes of
hematemesis, < 1 cup.
.
Denies dizziness, lightheadedness, syncope, chest pain. No
recent travel or food experiementation. She does note a tick
bite to her right thigh about 1 week ago. She removed it
promptly, and did not have any rash.
.
On arrival to the ED VS were 97.1 98 102/59 15 99% RA. NGT was
placed, removed mild BRB and coffee grounds, cleared after 500cc
lavage. Guaiac negative brown stool. Hct 40. Called GI,
thought likely ___ tear, would consider endoscopy in
am. Started on pantoprazole bolus + drip, 2 18g PIVs placed.
Given 2L NS. Admitted to ICU for UGIB.
.
On arrival to the MICU, she feels shaky, but nausea is improved
since arrival.
Past Medical History:
None
Social History:
___
Family History:
Father with type ___ DM and bladder cancer, mother with lung
cancer.
Physical Exam:
ADMISSION EXAM:
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, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L
Gen: Well-appearing, alert, and communicative
HEENT: MMM
Lungs: Minimal crackles anteriorly R>L.
Heart: RRR, no murmuirs, no rubs
Abd: Soft, nontender, nondistended
Ext: Trace pedal edema, edema of right hand, clubbing of
fingers. No further rashon legs
Pertinent Results:
ADMISSION LABS:
___ 09:30PM BLOOD WBC-15.6* RBC-4.54 Hgb-13.8 Hct-40.6
MCV-89 MCH-30.3 MCHC-33.9 RDW-11.8 Plt ___
___ 09:30PM BLOOD Neuts-87.7* Lymphs-6.1* Monos-5.6 Eos-0.4
Baso-0.2
___ 09:30PM BLOOD ___ PTT-29.8 ___
___ 09:30PM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-128*
K-3.6 Cl-89* HCO3-25 AnGap-18
___ 09:30PM BLOOD ALT-59* AST-51* AlkPhos-68 TotBili-0.6
.
DISCHARGE LABS:
___ 01:30PM BLOOD WBC-8.3 RBC-4.09* Hgb-12.1 Hct-38.0
MCV-93 MCH-29.6 MCHC-31.9 RDW-12.9 Plt ___
___ 06:15AM BLOOD Neuts-79.3* Lymphs-15.4* Monos-4.7
Eos-0.1 Baso-0.5
___ 04:25AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL
___ 05:15PM BLOOD Parst S-NEGATIVE
___ 01:30PM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-138
K-4.5 Cl-103 HCO3-27 AnGap-13
___ 06:15AM BLOOD ALT-49* AST-59* AlkPhos-63 TotBili-0.4
.
MICROBIOLOGY:
___ Urine culture: mixed flora
___ Blood culture: no growth to date
___ Influenza A/B nasopharyngeal swab: negative
___ Lyme serology: pending
___ H. pylori Ab: negative
___ Urine Legionella Ag: negative
___ Blood culture: no growth to date
___ Blood culture: no growth to date
___ Blood culture (mycolytic): no growth to date
___ Stool culture/C. diff: pending
.
IMAGING:
___ CXR: The lung apices are not depicted. NG tube ends in
the gastric antrum in appropriate position. The lungs are clear,
the cardiomediastinal silhouette and hila are normal. There is
no pleural effusion and no pneumothorax. Partially visualized
abdomen shows normal bowel gas pattern.
EGD ___:
Esophagitis in the lower third of the esophagus
Small hiatal hernia
Friability and erythema in the antrum and stomach body
compatible with gastritis
Ulcer in the pylorus
Ulcers in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: Prilosec 40mg BID
Advance diet as tolerated. Avoid NSAIDs. Serial hcts. Active
type and cross. GI bleeding is unlikely the cause of the
patient's current hypotensive episodes and warrents further
investigation for a possible infectious cause. Given the clear
history of NSAID use, follow up egd is not required but would
check a h pylori serology and treat if positive. Would need a
test of cure 4 weeks post h pylori serology as well.
.
___ CTA chest:
1. No PE.
2. Mild pulmonary edema.
3. Upper lobe peribronchovascular airspace filling could be
edema or a manifestation of more severe airspace abnormality in
the lower lungs, mostly consolidation, partially atelectasis,
due to aspiration, multifocal
pneumonia, or less likely hemorrhage. In the setting of a recent
transfusions, transfusion reaction may be contributory.
4. Esophageal wall thickening, with diffuse infiltration of the
mediastinal fat which may reflect inflammatory change or
confluent lymphadenopathy, though the progression from normal
mediastinal contours on ___ favors a rapidly evolving
inflammatory process. There is no finding to suggest esophageal
perforation.
.
___ CXR: As compared to the previous radiograph, there is a
massive increase in extent and severity of multifocal pneumonia.
The resulting very widespread parenchymal opacities are more
extensive on the right than on the left and show multiple air
bronchograms. In addition, retrocardiac atelectasis has newly
appeared, and there is a small right pleural effusion. The
opacities are better displayed on the CTA examination, performed
yesterday at 9:41 p.m. Moderate cardiomegaly.
Brief Hospital Course:
___ year old woman with no known medical history who presented
with subjective fevers, abdominal pain, and hematemesis and
developed hypoxic respiratory failure. Clinical picture likely
consistent with an initial gastroenteritis with emesis likely
leading to aspiration pneumonia and hematemesis.
# Hematemesis: EGD revealed mild esophagitis, a non-bleeding 7mm
ulcer in the pylorus, and several superficial non-bleeding
ulcers ranging in size from 3mm to 5mm in the duodenal bulb.
This was likely due to aspirin use and recurrent emesis. H.
pylori antibody is negative. Her HCT continued to rise and she
was transitioned from a pantoprazole gtt to pantoprazole 40mg PO
Q12h.
# Hypoxemic Respiratory Failure: Patient developed fevers and
new hypoxia on ___. She was empirically treated for pneumonia
with ceftriaxone. CT chest showed likely multifocal pneumonia
which was possible due to aspiration. Given these findings,
antibiotics were broadened to vanc/levo/flagyl and ID was
consulted. The vanc was discontinued on ___ and the patient was
discharged with PO levo and flagyl for likely aspiration
pneumonia. Her pulmonary status improved significantly during
hosptialization and she was satting 100% on RA at discharge.
# Volume overload: the patient received over 12L of IV fluids in
the ICU in the setting of hypotension (BP 80/40s with fever,
mottled legs, likely sepsis with pulmonary source). After pt
stabalized, she was gently diuresed.
# Diarrhea/Abdominal Pain: Likely viral gastroenteritis as this
resolved during the hospitalization. Stool cultures, including C
diff, were negative.
# Tick Bite: Recent tick bite removed quickly. Lyme serologies
were negative and smear was negative for babesiosis although
ANAPLASMA PHAGOCYTOPHILUM was negative.
.
# Transaminitis: Very mild transaminitis (50s). No RUQ pain, no
hyperbilirubinemia. Likely related to viral
gastroenteritis/acute infectious process.
Transitional issues/INcidental radiographic findings.
-Pt will require primary care follow up: has not seen a PCP ___
___ years. Would follow LFT's as well.
-Pt has recently decided to stop smoking. Outpatient support
should be provided to support this goal.
-Pt still mildly volume overload at discharge. She was
mobilizing and self-diuresing effectively and will follow up
with PCP closely to see if she would benefit from lasix.
-___ WAS NOTED TO HAVE ESOPHAGEAL WALL THICKENING ON CT WITH
CONFLUENT LYMPHADENOPATHY THAT FAVORED AN INFLAMMATORY PROCESS.
This will likely require further work up
Medications on Admission:
None
Discharge Medications:
1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days
RX *metronidazole 500 mg Every 8 hours Disp #*18 Tablet
Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*2
3. Levofloxacin 750 mg PO DAILY
RX *Levaquin 750 mg daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia- multifocal
Ulcers of the stomach and duodenum (upper small intestine).
Diarrhea
Gastroenteritis
Pulmonary Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were treated in the hospital for pneumonia and vomitting up
of blood clots that likely developed because of vomitting,
diarrhea, and fevers (possibly due to a stomach flu) as well as
high doses of aspirin that worsened your stomach and small
intestine ulcers.
It is important that you complete the course of antibiotics for
treatment of your pneumonia. Please take Levofloxacin 750 mg by
mouth daily and metronidazole 500 mg by mouth every 8 hours for
six more days.
As you know, you were given many liters of fluids through your
veins while you were in the intensive care unit because you were
so sick. You will continue to urinate out this fluid within the
next several days.
Because you vomitted blood, we took a look at your esophagus,
stomach, and upper small intestines with a camera. We saw that
you have an ulcer in your stomach and several ulcers of your
upper small intestine. To help treat your ulcers, it is
important that you start to take Prilosec (omeprazole) 40mg
twice a day. It is also important that you avoid all
non-steroidal anti-inflammatory drugs, including ibuprofen,
alleve, and aspirin. You may take tylenol.
You developed new diarrhea in the hospital. This is most likely
likely due to antibiotics and should resolve as your gut flora
return. You can take yogurt or lactobacillus supplements to
accelerate this process. If your diarrhea gets worse or you
develop any fevers, please see your doctor.
Finally, it is important that you begin to see a primary care
doctor regularly. Please follow-up regarding this
hospitalization with ___ NP (see appointment below). At
that time, you will also be set up with a primary care doctor.
We have made the following changes to your medications:
START Levofloxacin 750 mg by mouth daily and metronidazole 500
mg by mouth every 8 hours for six more days.
START Pantoprazole 40mg by mouth twice a day
Followup Instructions:
___
|
10009021-DS-18 | 10,009,021 | 27,368,161 | DS | 18 | 2132-04-13 00:00:00 | 2132-04-13 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lip and chin mass
Major Surgical or Invasive Procedure:
Biopsy of right chin mass ___
History of Present Illness:
Mr. ___ is a ___ gentleman followed at ___ with a
history of HIV (on HAART; ___ CD4+: 136, CD4%: 5, VL: <75)
and hepatitis C who present for management of R chin lesion.
Lesion first developed about three months ago and initially
looked like a small pimple; it has enlarged more rapidly over
the past two months and it is painful, draining yellow fluid.
Patient has taken multiple courses of antibiotics and
antivirals, including treatment-dose TMP-SMX and Valtrex without
improvement.
On ___, patient was seen in the ___, where he was told
lesion did not look viral but could be skin cancer. On ___,
patient was seen in the ___ ___ where his lesion was I&D's. He
was started on Keflex and treatment-dose TMP-SMX and referred to
Dermatology. He was seen by ___ Dermatology on ___, where
the lesion was biopsied. On ___, micro grew MRSA and patient
was started on minocycline and vicodin for pain control. Biopsy
also showed epidermal necrosis with multinucleated keratinocytes
consistent with HSV infection. Fungal culture is still pending.
In the ___, initial VS were 99.0 82 123/74 18 100%. Exam showed a
3 x 5 cm yellow crusted lesion extending from the R lip to the R
chin without involvement of mucous membranes. Labs were notable
for normal electrolytes, normal WBC. The patient was seen by
plastic surgery who recommeded admission to medicine for IV
antibiotics and raised concern that this rapidly growing lesion
could represent malignancy. Received vancomycin 1 gram and was
admitted to the medicine service for futher management.
On arrival to the floor, vital signs were 98.2 118/74 79 16 99
RA, 78.9 kg. Patient denies fevers, chills, nausea, vomiting,
abdominal pain, night sweats, weight loss. There is no family
history of skin cancer; patient has a history of anal
condyloma/AIN1 but no malignancy. No history of excessive sun
exposure.
Review of Systems: per HPI. Also specifically denies mouth pain,
gum pain, dysphagia, difficulty swallowing.
Past Medical History:
- Dizziness
- HIV
- Hepatitis C
- HSV
- HPV
- Hypertension
- Rectal mass: anal condylomata, surgically removed ___ (AIN I,
low-grade dysplasia)
- Shoulder pain
- Abnormal LFT's
- Anemia
- Tinea cruris
- Diarrhea
- Hip pain (bilateral): previously on narcotics contract
- DJD right hip
- R hip labral tear, chronic
- Dysplastic hips
- Knee derangement
- Hyperlipidemia
- Hypertension
- Tobacco use
- Presbyopia
- Polysubstace abuse (cocaine, crystal meth, MJ)
- Depression
Social History:
___
Family History:
Includes breast, lung cancer. No skin cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.2 118/74 79 16 99 RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM with minimal white exudate on
bilateral buccal mucosa but no erythema or lesions in mouth. 2cm
x 2.5 cm hypertrophic lesion on R lower ___ border of lip
with satellite 1 x 1 cm lesion on R chin draining serosanguinous
fluis, portions ulcerated, tender to palpation. Does not extend
into mucosa.
Neck- Supple, JVP not elevated, submandibular LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, A+O x 3
DISCHARGE PHYSICAL EXAM:
Vitals- Tm98.9 ___ 98-99%RA
General- Alert, oriented, no acute distress
HEENT- Dressing clean, no drainage noted. 2cm x 2 cm fungating
yellow lesion on R lower ___ border of lip with satellite
lesion 0.8, biopsied. Minimal exudate. Does not extend into
mucosa.
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present
GU- no foley
Ext- warm, well perfused, no edema
Pertinent Results:
Admission Labs
___ 04:50PM BLOOD WBC-4.2 RBC-5.16 Hgb-12.9* Hct-41.1
MCV-80* MCH-25.0* MCHC-31.3 RDW-15.4 Plt ___
___ 04:50PM BLOOD Neuts-44.7* ___ Monos-5.5
Eos-7.9* Baso-0.7
___ 04:50PM BLOOD Glucose-73 UreaN-11 Creat-0.9 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
___ 08:05AM BLOOD ALT-83* AST-48* AlkPhos-56 TotBili-0.4
___ 08:05AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
___ 04:50PM BLOOD Neuts-44.7* ___ Monos-5.5
Eos-7.9* Baso-0.7
Pertinent Labs
___ 08:22AM BLOOD WBC-4.7 Lymph-41 Abs ___ CD3%-84
Abs CD3-1610 CD4%-6 Abs CD4-119* CD8%-74 Abs CD8-1417*
CD4/CD8-0.1*
___ 08:05AM BLOOD ALT-83* AST-48* AlkPhos-56 TotBili-0.4
___ 06:02AM BLOOD ALT-125* AST-80* AlkPhos-49 TotBili-1.2
___ 06:04AM BLOOD ALT-113* AST-66* AlkPhos-51 TotBili-1.4
___ 06:02AM BLOOD Vanco-4.5*
Discharge Labs
___ 06:04AM BLOOD WBC-6.0 RBC-4.30* Hgb-10.8* Hct-34.4*
MCV-80* MCH-25.1* MCHC-31.4 RDW-16.0* Plt ___
___ 06:04AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-140
K-3.7 Cl-105 HCO3-28 AnGap-11
___ 06:04AM BLOOD Calcium-9.6 Phos-5.0* Mg-1.7
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 4:29 pm
SKIN SCRAPINGS
**FINAL REPORT ___
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
VARICELLA-ZOSTER CULTURE (Final ___:
NO FURTHER WORK UP.
Refer to Herpes simplex viral culture for further
information.
__________________________________________________________
___ 8:22 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
34 copies/ml.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
__________________________________________________________
___ 8:15 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:05 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ PICC LINE INSERTION
In comparison with the earlier study of this date, the PICC line
has been re-directed with the tip in the region of the mid
portion of the SVC.
___ Skin biopsy right chin mass: PENDING
Brief Hospital Course:
___ M with HIV (on HAART; ___ CD4+: 136, CD4%: 5, VL: <75)
and recently diagnosed hepatitis C with a R lip/chin lesion
rapidly increasing in size, positive for MRSA and resistant to
acyclovir, bactrim, keflex, minocycline.
Patient with HIV (CD4 119, VL 34 on this admission) on HAART
presented with rapidly enlarging lip/chin lesion/mass over past
three months, resistant to bactrim, acyclovir, keflex. It was
positive for MRSA without improvement on minocycline. He was
admitted for IV vanc, and evaluated by derm and ID and felt to
be HSV (possibly verrucous HSV per derm) vs malignancy with MRSA
superinfection. He was treated with IV vanc and initially
high-dose acyclovir then switched to foscarnet per ID and derm
consult recs. Viral culture of lesion was positive for HSV-2.
Biopsy of the satellite newer lesion is pending at discharge. A
PICC line was placed for IV abx with home ___. He is to continue
foscarnet for ___ weeks (exact duration to be determined on
outpatient followup) with 500cc normal saline infusion prior to
each foscarnet infusion. Electrolytes and renal function to be
checked twice weekly while on foscarnet. Vancomycin was
increased from 1g Q12H dosing to 1750mg Q12H due to low vanc
trough. He is to continue vancomycin through ___ with trough to
be checked on ___. Follow up with PCP ___, and
___ clinic were scheduled at discharge.
# HIV Infection: Checked with CD4 count ___.
Continued on atazanavir, ritonavir, abacavir-lamivudine, Bactrim
ppx.
# Hepatitis C: Recently diagnosed with LFTs elevated, which were
stable/downtrending at discharge. Previously referred to Dr.
___ with no appointments made. He will follow up with
___ clinic for current lip/chin lesion and will subsequently be
scheduled for followup for his hepatitis C.
CHRONIC ISSUES:
# Hip Pain: Bilateral, chronic. managed on tramadol, naproxen
and tylenol.
# Substance Abuse: History of cocaine and crystal meth abuse
(reports none in past 4 months). Uses MJ for pain. Patient
should continue counseling at Adcare (1hr x 2d/week) at
discharge.
# HTN
- Continued amlodipine, losartan, HCTZ
# Cardiac prophylaxis
- Continued aspirin 81 mg daily
TRANSITIONAL ISSUES:
**Continue foscarnet for ___ weeks (exact duration to be
determined on outpatient followup). Please monitor electrolytes
twice weekly while on foscarnet. Should have 500cc normal saline
infusion prior to each foscarnet infusion.
**Continue vancomycin through ___. Trough to be checked ___.
**Elevated LFTs which were stable/down trending at discharge.
**Pending at discharge: pathology from biopsy of right lip/chin.
**Ordered for chem panel, LFTs and vanc trough on ___.
**Patient needs to schedule a visit with ID for hepatitis C; has
___ clinic f/u for now regarding current lip/chin lesion on ___.
**Biopsy sutures can be removed at derm appointment ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atazanavir 300 mg PO DAILY
2. RiTONAvir 100 mg PO DAILY
3. abacavir-lamivudine 600-300 mg oral daily
4. Minocycline 100 mg PO Q12H
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
7. Naproxen 500 mg PO Q12H
8. Acetaminophen 1000 mg PO Q6H:PRN pain
9. Amlodipine 5 mg PO DAILY
10. losartan-hydrochlorothiazide 50-12.5 mg oral daily
11. Aspirin 81 mg PO DAILY
12. Cialis (tadalafil) 10 mg oral 1 hour prior to sexual
activity as needed
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Senna 1 TAB PO HS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atazanavir 300 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Naproxen 500 mg PO Q12H
7. RiTONAvir 100 mg PO DAILY
8. abacavir-lamivudine 600-300 mg oral daily
9. losartan-hydrochlorothiazide 50-12.5 mg oral daily
10. Cialis (tadalafil) 10 mg oral 1 hour prior to sexual
activity as needed
11. Foscarnet Sodium 4500 mg IV Q12H
RX *foscarnet 24 mg/mL 4500 mg IV q12 h Disp ___ Milligram
Refills:*0
12. IV fluids
Normal Saline (0.9%) 500ml to be given with each Foscarnet
infusion.
Dispense- quantity sufficient for 3 week course of foscarnet
13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Senna 1 TAB PO HS
16. Vancomycin 1750 mg IV Q 12H
RX *vancomycin 750 mg 750 mg IV every twelve hours Disp #*9 Vial
Refills:*0
RX *vancomycin 1 gram 1 gram IV every twelve hours Disp #*9 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Herpes simplex virus infection
Methicillin resistant staphylococcus aureus
Human immunodeficiency virus with acquired immune deficiency
syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for IV treatment of your lip and chin
ulcer/mass. You were evaluated by dermatology and infectious
disease, and your ulcer/mass was thought to be a herpes lesion
with a bacterial (MRSA) infection. The mass was biopsied and
sent for pathology, which is still pending. You were treated
for MRSA with vancomycin, and HSV was treated at first with
acyclovir, then switched to foscarnet. You will continue
vancomycin through ___ and foscarnet for ___ weeks (exact
duration to be determined at outpatient visit).
You will need frequent laboratory monitoring of your kidney
function while on the foscarnet. Please go to the ___ clinic
lab on ___ between ___ AM (before your morning vancomycin
infusion) for your lab draw.
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10009049-DS-16 | 10,009,049 | 22,995,465 | DS | 16 | 2174-05-31 00:00:00 | 2174-06-03 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with hx remote paroxysmal afib presenting as
transfer from OSH with c/o cough, n/diarrhea, and chest pain.
Patient reports onset of cough/congestion 4d ago. Cough
productive of green sputum. Had progressive fatigue, and
yesterday had 6 episodes watery diarrhea with nonbloody emesis
x1. Denies fevers/chills although did not take temp at home, no
recent travel or sick contacts
Yesterday evening then developed sharp left sided chest pain,
left sided, ___, also involving left shoulder. Pain lasted
about 10mins and went away on its own, denies associated
aggravating or releiving factors.
He presented to ___ where initial EKG showed STE in I, avL.
Patient received nitro/morphine x1 with improvement in chest
pain, however became bradycardic to the ___ with SBP 73/44,
received 0.5mg atropine. Also received ASA 325, ceftriaxone,
lovenox ___, toradol and 1L IVF. Plan was for PCI but this
was aborted after reviewing subsequent EKGs.
Also ceftriaxone x1 and 2L IVF. Trop/MB neg x2, WBC @ 15.3 with
52% bands. He was transferred to our ED for further eval.
In the ED, initial vitals: 99 87 126/68 18 96% 3L, Tm 104.9.
Iniital labs notable for chem-7 with bicarb 21, Bun/Cr ___
(baseline 1.0). CBC with plt 134, INR 1.3, lactate 2.5. trop
neg, LFTs WNL. Patient was given tylenol, vanc/levofloxacin,
oseltamivir and toradol x1, and 2L IVF. CXR was done with
evidence of bibasilar opacities concerning for rapidly
developing pneumonia vs. alveolar hemorrhage.
On arrival to the MICU, patient has no complaints. Says he is
feeling a little better. Denies dyspnea, chest pain, abdominal
pain, no further episodes emesis or diarrhea since yesterday.
Denies hemoptysis.
Past Medical History:
Low back pain
Disc disorder of lumbar region
PROSTATITIS, UNSPEC
H/O SCC left forehead ___
Atopic Dermatitis
paroxysmal atrial fibrillation - noticed on ETT in ___,
asymptomatic
Social History:
___
Family History:
Unknown/adopted
Physical Exam:
Admission Physical Exam:
========================
Vitals- T: 98.4 BP: 106/64 hr 87 94% 4L
General- awake, alert, NAD
HEENT- EOMI, PERRLA, OMM no lesions
Neck- supple JVP mildly elevated at 30deg to under mandible
CV- RRR, split s2 more prominent during inhalation, no murmurs
Lungs- rhonchi bilaterally with fair air movement, + egophany
LLB
Abdomen- mildly distended/hypertympanic, no r/g/r, +BS
GU- no foley
Ext- WWP no c/c/e
Neuro- CN II-XII intact, strength ___ in UE and ___ b/l
Dishcarge Physical Exam:
=========================
Vitals - 97.9, 126/88, HR 72, 18, 97% on RA
General- awake, alert, NAD
HEENT- EOMI, PERRLA, OMM no lesions
Neck- supple JVP mildly elevated at 30deg to under mandible
CV- RRR, split s2 more prominent during inhalation, no murmurs
Lungs- CTAB, improved egophany LLB
Abdomen- mildly distended/hypertympanic, no r/g/r, +BS
GU- no foley
Ext- WWP no c/c/e
Neuro- CN II-XII intact, strength ___ in UE and ___ b/l
Pertinent Results:
ADMISSION LABS
===============
___ 05:05AM BLOOD WBC-6.8 RBC-4.95 Hgb-15.3 Hct-46.1 MCV-93
MCH-30.9 MCHC-33.2 RDW-12.5 Plt ___
___ 05:05AM BLOOD ___ PTT-36.9* ___
___ 05:05AM BLOOD Glucose-127* UreaN-26* Creat-1.4* Na-137
K-4.0 Cl-101 HCO3-21* AnGap-19
___ 05:05AM BLOOD Albumin-3.9
___ 05:25AM BLOOD Lactate-2.5*
DISCHARGE LABS
===============
___ 05:40AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.0* Hct-32.9*
MCV-93 MCH-30.9 MCHC-33.4 RDW-12.9 Plt ___
___ 05:40AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-145
K-3.4 Cl-106 HCO3-27 AnGap-15
___ 05:40AM BLOOD Calcium-7.4* Phos-3.3# Mg-1.9
IMAGING
=======
TTE: Normal global and regional biventricular systolic
function. No diastolic dysfunction, pulmonary hypertension or
pathologic valvular abnormality seen. No pericardial effusion.
CXR:
Short interval development of bibasilar opacities, which are
concerning for a rapidly developing pneumonia versus alveolar
hemorrhage.
CT CHEST W/CONTRAST (___): 1. Bilateral pleural effusions,
moderate on the left side without evidence of empyema. 2.
Multifocal airspace disease which is predominant at the lung
bases and is likely in keeping with multifocal pneumonia.
Multiple mediastinal and hilar reactive lymph nodes are noted.
3. Incidental finding of a 6 mm non-obstructing stone in the
upper pole of the left kidney.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ year old male with
no significant medical history presenting as transfer from OSH
with c/o cough, n/d/diarrhea, and chest pain found to have fever
and hypoxia. On further work-up, pt. was found to have a
multifocal pneumonia. Culture data was unrevealing. Pt. was
placed on antibiotics and continued to improve. His O2
requirement resolved and he was discharged with close follow-up.
ACTIVE ISSUES
=============
# Sepsis and Community Acquired Pneumonia: Mr. ___
presented with tachycardia, temp to 104, and multifocal
opacities seen on CXR. He was started on ceftriaxone and
levofloxacin in accordance to ___ guidelines for community
acquired pneumonia. Respiratory viral panel negative,
legionella negative, strep pneumo antigen negative, and cultures
were unrevealing. Pt. grew GPCs in clusters in blood ___
bottles) which raised concern for possible MRSA bacteremia from
MRSA pneumonia. Pt. has negative MRSA swab and without known
MRSA risk factors. TTE was negative for evidence of
endocarditis and surveillance blood cultures were negative.
Oxygen requirement had resolved by day 2 of admission and he was
transferred to the floor. He was transitioned to levofloxacin
to complete his course of antibiotics.
# Chest Pain: Pt. complained of left sided sharp chest pain
made worse with coughing and deep breathing. Most likely
pleuritic chest pain from underlying inflammatory pleuritis from
pneumonia. Cardiac enzymes neg x2 making cardiac ischemia less
likely. No ischemic changes or other notable changes seen on
ECG. TTE done on ___ and was grossly normal with LVEF 60-65%.
# Abdominal Distension: Initially, pt. presented with diarrhea,
CDiff negative. Continued to complain of abdominal distension.
KUB showed multiple air filled loops of bowel without air fluid
levels consistent with possible ileus. Pt. continued to
complain of minimal flatus, abdominal distension made worse with
consuming POs, and minimal BMs. Slowly, he began to tolerate PO
intake. At time of discharge, pt. was tolerating full liquids
without issue. He was encouraged to advance his diet as
tolerated.
# Anemia: Patient with downtrending Hct throughout this
admission. Initial and repeat DIC labs returned negative. Most
likely etiology ___ bone marrow suppression due to acute illness
with possible suppression ___ medication effect. No signs of
active bleeding.
# ___: Pt. with evidence ___ on admission. Likely pre-renal
etiology in the setting of pneumonia and sepsis. With IVF, pt's
creatinine returned to baseline and ___ resolved.
CHRONIC ISSUES
==============
# BPH: Stable. Continued on flomax
TRANSITIONAL ISSUES
===================
# Antibiotics: Pt. should continue levofloxacin for an
additional 4 days to complete a 10 day course.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 200 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth every 6 hours Disp #*1
Bottle Refills:*0
4. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pneumonia
Secondary: Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted after you were diagnosed with pneumonia. We
started you on antibiotics and you improved. You also had issues
with moving your bowels which resolved with conervative
measures. Please continue a full liquid diet at home (soups,
jello, shakes) and advance to regular diet slowly as tolerated.
___ MDs
Followup Instructions:
___
|
10009203-DS-9 | 10,009,203 | 23,598,550 | DS | 9 | 2201-08-14 00:00:00 | 2201-08-16 13:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody bowel movement
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ smoker w/ history of hyperlipidemia, BPH, GERD, DJD,
osteoarthritis, and colon polyps presents today with one bloody
BM, fever in AM and abdominal pain. Pt's last ___ was in ___
at which point he had some polyps that were benign.
The patient woke up in the morning in his usual state of health.
He went to work after eating a muffin and drinking a coffee.
While at work, he experienced a band of pain along his abdomen,
lasting for 45 minutes and was drenched in sweat. Had large
blood BM at 11 AM (blood covered stool). Since then has had ___
belly pain in lower quadrants in a horizontal band.
In the ED, initial vs at 14:22 were pain 6 t 98.6 64 133/78 16
99%. He was ound to have elevated WBC (19.2). CT shows colitis,
patient given 0.5 mg IV dilaudid, 400mg IV cipro. Transfer VS
98.1po 59 16 126/81 100% RA ___.
On arrival to the floor, patient reports continued abdominal
pain, but is comfortable. He also reports continuing smoking and
having a rash along his right axila. He denies any recent
antibiotics, travel, changes in his diet, or sick contacts.
REVIEW OF SYSTEMS:
Recent headache over the weekend, twice, which is new for him..
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
constipation, melena, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Status post appendectomy.
2. Status post sebaceous cyst excision.
3. Status post arthroscopy, left knee.
4. Status post arthroscopy, right knee.
Social History:
___
Family History:
Positive for lung cancer, CAD, hypertension, and diabetes. No
history of crohn disease or ulceraive colitis.
Physical Exam:
Admission:
VS 98.7, 146/89, 56, 18, 98%
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft tender along left lower quadrant. ND normoactive bowel
sounds, no hsm
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN small erythematous papular rash under right axila.
Discharge:
VS 98.4, 122/80, 65, 18, 96%RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, mildly tender with soft and deep palpation in LLQ, no
masses
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN small erythematous papular rash under right axila.
Pertinent Results:
Admission:
___ 02:32PM NEUTS-91.6* LYMPHS-5.7* MONOS-2.6 EOS-0
BASOS-0.1
___ 02:32PM WBC-19.2*# RBC-5.14 HGB-15.6 HCT-46.2 MCV-90
MCH-30.4 MCHC-33.8 RDW-13.1
___ 02:32PM LIPASE-51
___ 02:32PM PLT COUNT-346
___ 02:32PM ALT(SGPT)-30 AST(SGOT)-29 LD(LDH)-187 ALK
PHOS-73 TOT BILI-0.5
___ 02:32PM LIPASE-51
___ 02:32PM GLUCOSE-120* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
___ 02:40PM LACTATE-1.1
___ 07:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:52PM URINE COLOR-Yellow APPEAR-Clear SP
___
Discharge:
___ 07:00AM BLOOD WBC-12.2* RBC-4.90 Hgb-14.3 Hct-43.5
MCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-138
K-4.1 Cl-106 HCO3-25 AnGap-11
___ 07:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
Micro:
___ 9:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 2:52 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___BD & PELVIS WITH CO
IMPRESSION:
1. Acute colitis involving the descending and sigmoid colon.
Etiologies
include infectious, inflammatory and less likely ischemic.
2. Enlarged prostate, correlate with PSA.
3. Bilateral small indeterminate adrenal nodules.
4. Mild compression of T11 and T12 vertebral bodies.
Cardiovascular Report ECG Study Date of ___ 3:26:28 ___
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
Brief Hospital Course:
# Colitis: Patient presented with one bloody bowel movement
associated with crampy abdominal pain. CT showing acute colitis
of descending colon. Differential diagnosis includes infectious
(bacterial, viral, parasitic), ischemic, and inflammatory.
Ischemic possible given high white count, acute nature and
smoking history, however normal lactate. EKG with normal sinus
rhythm. Infectious possible with high white count, however
patient was afebrile and did not describe diarrhea or vomiting.
Further, patient had no travel history, sick contacts or
concerning food ingestion. First presentation of inflammatory
bowel disease is possible, however less likely given acute
nature and disease of only descending colon. Diverticuli seen
on previous colonoscopy, however elevated white count and pain
is not consistent with diverticular bleeding. The patient was
started on ciprofloxacin for possible infectious etiology and
given IV fluids. Gastroenterology was consulted due to concern
for ischemic etiology. Stool studes were sent and were negative
for salmonella, shigella, campylobacter, vibrio and yersinia.
C. difficile testing was not done as sample was unsuitable for
testing (solid). GI recommended discontinuing ciprofloxacin and
outpatient follow up given resolving symptoms with stable
hemodynamics and recent colonoscopy. The patient was scheduled
for outpatient follow up with gastroenterology.
Chronic Issues:
# T11/ T12 vetebral compression: Compression seen on CT scan.
Patient has no current back pain with normal neurological exam.
# Enlarged prostate: BPH, mildly symptomatic with stable PSA,
and a relatively recent prostate biopsy, which was negative for
malignancy. Patient continued on finasteride and Flomax as
prescribed.
Transitional Issues:
-follow up with GI for possible endoscopy as outpatient
-follow up with PCP
-___ cultures pending
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
Hold for SBP<100
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
Hold for SBP<100
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with an episode bloody bowel
movement. CT scan showed colitis, which may have be infectious.
You were seen by gastroenterology and will follow up with Dr.
___ in clinic.
Medication changes: none
Followup Instructions:
___
|
10009614-DS-9 | 10,009,614 | 24,377,082 | DS | 9 | 2188-09-19 00:00:00 | 2188-09-21 17:27:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine
Attending: ___
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
laparoscopic cholecystectomy ___
History of Present Illness:
___ s/p C-section ___ presents to the ___ ER after
experiencing an acute onset of RUQ pain after eating last night.
Patient states she ate a steak dinner yesterday evening and
approximately one hour after had an acute onset of sharp, severe
RUQ pain. The pain was constant and associated with nausea but
no
vomiting. She went an OSH hospital where her pain resolved with
pain medication and was told to follow up with her PCP. After
returning home she had two more episodes of pain which resolved
within an hour. She also reports having another episode of pain
2
weeks ago in a similar location, but less severe which resolved
after an hour. She denies fevers, vomiting, BRBPR or melena.
Past Medical History:
- Hairy cell leukemia (now status post 1 cycle Cladribine)
- History of diabetes mellitus, untreated /diet controlled .
- S/p knee and ankle surgeries x ___
- S/p appendectomy
Social History:
___
Family History:
Her mother is ___ and has thyroid disease and elevated
cholesterol. Her father is ___ and has coronary artery disease
and hemochromatosis. Her brother is ___ and well. She has one
paternal uncle who died in his ___ from an asbestos-related
cancer. No other family members have cancers or blood disorders.
Physical Exam:
Physical Exam:
Vitals: T 97.8 P 80 BP 130/90 RR 16 O2 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, negative ___ sign no
rebound or guarding, normoactive bowel sounds, no palpable
masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ WBC-6.4 RBC-3.96* HGB-11.7* HCT-35.0* MCV-89 MCH-29.7
MCHC-33.6 RDW-13.3
___ ALT-366* AST-396* AlkPhos-173* Amylase-39 TotBili-2.6*
DirBili-1.4* IndBili-1.2
___ ALT-342* AST-206* AlkPhos-166* Amylase-34 TotBili-3.2*
___ ALT-249* AST-101* AlkPhos-170* TotBili-1.5
___ ALT-158* AST-49* AlkPhos-144* TotBili-1.0
___ Lipase-29
RUQ (___)
1. Slightly distended gallbladder, but no evidence of
cholecystitis or cholelithiasis.
2. Echogenic liver consistent with fatty infiltration; other
forms of liver disease, including more significant hepatic
fibrosis or cirrhosis cannot be excluded on the basis of this
examination.
3. Mildly enlarged spleen measuring 13.2 cm.
ERCP ___
The major papilla was bulging proximal to the opening. There
appeared to be two openings to the biliary orifice consistent
with a possible fistula.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire. There was no
bleeding.
The intrahepatics were normal. The CBD was around 7 mm. There
was a distal CBD filling defect. The stone was extracted
successfully using a 9-12 mm stone extraction balloon. An
occlusion cholangiogram after the bile duct sweeps showed no
filling defects. There was excellent flow of bile and contrast.
Brief Hospital Course:
The patient was admitted to the ___ service on ___ for right
upper quadrant pain on elevated LFTs suggestive of
choledocolithiasis. She was made NPO and started on
maintainence IVFs. Her abdominal pain was well controlled on
the floor. Her follow-up LFTs on HD#2 revealed an uptrending
t-bili from admission (2.6->3.2). Interventional GI was
consulted and the patient underwent successfully ERCP removal of
a CBD stone with sphincterotomy on ___.
The patient did not exhibit complications from the ERCP and her
abdominal pain improved significantly following the procedure as
well. On HD#3, the patient's LFTs downtrended, most notable for
a t-bili of 1.5 (from 3.2), along with a decrease in her
transaminitis. Given the patient's clinical improvement and
downtrending LFTs, the decision was made to proceed to
laparoscopic cholecystectomy, which was performed on ___.
The procedure was without complication. The patient's diet was
advanced on POD#1, and she was tolerating a regular diet upon
discharge. She was instructed to follow-up in the ___ clinic in
2 weeks.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *Endocet 5 mg-325 mg ___ Tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*14
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
choledocolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgery service with
choledocolithiasis (a gallstone in you common bile duct). The
gallstone was removed by a procedure called an ERCP. You then
underwent a laparoscopic cholecystectomy to remove your
gallbladder without complication. Below are instructions to
follow post-operatively:
Please resume all regular home medications unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10009657-DS-3 | 10,009,657 | 26,435,790 | DS | 3 | 2139-05-16 00:00:00 | 2139-05-16 13:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
perirectal abscess
Major Surgical or Invasive Procedure:
Exam under anesthesia
Incision and drainage of complex ___ abscess
History of Present Illness:
Ms. ___ is a ___ woman who underwent incision and
drainage of a perirectal abscess approximately ___ years ago. She
now presents with recurrent
perirectal abscess and on a CAT scan that was obtained in the
emergency room before surgery consult; the patient was found to
have a horseshoe type of perirectal abscess extending from the
patient's left side and around the rectum on the dorsal aspect.
The patient was then taken to the OR for examination
under anesthesia and incision and drainage of the perirectal
abscess.
Past Medical History:
PMH: Depression, anxiety, perineal/perianal condylomata
PSH: Microscopically-assisted biopsy and transanal
laser destruction of anal, perineal, vulvar, and vaginal
condylomata ___
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Discharge Physical Exam
VS: 98.9 73 115/76 18 100%ra
Gen: alert and oriented x3 NAD
CV: RRR
Pulm: CTAB
Abd: Soft NT ND
Rectal: opened abscess cavity with some purulent drainage,
packed loosely with plain packing material
Pertinent Results:
___ 04:21PM LACTATE-0.9
___ 02:25PM WBC-19.1*# RBC-3.82* HGB-11.7* HCT-36.0
MCV-94 MCH-30.6 MCHC-32.5 RDW-11.9
___ 04:45AM BLOOD WBC-13.7* RBC-3.59* Hgb-11.2* Hct-33.4*
MCV-93 MCH-31.1 MCHC-33.5 RDW-11.6 Plt ___
Brief Hospital Course:
Ms. ___ has a history of prior perirectal abscesses, and
presented to the ED with symptoms of a recurrent abscess. She
was taken to the OR for incision and drainage of this large
horseshoe type abscess; for full details please see the dictated
operative summary. She tolerated the procedure well; a shortened
chest tube was left in the cavity to allow for irrigation
overnight.
She was brought back to the floor in good condition. She was
advanced to a regular diet and pain was controlled on oral
medications. She ambulated and voided appropriately. She
remained on cipro/flagyl for the duration of her hospital
course. Prior to discharge, the tube was removed from the cavity
and a loose packing was placed. She will remove the packing in
one day and follow up with Dr. ___ in clinic later this
week. She is discharged home in good condition on hospital day
2, POD#1.
Medications on Admission:
lamictal 100', dicyclomine 10'
Discharge Medications:
1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO once a day.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
___ abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the colorectal surgery service after
drainage of a complex ___ abscess. You have done well
postoperatively and you are now ready to go home.
You will have a small wick inside the abscess. This should be
removed tomorrow. After it is removed, please start taking ___
baths daily and after bowel movements. Continue to take pain
medication as needed and also take stool softeners to prevent
constipation.
Followup Instructions:
___
|
10009657-DS-4 | 10,009,657 | 29,867,282 | DS | 4 | 2139-05-27 00:00:00 | 2139-05-27 22:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman whose PMH includes laser ablation for perianal
condylomata and subsequent hx of complex ischiorectal abscess
requiring operative drainage, s/p resection of perianal abscess
___, p/w n/v/d since this AM. Pt reports that the diarrhea is
watery, emesis is nonbilious, non-bloody. Denies f/c. Denies
cp/sob/ha. Pt reports that she initially had onset of abdominal
pain shortly before diarrhea. Reports no rectal pain.She felt
very well on the day of presentation and only after
participating in cleaning day did she experienced gradual ->
severe abdominal pain/supra-pelvic burning -> nausea -> emesis
and diarrhea. Earlier outbreak of norovirus at her school where
she works but none recently. No clear sick contacts. No foreign
travel. No strange foods. No vaginal discharge or bleeding.
On examination in the ED, moderate abdominal ttp below the
umbilicus with rebound. Per rectum, purulent-appearing mucoid
discharge which is occult positive.
In ER: (Triage Vitals:9 96.9 77 101/54 16 100% RA )
Meds Given: ___ 14:15 Ondansetron 2mg/mL-2mL 1 ___
___ 15:38 Ondansetron 2mg/mL-2mL 1 ___
___ 15:50 Readi-Cat 2 (Barium Sulfate 2% Suspension) 450 mL
Bottle 2 ___
___ 16:15 Morphine 5 mg Vial [class 2]
Radiology Studies: abdominal CT
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ -] Fever [- ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ -] _____ lbs. weight loss/gain over _____ months
Eyes [X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [x] WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling
[+] Diarrhea [ ] Constipation [ ] Hematemesis
[- ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [] All Normal
[+] Easy bruising- chronic [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[- ]Medication allergies [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
PMH: Depression, anxiety, perineal/perianal condylomata
PSH:
# Microscopically-assisted biopsy and transanal laser
destruction of anal, perineal, vulvar, and vaginal condylomata
___
# perirectal abscess drainage in ___
# perirectal abscess drainage ___
Social History:
___
Family History:
Maternal grandmother with skin cancer. Paternal aunt with
breast cancer.
Physical Exam:
1. VS T = 98.9 P = 73 BP = 127/76 RR = 18 O2Sat on _100% on RA
GENERAL: Well appearing very pleasant female.
Nourishment: good
Grooming: good
Mentation
2. Eyes: [X] WNL
EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric
3. ENT [X] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
Soft, non tender all quadrants. She reports that her abdomen was
tender when examined in the ED but now it is much improved.
Rectum: site of ___ abscess drainage non-tender and
without erythema
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [x ]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL [ ] Demented [ ] No
pronator drift [] Fluent speech
9. Integument [] WNL
Warm and dry with multiple tatooes
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ X] WNL
[X] No cervical ___ [] No axillary ___ [] No supraclavicular
___ [] No inguinal ___ [] Thyroid WNL
TRACH: []present [X]none
PEG: []present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Pertinent Results:
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE UCG-NEGATIVE
___ 04:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 04:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-4
___ 04:00PM URINE MUCOUS-MANY
___ 02:29PM LACTATE-3.3*
___ 02:15PM GLUCOSE-113* UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 02:15PM estGFR-Using this
___ 02:15PM ALT(SGPT)-31 AST(SGOT)-29 ALK PHOS-73 TOT
BILI-0.3
___ 02:15PM LIPASE-88*
___ 02:15PM ALBUMIN-4.9 CALCIUM-9.8 PHOSPHATE-3.6
MAGNESIUM-1.7
___ 02:15PM WBC-37.1*# RBC-4.99# HGB-15.3# HCT-46.8#
MCV-94 MCH-30.6 MCHC-32.6 RDW-12.5
___ 02:15PM NEUTS-92.4* LYMPHS-4.5* MONOS-2.4 EOS-0.5
BASOS-0.2
___ 02:15PM PLT COUNT-482*#
--------------
Brief Hospital Course:
The patient is a lovely ___ year old female with h/o perirectal
abscess x ___ s/p drainage of a perirectal abscess now presenting
with abdominal pain, nausea, vomiting, diarrhea.
# viral gastroenteritis, likely Norovirus: Clinically stable,
quickly improved, able to tolerate po and advance to regular
diet within 12 hours of admission. Leukocytosis much improved.
No indication for antibiotics.
# perirectal abscess: no acute issues, s/p drainage on ___
# IBS: stable, continued dicyclomine
.
# ovarian cyst: noted on CT scan; obtained pelvic US to further
evaluate. It showed simple right ovarian cyst measuring up to
5.2 cm in maximum dimension. Ultrasound followup in one year is
recommended.
# depression/ anxiety: stable, continued lamictal
Medications on Admission:
dicyclomine 10 mg Capsule 1 (One) Capsule(s) by mouth four times
a day take before each meal and at bedtime ___
lamotrigine [Lamictal] 100 mg Tablet
1 (One) Tablet(s) by mouth once a day (Prescribed by Other
Provider) ___
Discharge Medications:
1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO four times
a day: before meals and at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
viral gastroenteritis
Secondary diagnoses:
pelvic cyst, needs f/u
IBS
depression/ anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
See below.
We made no changes in your outpatient medications.
Followup Instructions:
___
|
10010058-DS-12 | 10,010,058 | 28,963,312 | DS | 12 | 2145-10-03 00:00:00 | 2145-10-03 17:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ year-old male with a past medical history of
hyperlipidemia, CAD, anterior MI, ischemic cardiomyopathy with
LVEF 35%, mild- moderate MR, CKD,
and AF with CHB s/p BiVICD implant, here with failure to thrive,
lightheadedness, and mild confusion. History is very limited
due to patient being deaf and confused. Pt is also ___
speaking however does seem to understand some ___ and is
able to read ___ when I write down questions. I was also
unable to reach family members by phone. Per ED records, pt has
had poor PO intake for weeks, however in the past week it has
decreased even more and he has had bilious small amounts of
vomit in the AMs. Denies fevers, chills, sweats, cough,
shortness of breath. Endorses incontinence x about 1 week.
Patient's daughter also endorses mild confusion. In the ED,
patient was able to recognize daughters and knows his own name,
however was unsure what date it was - which is not his baseline.
In the ED, initial vitals were: 98.6 60 96/51 16 100% RA. Labs
were notable for trop of 0.15--)0.13-->>0.11, LDH 373, Na 130,
creatinine 3.4, bland UA, plts 48. CT head showed no acute
process, CXR was nl. Pt was given 2 L NS.
On the floor, pt states that he is tired but is unable to answer
any other questions, I think due to a combination of confusion
and difficulty hearing. When I write my questions on paper, he
reads the first part however then becomes confused. He states
he is not on any pain. Provides phone numbers for his
granddaughter however one of them is not a valid number.
Review of systems: unable to obtain due to confusion and HOH
Past Medical History:
(per chart, unable to confirm with patient):
hypertension
hyperlipidemia
AFib
CAD
CHF
hearing loss
CORONARY ARTERY DISEASE
GOUT
HYPERLIPIDEMIA
MEMORY LOSS
PACEMAKER
CHRONIC KIDNEY DISEASE
HYPERTENSION
ISCHEMIC CARDIOMYOPATHY
Social History:
___
Family History:
unknown
Physical Exam:
97.8 116 / 56 60 16 99 Ra
Constitutional: Alert, confused, NAD
EYES: Sclera anicteric, EOMI, PERRL
ENT: MMD, oropharynx clear,
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: unable to assess, responds to questioning but answers are
unclear, moves all extermities, CNS grossly intact
SKIN: no rashes or lesions
Pertinent Results:
___ 06:30PM LD(LDH)-373* TOT BILI-0.6
___ 06:30PM cTropnT-0.11*
___ 06:30PM CK-MB-6 cTropnT-0.13*
___ 06:30PM HAPTOGLOB-241*
___ 02:14PM ___ PTT-34.6 ___
___ 01:30PM URINE HOURS-RANDOM
___ 01:30PM URINE UHOLD-HOLD
___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:30PM URINE RBC-4* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 01:30PM URINE AMORPH-RARE
___ 01:30PM URINE MUCOUS-RARE
___ 12:45PM GLUCOSE-99 UREA N-140* CREAT-3.4*#
SODIUM-130* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-13* ANION
GAP-25*
___ 12:45PM estGFR-Using this
___ 12:45PM ALT(SGPT)-29 AST(SGOT)-44* CK(CPK)-248 ALK
PHOS-71 TOT BILI-0.6
___ 12:45PM LIPASE-132*
___ 12:45PM cTropnT-0.15*
___ 12:45PM CK-MB-6
___ 12:45PM ALBUMIN-4.1
___ 12:45PM WBC-7.2 RBC-3.78* HGB-11.3* HCT-32.3* MCV-85#
MCH-29.9 MCHC-35.0 RDW-15.1 RDWSD-46.9*
___ 12:45PM NEUTS-74.0* LYMPHS-8.5* MONOS-16.3* EOS-0.4*
BASOS-0.1 IM ___ AbsNeut-5.33 AbsLymp-0.61* AbsMono-1.17*
AbsEos-0.03* AbsBaso-0.01
___ 12:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-1+ ELLIPTOCY-OCCASIONAL
___ 12:45PM PLT COUNT-48*#
___ 12:45PM RET AUT-1.0 ABS RET-0.04
MICRO: urine cxs pending
STUDIES:
CT head: No acute intracranial process.
CXR: no acute process
EKG: paced rhythm with underlying afib, TWI in V1, V2, LVH, LAD
___ 06:25AM BLOOD WBC-5.7 RBC-3.40* Hgb-10.2* Hct-28.6*
MCV-84 MCH-30.0 MCHC-35.7 RDW-15.1 RDWSD-46.4* Plt Ct-47*
___ 06:25AM BLOOD Plt Ct-47*
___ 06:25AM BLOOD ___
___ 06:25AM BLOOD Glucose-137* UreaN-110* Creat-3.0* Na-137
K-3.2* Cl-106 HCO3-12* AnGap-20
___ 06:30PM BLOOD cTropnT-0.11*
___ 06:30PM BLOOD CK-MB-6 cTropnT-0.13*
___ 12:45PM BLOOD cTropnT-0.15*
___ 06:25AM BLOOD TSH-1.3
___ 06:25AM BLOOD calTIBC-241* VitB12-862 Folate->20
Ferritn-706* TRF-185*
___ 06:30PM BLOOD Hapto-241*
___ 06:25AM BLOOD Digoxin-1.6
___ 06:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:25AM BLOOD COPPER (SERUM)-PND
C
IMPRESSION:
1. Fusiform and saccular aneurysmal dilatation of the infrarenal
abdominal
aorta measuring up to 3.9 cm extending into both common iliac
arteries and the
right external iliac artery. Linear areas of calcification
within the
aneurysm sac at the level of the third portion of the duodenum
is suspicious
for dissection which is limited in the absence of intravenous
contrast. The
aneurysm sac exerts mass effect on the third portion of the
duodenum which is
decompressed. There is no upstream dilatation of the duodenum to
suggest
obstruction. The distance between the anterior aspect of the
aortic aneurysm
to the anterior wall peritoneal is approximately 1.5 cm.
2. Colonic diverticulosis without CT evidence of acute
diverticulitis.
3. Cholelithiasis without CT evidence of acute cholecystitis.
4. Asymmetric sclerosis and narrowing of the right SI joint
likely reflecting
prior sacroiliitis.
5. Mild-to-moderate cardiomegaly with at least right and
possibly biatrial
enlargement. Stable size of a known left ventricular aneurysm
with increased
interval calcifications since ___.
6. Two 2 mm pulmonary micro nodules in the right lung base. In a
patient with
no known risk factors for lung cancer, these are presumed to be
benign and no
follow-up is recommended. In a patient with risk factors for
lung cancer, ___
year follow-up is recommended.
T abdomen/pelvis:
Brief Hospital Course:
___ y.o male with h.o HL, CAD, MI, ___ with EF 35%, CKD,
afib with CHF s/p biVICD who presented with weight loss,
inability to tolerate PO, confusion, weakness found to have
acidosis and ___ on CKD.
#weight loss
#inability to tolerate PO
#nausea with vomiting
#severe protein calorie malnutrition
Symptoms are concerning for underlying malignancy. Pt with signs
of dehydration and weight loss. No apparent prior w/u for these
symptoms and pt has yet to see PCP. Unknown if prior
colonoscopy.
CT scan without revealing cause. Nutrition consulted and pt
given IVF.
However, pt and family after much discussion with ___
___ present and again with pt's PCP on speaker phone, pt
and family elected to leave AMA accepting risks of dehydration,
malnutrition, undiagnosed illness, cancer, electrolyte abn,
worsening renal function, risk of falls and injury due to
weakness.
Pt advised to f/u with PCP ___.
#acute encephalopathy-likely due to metabolic derangements. Head
CT without acute process. Tox screen neg. TSH, LFts, b12/folate
WNL. IVF given. Held mirtazapine.
___ on CKD, baseline appears to be Cr 2.4-2.5. Likely prerenal
due to above. Pt given some IVF.
#thrombocytopenia-b12/folate WNL. Iron studies c/w ACD.
Haptoglobin elevated, less likely hemolysis. Outpt f/u given AMA
discharge.
#anemia-most likely AOCD. Outpt f/u given AMA discharge.
#hyponatremia-improved
#AGMA-likely due to ___. Lactate WNL. Outpt f /u given AMA
discharge.
#HTN, HL, afib, CAD, chronic systolic CHF
-continued home meds (BB, statin, held dig and eliquis given
tpenia. Currently hypovolemic.
#gout-no e/o acute flare. Continue appropriately dosed
allopurinol. HOld colchicine given CKD.
Pt was never able to see ___ as he left AMA before consult.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Colchicine 0.6 mg PO TID:PRN joint pain
4. Digoxin 0.25 mg PO DAILY
5. ipratropium bromide 0.03 % nasal Other
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Mirtazapine 30 mg PO QHS
8. Rosuvastatin Calcium 20 mg PO QPM
9. Aspirin 81 mg PO DAILY
10. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. ipratropium bromide 0.03 % nasal Other
3. Loratadine 10 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Rosuvastatin Calcium 20 mg PO QPM
6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do
not restart Apixaban until you discuss with your doctor due to
your low platlet count
7. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you discuss with your doctor due to
your low platelet count
8. HELD- Colchicine 0.6 mg PO TID:PRN joint pain This
medication was held. Do not restart Colchicine until you discuss
with your doctor
9. HELD- Digoxin 0.25 mg PO DAILY This medication was held. Do
not restart Digoxin until you discuss with your doctor
10. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do
not restart Mirtazapine until you discuss with your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
weakness
dehydration
nausea with vomiting
weight loss
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for monitoring and further work up of weight
loss, nausea, vomiting, dehydration, kidney failure and
weakness. For this, you had lab testing and were given IV fluids
and had a CT scan. Due to the unexplained dehydration and weight
loss as well as weakness, renal failure, electrolyte
abnormalities, and concern for falls and fractures due to
weakness we recommended that you stay inpatient for further work
up and monitoring but you declined. Risks of leaving against
medical advice include infection, worsened renal failure,
electrolyte abnormalities, undiagnosed cancer and including
death. We recommend that you see your PCP ___ for ongoing care.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10010058-DS-13 | 10,010,058 | 21,955,805 | DS | 13 | 2147-01-06 00:00:00 | 2147-01-07 18:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ year old male with past medical history
significant for ischemic cardiomyopathy with LVEF 35%, coronary
artery disease ___ silent anterior MI of indeterminate age
(presumed to be years ago), permanent AF w/ CHB ___ BiV-ICD
implant, mild-moderate MR, CKD, hyperlipidemia who presents to
the emergency department today with complaint of chest and
epigastric pain. Pain occurred in middle of night and awoke
patient from his sleep. Pain is associated with nausea, dyspnea,
and diaphoresis. Denies any pain similar to this in the past.
Denies any pain in his back, fevers, chills, or emesis.
In the ED initial vitals were: T 96.7, HR 57, BP 99/57, RR 18,
SpO2 99% RA
Past Medical History:
(per chart, unable to confirm with patient):
hypertension
hyperlipidemia
AFib
CAD
CHF
hearing loss
CORONARY ARTERY DISEASE
GOUT
HYPERLIPIDEMIA
MEMORY LOSS
PACEMAKER
CHRONIC KIDNEY DISEASE
HYPERTENSION
ISCHEMIC CARDIOMYOPATHY
Social History:
___
Family History:
Noncontributory to patient's presentation
Physical Exam:
Admission
___ Temp: 97.7 PO BP: 108/67 R Lying HR: 60 RR: 16 O2
sat: 96% O2 delivery: 2LNC
GENERAL: lying in bed, interactive but hard of hearing.
HEENT: PERRL. EOMI. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP 14-15cm
CARDIAC: Normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: Bibasilar crackles and dullness at bases.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: 1+ bilateral edema. WWP.
PULSES: 2+ peripheral pulses.
Discharge
___ 0710 Temp: 97.5 PO BP: 115/61 R Lying HR: 60 RR: 16 O2
sat: 100% O2 delivery: Ra
___ Total Intake: 1570ml PO Amt: 1570ml
___ Total Output: 650ml Urine Amt: 650ml
GENERAL: NAD
HEENT: PERRL. MMM.
NECK: JVP noted at the clavicle with patient at 30 degrees
CARDIAC: Normal S1, S2. Grade ___ systolic murmur
LUNGS: Clear to auscultation bilaterally
EXTREMITIES: No ___ edema noted. Warm and well perfused.
PULSES: 2+ peripheral pulses.
Pertinent Results:
Admission
___ 04:05AM BLOOD WBC-7.3 RBC-3.39* Hgb-10.4* Hct-31.8*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.5 RDWSD-49.7* Plt ___
___ 04:05AM BLOOD Neuts-73.4* Lymphs-14.6* Monos-9.6
Eos-1.6 Baso-0.4 Im ___ AbsNeut-5.36 AbsLymp-1.07*
AbsMono-0.70 AbsEos-0.12 AbsBaso-0.03
___ 04:05AM BLOOD ___ PTT-39.0* ___
___ 04:05AM BLOOD Glucose-118* UreaN-34* Creat-1.8* Na-137
K-4.5 Cl-102 HCO3-20* AnGap-15
___ 04:05AM BLOOD ALT-34 AST-48* CK(CPK)-153 AlkPhos-59
TotBili-0.6
___ 04:05AM BLOOD CK-MB-6 ___
___ 04:05AM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.2
___ 04:05AM BLOOD D-Dimer-2200*
___ 07:40AM BLOOD TSH-2.2
___ 07:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 07:50AM BLOOD HBV VL-NOT DETECT
___ 07:30AM BLOOD HCV Ab-NEG
Discharge
___ 07:50AM BLOOD WBC-6.2 RBC-3.24* Hgb-10.2* Hct-31.4*
MCV-97 MCH-31.5 MCHC-32.5 RDW-15.6* RDWSD-55.2* Plt ___
___ 07:50AM BLOOD Neuts-67.8 Lymphs-16.0* Monos-11.3
Eos-3.9 Baso-0.2 Im ___ AbsNeut-4.21 AbsLymp-0.99*
AbsMono-0.70 AbsEos-0.24 AbsBaso-0.01
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-92 UreaN-68* Creat-2.5* Na-140
K-5.8* Cl-100 HCO3-27 AnGap-13
___ 07:50AM BLOOD ALT-86* AST-63* LD(LDH)-285* AlkPhos-68
TotBili-0.5
___ 06:50AM BLOOD ___
___ 07:50AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.7*
___ 06:17AM BLOOD Hapto-154
Studies
___ RUQ US
1. Cholelithiasis.
2. Mild gallbladder wall edema is significantly improved
compared to recent CT
from ___. No other evidence of cholecystitis.
___ ECHO
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. The
estimated right atrial pressure is >15mmHg. There is normal left
ventricular wall thickness with a
moderately increased/dilated cavity. The apex is aneurysmal. A
left ventricular thrombus/mass cannot be
excluded. Overall left ventricular systolic function is severely
depressed secondary to akinesis of the
anterior septum and apex with focal apical dyskinesis, severe
hypokinesis with focal basal akinesis of
the inferior septum and inferior free wall, and hypokinesis of
the anterior ftree wall and lateral wall.
Quantitative biplane left ventricular ejection fraction is 27 %.
The right ventricular free wall is
hypertrophied. Dilated right ventricular cavity with low normal
free wall motion. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. The aortic sinus
diameter is normal for gender with mildly dilated ascending
aorta. The aortic arch diameter is normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is moderate
[2+] aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse.
There is moderate to severe [3+] mitral regurgitation. The
tricuspid valve leaflets appear structurally
normal. There is moderate to severe [3+] tricuspid
regurgitation. Due to acoustic shadowing, the severity
of tricuspid regurgitation may be UNDERestimated. There is
mild-moderate pulmonary artery systolic
hypetension. In the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery
systolic pressure may be UNDERestimated. There is no pericardial
effusion. A left pleural effusion is
present.
Compared with the prior TTE ___, left ventricular
ejection fraction is further reduced, with
increased mitral and tricuspid regurgitation.
EMR
___ CTA
1. 7 mm penetrating plaque in the distal portion of the aortic
arch, without
prior imaging for 2 studies acuity. A short-segment focal
dissection in the
mid aortic arch, appears chronic.
2. Signs of heart failure with cardiomegaly, pulmonary edema,
bilateral
pleural effusions greater on the right, as well as
gallbladder-wall edema.
3. Infrarenal aortic aneurysm and left common iliac aneurysm.
Please note
that the prior study was done without IV contrast however based
on wall
calcifications in overall diameter it is grossly unchanged.
Brief Hospital Course:
Mr. ___ is a ___ year old male with PMH significant for
ischemic cardiomyopathy (LVEF 27% on ___ ECHO), CAD ___
silent anterior MI of indeterminate age), permanent AF w/ CHB
___ BiV-ICD implant (on apixaban), CKD, hyperlipidemia who
presented for chest/epigastric pain. He was found to have
elevated troponins and decompensated heart failure. He was
medically treated for NSTEMI with heparin drip and continuation
of home medications including aspirin, statin, and beta blocker.
He was diuresed with Lasix drip. He was also managed for ___
during this time, which was improving at time of discharge.
While inpatient he had a reaction to likely hydralazine that
resulted in a morbilliform drug rash. The drug was discontinued
and his rash improved. Corresponding to that rash he had
elevated LFTs that were downtrending by time of admission. He
was found to have isolated hepatitis B antibody.
# CORONARIES: CAD ___ silent anterior MI
# PUMP: HFrEF (EF 35%)
# RHYTHM: permanent AF and CHB ___ BiV-ICD
ACTIVE ISSUES:
==============
#Acute decompensated HFrEF (EF 35%)
#Ischemic Cardiomyopathy
#LBBB ___ CRT-D
The patient presented with clinical evidence of volume overload
with rales, elevated JVP, mild pulmonary edema on CXR, and
congestive gallbladder and ascending colon on CT. BNP >50000.
Diuresed on a Lasix drip at 10cc/hr.
- Admission weight 51 kg, discharge dry weight 45.4 kg
- Preload: 10 mg furosemide daily
- Afterload: Imdur 90 mg daily (previous intolerance to ACE + he
has hyperkalemia)
- Neurohormonal blockade: metoprolol 50 mg XL
- Digoxin was discontinued w/ supratherapeutic level, worsening
renal failure, and stable cardiac function after diuresis
#NSTEMI
#CAD with prior silent MI
Initial trop elevated with peak to 2.60, without clear new ECG
changes. Unclear if initial presentation was Type 1 NSTEMI
versus demand in the setting of severe decompensated CHF. He
received 48 hour heparin drip, aspirin, and rosuvastatin. After
discussion with the patient and family, it was determined that
he did not desire any invasive intervention such as cardiac
catheterization. He will continue on aspirin, rosuvastatin 20
mg, and metoprolol succinate 50 mg qD at home.
___ on CKD
Baseline appears to be ___ and was at baseline at
presentation, but increased to a peak of 3.4 with diuresis. It
was not clear the etiology of his ___, but possibly prerenal in
the setting of his low flow state. No urinalysis sediment
evidence of ATN. No post-renal obstruction. Renal function was
improving at the time of discharge, with creatinine down to 2.5.
We did suspend apixaban for some time, but it was restarted once
renal function improved.
#Hyperkalemia
Persistently hyperkalemic during the admission. Likely a
combination of both diet and acute renal failure. Patient was
found to have pile of bananas in his room. He likes eating them
because they are soft. Patient and patient's family education on
low potassium foods. He was not discharged on any potassium
elevating agents at the time of discharge. His levels will need
to be followed closely as ___ outpatient.
# Transaminitis
Mild transaminitis of unclear etiology. Initially thought to be
due to vascular congestion, but has remained elevated even after
diuresis. RUQ without evidence for cholecystitis. Possibly
hypersensitivity
to hydralazine, as LFTs increased after drug was introduced. Was
also Hep B core Ig positive without Ag or Ab positive, which is
nonspecific. LFTs were downtrending at time of discharge.
Hepatitis B viral load pending at time of discharge. He should
receive a fibroscan to follow up for possible cirrhosis
secondary to possible chronic disease.
# Morbilliform Drug Eruption
Patient with erythematous itchy macular rash that started on
back and
thighs and since spread to abdomen anteriorly. Derm consulted,
believes to be drug eruption, but unclear which drug. Patient
started on hydralazine, furosemide, isosorbide mononitrite at
the same time. Hydralazine was held at is was believed to be
likely culprit, and rash improved. He was started on 14 day
course of betamethasone steroid cream, per derm.
#Ulceration of aortic arch
#Aortic dissection
Found on CT in ED. Cardiac surgery was consulted and recommended
medical management with blood pressure control with systolic
blood pressures < 120 mmHg. This should be continued as ___
outpatient.
# Anemia
Stable between ___ without any further acute drops. No
evidence for
hemolysis or active bleeding at this time.
CHRONIC ISSUES:
===============
#AF ___ BiV-ICD:
Patient continued home metoprolol, as above, and will be able
to continue apixaban for anticoagulation. He has a BiV-ICD in
place.
Transitional Issues:
====================
[ ] Persistent hyperkalemia while inpatient, please follow at
next appointment (lab slip provided on discharge).
[ ] Patient with elevated transaminases during admission.
Improving on discharge. Please follow with repeat LFTs at PCP
___
[ ] Follow up hepatitis B viral load (to r/o active Hep B
infection). Currently pending in OMR.
[ ] Due to prior hepatitis B infection, patient may benefit from
fibroscan.
[ ] Follow weights to ensure proper diuretic dose on furosemide
10 mg qD
[ ] Follow blood pressures to ensure adequate afterload
reduction (ideally systolic < 120 mmHg), previously intolerant
to ACE inhibitors (and hyperkalemic) thus not initiated on
discharge
[ ] Discuss with patient whether or not to inactivate ICD given
DNR/DNI code status
Cr: 2.5
Wt: 45.4 kg
CODE STATUS: DNR/DNI
CONTACT:
___
Relationship: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO QPM
4. ipratropium bromide 0.03 % nasal Other
5. Loratadine 10 mg PO DAILY
6. Mirtazapine 45 mg PO QHS
7. Digoxin 0.25 mg PO DAILY
8. Colchicine 0.6 mg PO TID:PRN joint pain
9. Apixaban 2.5 mg PO BID
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
RX *betamethasone dipropionate 0.05 % Apply to affected areas
(not on face, groin, axilla) twice a day Refills:*0
2. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*15 Tablet Refills:*3
3. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*3
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*12
5. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
8. ipratropium bromide 0.03 % nasal Other
RX *ipratropium bromide 21 mcg (0.03 %) 1 spray nasal once a day
Disp #*1 Spray Refills:*0
9. Loratadine 10 mg PO DAILY
RX *loratadine [Claritin] 10 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
11. Mirtazapine 45 mg PO QHS
RX *mirtazapine 45 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
12. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
13.Outpatient Lab Work
ICD 10 N17.9: acute kidney injury
R74.0 transaminitis
Please obtain CMP, lytes, and LFTs (ALT/ALT/LDH/TBili/Albumin)
and provide to outpatient PCP ___
___ Fax ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute Decompensated Systolic Heart Failure
Non-ST Elevation MI
Secondary:
Acute Kidney Injury
Transaminitis
Hyperkalemia
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___
You were admitted to ___
because you had a small heart attack. You had extra fluid that
caused weight gain. This is called heart failure.
While you were here we gave you a medication to help you urinate
more and remove fluid.
What to do when you go home:
* Please weigh yourself every daily. Do this in the morning
after you go to the bathroom and before you get dressed.
* If your weight goes up by more than 3 lbs in 1 day or more
than 5 lbs in 3 days, please call your heart doctor or your
primary care doctor and alert them to this change.
* We have made changes to your medication list, so please make
sure to take your medications as listed below
* You will also need to have close follow up with your heart
doctor and your primary care doctor.
It was a pleasure to take care of you. We wish you the best
with your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
10010231-DS-28 | 10,010,231 | 27,998,273 | DS | 28 | 2118-05-09 00:00:00 | 2118-05-09 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
febrile neutropenia
Major Surgical or Invasive Procedure:
POC removal ___
History of Present Illness:
HPI:
___ with history of AML on HiDAC C4D13 presenting to the ED
with fever and submandibular swelling. The patient reports he
had a small "bump" under his chin for over a week. This morning
he awoke and found the bump had dramatically enlarged, became
tender to touch, and he developed fevers. He then presented to
the hospital. He denies CP, SOB, N/V/D, abdominal pain.
In the ED:
VS: T 102.9 | HR120 | BP 137/87 | 20 | 100% RA
His evam was notable for: Small pustule on R scalp, palpable
fluctuant 3cm diameter ? abscess in submandibular region.
Labs Notable for WBC 0.1, HGB of 8.4 and plt of 14. Also sodium
of 131.
He was given:
13:22 IVF NS
14:19 PO Acetaminophen 1000 mg
14:37 IV Vancomycin
16:21 IV CefePIME 2 g
On the floor, he arrived in stable condition, still febrile and
confirmed the above story
Past Medical History:
Past Medical History:
Other than his malignancy, he has no medical conditions.
Past Onc History:
Initial presentation of AML on ___ to ___,
transferred to ___ for Leukocyotosis with blastsand Bone
marrow confirmed. Bone marrow biopsy confirmed acute myeloid
leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement.
Patient was started on 7+3 on ___. Day 14 bone marrow with
aplasia but persistent t(8;21) in 40% of cells per karyotype and
RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made
not to re-induce. Day 21 bone marrow on ___ was with no
morphologic or cytogenetic evidence of residual disease.
Treatment History:
- ___: 7+3
- ___: BMB with ___
- ___: C1D1 HiDAC
- ___: C2D1 HiDAC
- ___: C3D1 HiDAC
- ___: C4D1 HiDAC
Social History:
___
Family History:
Both mother and father died of old age. He denies any family
history of malignancy or blood disorders.
Physical Exam:
Admission Physical Exam:
Vitals: 98.8 | PO 130/69 | 87 | 18 | 100% RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: 2cm fluctuant nodule in left submandibular region with
small central lesion. No JVP appreciated.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses other than
noted above
NEURO: A&Ox3.
LINES: Left Portacath heparin dependent
Discharge Physical Exam:
VS: TC 97.7 ___ 94-99%RA
Gen: pleasant & conversant, NAD.
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: submandibular swelling and erythema resolved. No
fluctuance
or tenderness appreciated.
CV: Normocardic, regular. Normal S1/S2. No MRG.
LUNGS: No increased WOB. CTAB.
ABD: +BS, soft, NT/ND
EXT: WWP. No ___ edema.
SKIN: Except as described above. No other petechiae/purpura
ecchymoses.
NEURO: A&Ox3, grossly non-focal
Pertinent Results:
ADMISSION LABS:
___ 09:00AM BLOOD WBC-0.2*# RBC-2.51* Hgb-8.5* Hct-24.4*
MCV-97 MCH-33.9* MCHC-34.8 RDW-15.9* RDWSD-56.5* Plt Ct-10*#
___ 09:00AM BLOOD Neuts-23* Bands-0 Lymphs-75* Monos-0
Eos-1 Baso-1 ___ Myelos-0 AbsNeut-0.05*
AbsLymp-0.15* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 09:00AM BLOOD UreaN-14 Creat-0.7 Na-134 K-4.0 Cl-101
HCO3-24 AnGap-13
___ 09:00AM BLOOD ALT-99* AST-41* AlkPhos-85 TotBili-0.4
___ 09:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
Microbiology:
___ 1:15 pm BLOOD CULTURE positive x2
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ (___),
@11:10 ON
___.
IMAGING:
___ CT Neck IMPRESSION:
1. There are a few prominent, though nonenlarged, cervical lymph
nodes. 1 of which may correspond to the clinical area of
concern, but is not pathologically enlarged or necrotic. No
mass or abscess is identified.
2. Mild, nonspecific soft tissue stranding in the subcutaneous
tissues
inferior to the chin.
3. Moderate mucosal thickening in the left maxillary sinus.
___ CT Neck IMPRESSION:
1. Left greater than right submental subcutaneous edema,
consistent with known cellulitis in this area, demonstrates mild
progression compared to 3 days earlier on ___. No
free fluid or abscess.
2. Multiple small right upper lobe lung nodules measuring up to
5 mm are new compared ___. In the setting of
bacteremia, these may represent septic emboli. Atypical
infection may also be considered as the patient is neutropenic
(Nocardia, etc).
3. Moderate polypoid mucosal thickening in the left maxillary
sinus with
occlusion of the left ostiomeatal unit and a mucous retention
cyst in the right maxillary sinus, similar to prior. Given the
small periapical lucency involving ___ 14 or 15, as detailed
above, please correlate clinically whether there may be
odontogenic etiology of sinus disease.
___ CT Chest IMPRESSION:
1. Numerous bilateral pulmonary nodules appear increased in
number at least in the upper lobes since the prior neck CT and
favor infectious etiology, likely fungal in the setting of
febrile neutropenia. Correlate with clinical assessment. If
the patient's symptoms persist despite treatment, consider
repeat Chest CT in ___ weeks to reevaluate.
2. Anemia.
3. Minimal colonic diverticulosis.
___ US Neck IMPRESSION:
1. No drainable fluid collection. No abnormal lymph nodes.
2. Mild skin thickening and subcutaneous edema of the submental
area,
consistent with patient's known cellulitis.
___ MANDIBLE PANOREX
IMPRESSION: No periapical lucency.
___ LIVER U/S
IMPRESSION:
Echogenic liver consistent with steatosis. Other forms of liver
disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on this examination. Unchanged from prior.
CT CHEST ___
IMPRESSION:
Multiple scattered pulmonary nodules are minimally decreased in
size as
compared to chest CT ___. No new pulmonary nodules
identified.
DISCHARGE LABS:
___ 08:15AM BLOOD WBC-2.8* RBC-2.80* Hgb-9.4* Hct-28.3*
MCV-101* MCH-33.6* MCHC-33.2 RDW-20.9* RDWSD-76.9* Plt ___
___ 08:15AM BLOOD Neuts-42.9 ___ Monos-25.9*
Eos-0.4* Baso-0.7 NRBC-1.4* Im ___ AbsNeut-1.21*
AbsLymp-0.83* AbsMono-0.73 AbsEos-0.01* AbsBaso-0.02
___ 08:15AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+ Tear
Dr-1+
___ 08:15AM BLOOD Plt Smr-NORMAL Plt ___
___ 08:15AM BLOOD Glucose-103* UreaN-6 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-28 AnGap-13
___ 08:15AM BLOOD ALT-51* AST-58* LD(LDH)-204 AlkPhos-82
TotBili-0.3
___ 08:15AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.9 Mg-2.1
___ 08:15AM BLOOD
Brief Hospital Course:
ASSESSMENT/PLAN: Mr. ___ is a ___ year old male with AML s/p C4
of HiDAC (___) who presents with febrile neutropenia found to
have MSSA bacteremia and new pulmonary nodules.
C4D38 ___
#Febrile Neutropenia:
#MSSA bacteremia: Likely source is skin and soft tissue
infection
from an ingrown hair/folliculitis. MSSA growing from first set
of
blood cultures on ___, was on vancomycin and meropenem but
narrowed to cefazolin x 4 week course from POC removal
(___). Patient has completed mandatory 2 weeks
course
of IV ABX with cefazolin in-house with NTD surveillance
cultures.
However, given concern for medical contraindication for central
line access to provide intravenous antibiotics at home, we
recommend changing from cefazolin to linezolid PO as there is no
better alternative for patient. Patient transitioned to
linezolid
on ___ and will continue until ___
-surveillance cultures have been negative to date as above.
-CT Neck negative for abscess
-TTE no significant findings
-ID consulted, recs appreciated--felt more comfortable tx as
endovascular infection for extended course, per ___ team will
treat 4 week course from POC removal (___)
- Chest CT concerning for fungal infection, see below
- F/U panorex for abscess - negative
- F/U b-glucan/galactomannan - negative on ___, see below
for repeat on ___
#Lung Nodules: concerning for fungal infection, found
incidentally on neck CT that were new and worsening on repeat
imaging. Patient was switched from fluconazole to posaconazole
on ___ given these findings. However, due to elevated LFTs,
discontinued posaconazole (___) which was thought to be
the likely culprit as well as ciprofloxacin. Per ID, patient
will require repeat CT chest in 4 weeks to monitor nodules but
may obtain earlier per primary oncologist. Repeat CT chest on
___ showed multiple scattered pulmonary nodules that are
minimally decreased in size as compared to chest CT ___. Although no new pulmonary nodules were identified, patient
now has elevated BD glucan and given his AML, he is at a high
risk for fungal PNA so initiated on voriconazole (d1: ___ with
plan to follow up radiographically as above. He will likely need
a 6WK course.
-Beta glucan 61 on ___ (was negative on ___
-Asp galactomannan negative on ___
#Transaminitis: (improving). Thought to be secondary to
medication-effect (posaconazole likely culprit which was
discontinued on ___. Liver ultrasound on ___ showed
echogenic liver consistent with steatosis. Other forms of liver
disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on this examination. Hep serologies
were unremarkable on ___. Re-consulted ID on ___ in light
of worsening transaminitis to consider switch from cefazolin to
vancomycin. ID thinks that his transaminitis is potentially from
posaconazole which has been discontinued, as above, and would
not expect his LFTs to plateau until ___ days after
discontinuing the offending agent. We will continue to monitor
and trend LFTs closely particularly given initiation of
voriconaozle.
#AML on HiDAC: s/p 4C of HIDAC. Patient counts now recovered,
continue with Acyclovir 400mg BID prophylactically.
#Pancytopenia: now recovered although noted some mild
downtrending of his WBC and ANC, etiology most likely secondary
to chemotherapy. He had a positive hemoocult test on ___ and
___. Repeat CBC/COAGS stable. Coombs negative. Will need GI
consult for further work-up
-stopped filgrastim ___
-Singulair 10mg daily for history or mild urticarial reaction to
plts transfusions
#ACCESS: POC removed. No access.
#CODE: Presumed Full
#Contact: ___
#DISPO: Discharged ___. RTC next week on ___ or ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Pantoprazole 40 mg PO Q24H
3. Simethicone 40-80 mg PO QID:PRN gas pains
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID
5. Ciprofloxacin HCl 500 mg PO Q12H
6. Fluconazole 400 mg PO Q24H
7. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Linezolid ___ mg PO Q12H
you will continue this medication until ___
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
2. Voriconazole 200 mg PO Q12H
3. Acyclovir 400 mg PO Q12H
4. Montelukast 10 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Simethicone 40-80 mg PO QID:PRN gas pains
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Febrile Neutrapenia
MSSA Bacteremia
Peripheral Pulmonary Nodules
Secondary Diagnosis:
AML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted due to fever when your blood counts were very
low. You were found to have a blood infection and you were
treated with IV antibiotics. Your fever has now resolved so we
transitioned you to an oral regimen of antibiotics with plan of
completing on ___.
Please refer below for your appointment with Dr. ___
___ was a pleasure taking care of you.
Sincerely
Your ___ TEAM
Followup Instructions:
___
|
10010393-DS-5 | 10,010,393 | 27,377,841 | DS | 5 | 2136-07-02 00:00:00 | 2136-07-02 21:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Topamax / Reglan
Attending: ___.
Chief Complaint:
Urinary retention, pain at intrathecal pump catheter site
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with history of pudendal neuralgia
s/p intrathecal pump placement in ___ and with ongoing
narcotic use, hypothyroidism and history of an arrhythmia who
presents with pain at the site of her intrathecal pain pump
catheter and urinary retention, transferred from ___
for rule-out of cord compression.
Patient has had several years of pain so disabling that she "has
not been able to get out of bed for ___ years." She trialed many
different pain regimens (see pain management notes from this
institution) and ultimately was seen by a pain management
physician in ___ for placement of an intrathecal pain pump in
___. Since then, she has been able to get out of bed on at
least two occasions, though her pain is only moderately
improved. This week she developed new back pain at the site of
the pump's insertion and urinary retention. Also with one
episode of fecal incontinence in the setting of new nausea,
vomiting X ___ yesterday and multiple episodes of watery diarrhea
over the past week. No other incontinence during this time. No
fevers, chills, chest pain, shortness of breath, melena, BRBPR.
Given the pain at the insertion site, she presented to ___
___ where she was reportedly neurologically stable and a CT
with IV contrast was unremarkable. She was bladder scanned there
for 800 cc urine, Foley was placed and she put out 1200cc urine.
Required 4mg IV dilaudid for pain control. She was then
transferred to ___ to rule out cord compression given pain and
new urinary retention.
Upon arrival to the floor, she complains the light is bothering
her eyes. She also details the history above.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
cough, fevers, chills, dyspnea, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, dysuria, rash and
weakness.
Past Medical History:
HYPOTHYROIDISM
ARRHYTHMIA
PUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT
SOMATIZATION DISORDER
Social History:
___
Family History:
No cardiac or cancer history in either parent. Mother and sister
with depression.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.9F 113/68 76 18 96% on RA
GENERAL: no acute distress, lying in bed
HEENT: NC/AT, no scleral icterus, PERRLA, EOMI
NECK: supple
CARDIAC: RRR, normal S1/S2, no murmurs
PULMONARY: clear to auscultation bilaterally
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema. Mild tenderness to palpation over lumbar incision site
where pump catheter is.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, strength normal and
symmetric in the bilateral UE and ___
DISCHARGE PHYSICAL EXAM:
VITALS: 98.3F 116/85 77 18 97% on RA
GENERAL: no acute distress, lying in bed
HEENT: NC/AT, no scleral icterus, PERRLA, EOMI
NECK: supple
CARDIAC: RRR, normal S1/S2, no murmurs
PULMONARY: clear to auscultation bilaterally
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, strength normal and
symmetric in the bilateral UE and ___
Pertinent Results:
ADMISSION LABS:
___ 12:20AM BLOOD WBC-3.2* RBC-3.84* Hgb-11.5 Hct-33.4*
MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.7 Plt ___
___ 12:20AM BLOOD Neuts-28.9* Lymphs-56.1* Monos-12.5
Eos-1.6 Baso-0.9 AbsNeut-0.93* AbsLymp-1.80 AbsMono-0.40
AbsEos-0.05 AbsBaso-0.03
___ 12:20AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-142
K-3.9 Cl-107 HCO3-27 AnGap-12
___ 12:20AM BLOOD CK(CPK)-80
___ 12:49AM URINE Type-RANDOM Color-Yellow Appear-Clear Sp
___
___ 12:49AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
___ 12:49AM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 12:49AM URINE Mucous-RARE
___ 12:14PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE
DISCHARGE LABS:
___ 05:52AM BLOOD WBC-2.7* RBC-3.65* Hgb-10.9* Hct-31.7*
MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.8 Plt ___
MICROBIOLOGY:
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
ECG Study Date of ___ 7:51:52 AM
Clinical indication for EKG: ___.___ - QT interval for
medication
monitoring
Sinus rhythm. Normal tracing.
Read by: ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
83 ___ 426 54 63 55
IMAGING:
SECOND OPINION READ OF CT (___) L-SPINE
FINDINGS:
There is normal alignment of the lumbar spine. Mild ligamentum
flavum
thickening is seen at L3-4, L4-5 and L5-S1. No significant
spinal canal or neural foraminal stenosis is seen. There is no
acute fracture or
malalignment.
There is an intrathecal catheter which courses from the pump,
which is not
visualized, through the left subcutaneous soft tissues of the
back, between the L2-3 spinous process and into the thecal sac.
Two linear hyperdensities are noted within the soft tissues at
the level of the L3 spinous process, consistent with surgical
sutures. Minimal stranding is noted within the posterior soft
tissues, at the level of the L3 spinous process, likely
secondary to postsurgical changes. No fluid collection or soft
tissue mass is identified along the course of the catheter. The
catheter extends from the through the T11- L2 spinal canal. No
discontinuity is noted in the visualized catheter.
A fluid-filled distended bladder is seen. Multiple sub cm
hypodensities are noted in the kidneys, which are too small to
characterize and likely represent simple cysts.
IMPRESSION:
1. Minimal soft tissue stranding in the posterior soft tissues
of the back, at the L2-3 level, consistent with postsurgical
changes. No fluid collection or abscess identified along the
course of the visualized catheter.
Brief Hospital Course:
___ with chronic pudendal impingement syndrome s/p intrathecal
pump for ziconotide infusion who was admitted for acute urinary
retention and pain at intrathecal pump catheter site.
#Acute urinary retention - Timing seems to coincide with recent
increase in ziconotide dose on ___. ___ Pain service was
consulted and recommended decreasing the ziconotide dose 20%, to
previous dose. However, ___ Pain service only has equipment
for ___ pumps and were not able to interrogate or adjust
the Flowonix Prometra pump, which the patient has.
Administrative approval was obtained for Pentec, the company who
manages patient's pump in the outpatient setting, to provide
services as inpatient. Given delay in ability of pump service
agency to provide adjustment in the inpatient setting, patient
was discharged with Foley catheter with plan for decrease in
ziconotide dose as an outpatient, followed by Foley removal and
voiding trial.
#Acute pain over intrathecal pump catheter site - Developed over
the ___ weeks prior to admission. CT L spine revealed no signs
of infection. However, where catheter bends and overlaps the L2
spinous process is quite superficial and had some mild
surrounding inflammatory stranding of the soft tissue. Per
___ Pain Service, this inflammation could be causing the pain.
Pressure on the site over time from supine position (patient
spends most of her time in bed due to debilitating pain) could
explain the timing of the pain 6 months after pump was placed.
The pain was partially relieved by lidocaine patches. Patient
was discharged with lidocaine ointment and Voltaren gel. Dr.
___ at the ___ in ___,
who placed the pump, was contacted by phone on ___ regarding
this issue, and did not feel the catheter was causing the pain
but was willing to see the patient in followup. He recommended
that the patient find a local pain specialist in ___
who could manage the pump and the ziconotide but was unable to
provide a referral to a specific specialist. ___ Pain was
also unable to provide this referral as the Flowonix brand of
intrathecal pumps is essentially never used in the ___ of
___. Patient will contact the vendor to request a
referral to an appropriate local provider.
#Chronic low back pain and pelvic pain: Patient has been
debilitated by this pain for several years despite multiple
procedures. Her current narcotics are managed by Dr. ___
___ in ___ and her pump is managed by Dr. ___
___ in ___. She was continued on her home pain regimen,
which was confirmed per phone conversation with Dr. ___ on
___, with the exception of substituting regular release
hydromorphone for her extended release hydromorphone due to it
being non-formulary at ___.
#Orthostatic hypotension: Pt had been having loose stools and
decreased PO intake, likely due to a viral gastroenteritis. She
was also on higher doses of hydromorphone at the beginning of
the hospitalization for acute on chronic pain. The orthostasis
resolved with IV fluids, weaning of narcotics, and improvement
in her gastroenteritis. Stool studies were negative for
infectious source.
CHRONIC ISSUES:
#HYPOTHYROIDISM: Continued levothyroxine.
#HX OF HTN/CARDIAC ARRHYTHMIA: Continued home Verapamil.
#PSYCH: Continued home medications.
TRANSITIONAL ISSUES:
- Patient will require routine Foley care
- Voiding trial to be performed after intrathecal ziconotide
dose is decreased by 20%. If no void within 8 hours, seek urgent
medical attention.
- Patient will require ongoing followup with pain specialist and
evaluation of intrathecal pump catheter incision site.
- Patient had mild leukopenia (WBC 2.8) and anemia (Hgb ___
that was stable during this admission. Consider outpatient
workup.
- Consider routine periodic monitoring of CK levels while
patient is on ziconotide.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN
2. LORazepam 1 mg PO Q4H:PRN anxiety
3. Methadone 5 mg PO TID
4. DULoxetine 60 mg PO BID
5. Pregabalin ___ mg PO DAILY
6. NexIUM (esomeprazole magnesium) 40 mg oral DAILY
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Vitamin D ___ UNIT PO 1X/WEEK (WE)
9. BusPIRone 15 mg PO TID
10. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR
11. Tizanidine 2 mg PO TID
12. TraZODone 150 mg PO QHS:PRN insomnia
13. Verapamil SR 120 mg PO Q24H
14. Polyethylene Glycol 17 g PO DAILY
15. Ranitidine 300 mg PO QHS
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Dilaudid (HYDROmorphone) 16 mg oral QAM
18. ziconotide 8.01 mcg/day injection INFUSION
Discharge Medications:
1. BusPIRone 15 mg PO TID
2. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN
3. Levothyroxine Sodium 137 mcg PO DAILY
4. LORazepam 1 mg PO Q4H:PRN anxiety
5. Methadone 5 mg PO TID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Polyethylene Glycol 17 g PO DAILY
8. Pregabalin ___ mg PO DAILY
9. Ranitidine 300 mg PO QHS
10. Tizanidine 2 mg PO TID
11. TraZODone 150 mg PO QHS:PRN insomnia
12. Verapamil SR 120 mg PO Q24H
Do not take this medication if your systolic blood pressure in
the morning is below 100.
13. DULoxetine 60 mg PO BID
14. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR
15. NexIUM (esomeprazole magnesium) 40 mg oral DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (WE)
17. HYDROmorphone (Dilaudid) (HYDROmorphone) 16 mg ORAL QAM
18. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain
RX *diclofenac sodium [Voltaren] 1 % Apply to painful site of
lower back 4 times per day Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute urinary retention
Acute viral gastroenteritis
SECONDARY DIAGNOSES:
Postsurgical pain of incision site
Chronic pudendal impingement syndrome
Hypothyroidism
Unspecified cardiac arrhythmia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
urinary retention and pain over your intrathecal pump catheter
incision site.
We believe the urinary retention was due to the recent increase
in the ziconotide dose running through your pump. We were able
to get administrative approval for the company who adjusts your
pump settings to come provide their services in the inpatient
setting, however they are able to visit you in your home to
adjust the settings sooner. You will have additional nursing
services to care for your new Foley catheter. Once your
ziconotide dose is decreased, the Foley catheter should be
removed to allow a trial of urination. If you are still unable
to urinate, you should return to the hospital immediately.
Our radiologists and pain specialists reviewed the CT images of
your lumbar spine and we believe that the pain you are
experiencing is due to the superficial placement of the pump
catheter, which has some mild inflammatory changes around it.
Please continue lidocaine ointment or patches and Voltaren gel
to relieve the pain in that area until you can see a pain
specialist who can manage this type of intrathecal pump.
It was a pleasure taking care of you.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10010440-DS-5 | 10,010,440 | 26,812,050 | DS | 5 | 2173-08-19 00:00:00 | 2173-08-19 14:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CODE CORD: Leg weakness, known T12 lesion
Major Surgical or Invasive Procedure:
1. Anterior arthrodesis T11-L1.
2. Application interbody cage T11-L1.
3. Biopsy of T12 vertebral body.
4. Posterior arthrodesis T10-L2.
5. Posterolateral posterior instrumentation T10-L2 segmental.
6. Open treatment fracture dislocation from metastatic disease
and destruction of the T12 vertebral body.
7. Laminectomy of partial L1, all of T12, and the inferior
aspect of T11.
8. Application of allograft.
ANESTHESIA: General endotracheal.
History of Present Illness:
History obtain largely from Daughter in law and PCP, ___ (___)
History of Present Illness: This is a ___ yo ___ female with a
history of a ___ secondary to an aneurysm with residual aphasia,
HTN, and hyperlipidemia and recent work-up initiated for
multiple
myeloma who presents with leg weakness and multiple falls.
Per the patient's daughter in law on ___ the patient had a
bad fall at home where she lives with her son and daughter in
law. She was down for 4 hours. She reported to her PCP that her
"legs gave out". She was seen at ___ where she had
plain films and a head CT that were normal. She received 6 weeks
of home ___ and was doing fairly well. When that concluded
though,
she began a slow decline. She has had decreased appetite, a
rapid
30 lbs weight loss and a few more falls. She complains of back
pain and it is unclear whether pain or weakness has been the
cause of her falls. She also became incontinent of urine, but
not
stool. Ultimately, 2 weeks ago when she could not even walk two
steps she went back to the ED where Xrays were negative. She
went
to rehab. A CT was not done. At the nursing home rehab she
continued to have pain and weakness with not much improvement.
Last night the patient was much more quiet than usual. This AM
she woke upset and in a lot of pain. She was screaming and
refusing to take her medications. The daughter encouraged the
rehab nursing home to send her to the ED. At the ___ ED she
received a spine CT that revealed, "Findings consistent with
multiple myeloma involving multiple levels and an associated
mass
arising from T12 extending into the canal and compressing the
thecal sac significantly." Of note the patient can not have an
MRI due to the aneurysm clips. A left toes fracture was also
found on plain films. The patient was sent to ___ for further
evaluation and treatment.
In the ED now the patient is in some mild pain, but reports
feeling ok. Of note a year ago the patient began a w/u for
multiple myeloma. She had a biopsy done of the T12 lytic lesion
that was inconclusive. She then had a bone marrow biopsy that
revealed pre Kappa light chains, but no conclusive evidence of
multiple myeloma.
Review of systems:
(+) Per HPI
(-) Denies recent weight gain. Denies nausea, vomiting,
diarrhea,
constipation or abdominal pain. No recent change in bowel
habits.
No dysuria. Denies arthralgias. Ten point review of systems is
otherwise negative.
On neuro ROS, No HA, visual aura. No loss of vision,
lightheadedness, vertigo, diplopia, dizziness, dysarthria,
dysphagia, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Weakness of ___. No numbness,
parasthesiae. Bladder incontinence, but no bowel incontinence.
Gait problems.
Past Medical History:
SAH, s/p b/l Aneurysm clipping. With frontal craniotomy.
Residual aphasia.
HTN
Hyperlipidemia
Right knee replacement
VP shunt
Social History:
___
Family History:
Multiple family members, particularly cousins
with brain aneurysms requiring clipping, some of who had
strokes.
No history of cancer in the family.
Physical Exam:
Vitals: T 98.2, HR 90, BP 106/72, RR 18, O2 99 % RA
General: Awake, cooperative, in NAD. Obese.
HEENT: NC/AT, no sclera icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted. No carotid bruits
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to place, person, and year with
choices (difficult exam as the patient's motor aphasia prevents
answers to multiple questions). Naming impaired, perseverative.
Follows commands, but again requires some mimicking to reliably
follow. Per PCP and daughter in law this is her cognitive
baseline.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 b/l, sluggishly reactive. Visual fields are
difficult to assess reliably. Appears to be some impairment in
peripheral fields.
III, IV, VI: EOMI without nystagmus. No diplopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger rub.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift. No
tremor or other adventitious movements. No asterixis noted. Nml
finger tapping.
Delt Bic Tri FFl FE IO IP Quad Ham TA ___
L 5 5 ___ 5 4- 4 ___- 3
R 5 5 ___ 5 2 4 4- 2 5- 5-
-Sensory: Intact and symmetric sensation to light touch, temp
and pinprick, although patient has some trouble understanding
the
questions.
Normal rectal tone.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 2
R 2 2 2 0* 2
Plantar response was extensor b/l.
* Knee replacement
-Coordination: No dysmetria on FNF.
-Gait: Not assessed. Unable to sit or stand unassisted.
Pertinent Results:
___ PATHOLOGY report from surgical resection (PRELIM):
Bone, T12 vertebra, lytic lesion; Bone and fibrous tissue with
dense plasma cell infiltrate, consistent with plasma cell
dyscrasia, see note.
___ ANKLE (AP, LAT & OBLIQU) FINAL
There are moderate degenerative changes of the tibiotalar joint
with narrowing and subchondral sclerosis. There is evidence of
prior avulsive injury arising off the medial malleolus and
likely the lateral malleolus as well. There is chronic deformity
of the lateral malleolus. No acute fracture is identified. There
is calcaneal enthesopathy. Soft tissue swelling is noted.
IMPRESSION: Moderate tibiotalar joint degenerative change. No
acute fracture appreciated.
___ CT HEAD
IMPRESSION:
1. No acute intracranial hemorrhage status post right
craniotomy and aneurysm clipping.
2. Hyperdensity of the left posterior cerebral hemisphere not
corresponding to vascular territory could conceivably represent
retained contrast related to the patient's recent myelogram.
Attention on followup is recommended.
3. Stable bifrontal encephalomalacia.
4. Unchanged position of a right parietal ventriculostomy
catheter.
___
TECHNIQUE: Thoracolumbar spine, five views.
FINDINGS: The patient is status post posterior fusion from T10
through L2 with a T12 corpectomy including placement of a
vertical fusion spacer. Moderate-to-severe degenerative changes
are incompletely characterized, but suspected, along the facet
joints along the mid through lower lumbar spine. Small anterior
osteophytes are present along the lower thoracic spine. There
is no evidence for hardware loosening. A PICC line terminates
in the upper right atrium. A ventriculoperitoneal shunt is also
noted.
IMPRESSION: Unremarkable post-operative appearance.
___ MRI SPINE
IMPRESSION:
Status post T12 corpectomy and T10-L2 fusion.
Posterior and right-sided intraspinal fluid collection
communicates through the laminectomy defect and causes anterior
and left lateral displacement of the thecal sac. This leads to
severe encroachment on the distal spinal cord. There are no
findings to suggest tumor in this location. The signal
intensity characteristics are typical of simple fluid, rather
than hemorrhage.
___ 05:14AM BLOOD WBC-22.1* RBC-3.39* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.2 MCHC-33.3 RDW-17.6* Plt ___
___ 12:06PM BLOOD Neuts-83.9* Lymphs-8.5* Monos-7.3 Eos-0.2
Baso-0.1
___ 05:14AM BLOOD Plt ___
___ 06:45AM BLOOD ___ PTT-30.2 ___
___ 05:49AM BLOOD Glucose-113* UreaN-27* Creat-0.9 Na-138
K-6.6* (HEMOLYZED FROM PICC - falsely elevated) Cl-106 HCO3-28
AnGap-11
___ 04:10AM BLOOD ALT-16 AST-29 LD(LDH)-425* AlkPhos-60
TotBili-0.3 DirBili-0.1 IndBili-0.2
___ 04:10AM BLOOD Hapto-422*
___ 9:01 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ w/ h/o of stroke ___ years ago with baseline of expressive
aphasia and RLE weakness, although family claims that she can
fully comprehend. Pt was found to have T12 mass concerning for
malignancy in ___, however bx of mass and BM was
inconclusive. She was asymptomatic at that time and family
decided not to persue further work-up. Pt now p/w with a 2.5
month h/o of progressive weakness and recurrent falls
unresponsive to ___, and weight loss from 250-->225. Pt had CT
at OSH which demonstrated expanding lesion at T12 and was
subsequently given 10mg IV dexamethasone and transfered to ___
for further management. Patient arrived on the floor afebrile
and hemodynamically stable. Immediate neurology and
neurosurgery consults were obtained. Her hospitalization course
is as follows:
# T12 lesion: Patient has profound lower extremity weakness
bilaterally, some of which is baseline from her previous CVA.
Her right sided neuro exam is notable for hyperreflexia and
clonus which is likely left over from her distant stroke. She
was continued on dexamethasone and ISS while on the high dose
steroids. The patient was also given a TLSO brace for
ambulation (although initially in too much pain to ambulate),
and the head of her bed was kept at <45 degrees. She received a
pre-op myelogram, consistent with an expanding T12 lesion from
prior imaging. She was subsequently taken for decompression
surgery by Ortho-Spine Team (s/p T10-L2 fusion, T12 Corpectomy)
and transferred to the Ortho-Spine service for post-op
management for two days. When she returned to the medicine
service on POD2, the patient was unable to move her lower
extremities bilaterally. Ortho-spine service indicated that the
patient required additional pain control. After consult with
Neuro-Onc, the patient was transitioned from dexamethasone 10mg
Q8 hours to dexamethasone 4mg BID on POD4. She was transferred
to the Neurology service for better management of her leg
weakness. It was felt this was likely due to post-op pain and
inability for her to express her pain level due to her aphasia.
Her medications were titrated and she did better on a higher
dose fentanyl patch with immediate release morphine and tylenol
for breaththrough pain. Subsequently her leg movements improved
on better pain control. She will require XRT for her other bony
lesions, and will need to follow up in ___ clinic
after XRT (to be arranged by XRT).
# FED/GI: Patient was found to initially have very mild
hypercalcemia on admission. She was NPO for procedure and
started on maintenence fluids overnight however did not require
agressive IVF. At the time of surgery, her hypercalcemia
resolved. She was advanced to a dysphagia diet post-operatively
and did well on that for the rest of her course. Electrolytes
were stable with the exception of potassium which kept returning
falsely elevated from hemolosis when drawn off her PICC.
# Foot Fracture: The patient was found to have R foot fracture
involving the base of the fifth proximal phalanx with extension
to the fifth MTP joint. This was consistent with repeat imaging
at ___. Her L foot and ankles were also imaged because the pt
was complaining of additional pain, however, films did not
reveal any additional acute fractures. The feet were vascularly
intact. Orthopedics recommended a hard sole boot for when the
patient became ambulatory, otherwise, no intervention necessary.
# Pain: Patient was found in extreme pain when transfered back
to medicine service on POD2. Unclear of origin as patient has
difficulty communicating due to her aphasia. Patient's pain was
controlled with standing acetaminophen, oxycodone, oxycontin,
fentanyl patch and dilaudid IV PRN. The pain team was also
consulted to help manage her pain. She was able to come off the
oxycontin on a higher dose of fentanyl patch, and had PO ___
oxycodone and tylenol for break through pain.
# Encephalopathy: On POD2, there was noted an increase in
aphasia, and confusion, which was difficult to assess given
baseline communication issues. HCHCT for acute bleed was
negative. The Pt was afebrile and infectious work-up including
UA was neg. Urine Ctx and blood ctx were negaitve for occult
infection. Her mental status improved with better pain control.
She got a little worse on ___ and was subsequently found to
have a new UTI (E Coli), which improved after treating with
first ceftriaxone and then Bactrim when sensitivies returned
pan-sensitive.
# Hct Drop: The patient Hct dropped from 32 on POD1-->22 on
POD2, Hemavac drained only 185cc, pt responded appropriately to
2U PRBC. Unclear where bleed is. Patients Hct subsequent
remained stable after transfusion. A T&L MRI revealed:
"Posterior and right-sided intraspinal fluid collection
communicates through
the laminectomy defect and causes anterior and left lateral
displacement of
the thecal sac. This leads to severe encroachment on the distal
spinal cord.
There are no findings to suggest tumor in this location. The
signal intensity
characteristics are typical of simple fluid, rather than
hemorrhage." Her Hct remained stable and the ultimate source of
her Hct drop was never identified but felt to be possibly due to
post-op hemolysis. The fluid collection was discussed with
ortho spine service who felt it could be conservatively watched
for now (likely just post-surgical changes).
# History of Stroke: The patient was continued on home dose of
aggrenox until the time of her surgery. When the patient was
transfered back to Medicine on POD2, the aggrenox was held. It
was restarted on ___ at the consent of orthopedics team.
# HTN: The patient was continued on home dose of losartan,
diltiazem and atenolol
# HLD: The patient was continued on her home dose of pravastatin
# ID: UTI discovered ___eveloped foul smelling
urine and WBC bumped to 22 (but this was felt to partially be
due to her dexamethasone as well). Treated with first
Ceftriaxone, then Bactrim, and culture grew out pan-sensitive E
Coli.
# Access: Pt had a PICC line placed and confirmed in good
position early on in her hopspitalization. Due to initial
concerns with dysphagia and patient frequently spitting out her
meds, we decided to keep her steroids IV to ensure she received
this crucial medication post-operatively. Once she has started
radiation therapy, however, the PICC may come out and the IV
steroids may be converted to the PO form.
Medications on Admission:
Lasix 20 qd
Pravastatin 80 qD
Allopurinol ___ qD
Colchicine PRN
Aggrenox 25 BID
Cozaar 50 qD
Atenolol 25 BID
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Pravastatin 80 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Docusate Sodium 100 mg PO BID
9. Fentanyl Patch 50 mcg/h TD Q72H
RX *fentanyl 50 mcg/hour place one patch on skin change every 72
hours Disp #*10 Transdermal Patch Refills:*0
10. Heparin 5000 UNIT SC TID
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
13. OxycoDONE (Immediate Release) 10 mg PO Q4H
RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 hours Disp
#*120 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
15. Ranitidine 150 mg PO BID
16. Senna 1 TAB PO BID
17. Dipyridamole-Aspirin 1 CAP PO BID
18. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
19. Allopurinol ___ mg PO DAILY
20. Dexamethasone 4 mg IV Q24H (may switch over to PO once
radiation therapy starts)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
T12 destruction spinal lesion - resected
Secondary diagnosis:
Post-surgical leg weakness, likely related to pain and
deconditioning
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair - advance per ___ recs.
TLSO brace to be worn with any and all attempts at ambulation.
Discharge Instructions:
You were admitted for surgery to remove a lesion in your
thoracic spine, and then was transferred to the Neurology
service for leg weakness after the surgery. This did get better
with pain control and supportive care, and we did not find any
othe reason for your new leg weakness. You likely have a
condition called multiple myeloma. This will require radiation
therapy for treatment, which have set up for you (see below).
Followup Instructions:
___
|
10010440-DS-7 | 10,010,440 | 29,040,430 | DS | 7 | 2173-10-27 00:00:00 | 2173-10-27 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ yo female patient with history of cognitive
impairment after ruptured cerebral aneurysm, recent diagnosis of
MM undergoing radiation treatment to lytic lesion to T12
vertebra who presents from her facility with altered mental
status after she refused radiation treatment today.
Per report, pt became increasingly agitated at her nursing home
facility this afternoon, refused to go to radiation treatment so
she was sectioned and sent to the ED for evaluation. On arrival
the the ED, vitals were 97.7 65 133/67 18 100%. She was unable
to say why she was in the emergency department. She denied any
symptoms, including no chest pain, abdominal pain. No shortness
of breath, cough, bladder or bowel symptoms. Her labs were
notable for WBC 11.1, hct 32.5, cr 0.4, normal lytes. She had a
UA with 10 WBC, no bacteria, small leuks, neg nit so she was
given 1 dose of levaquin.
Patient's daughter-in-law reports a more subacute decline in
mental status, beginning most notably after her surgery in ___.
She states that pt has been more agitated and confused since
that surgery, though her symptoms have definitely worsened over
the past few weeks to the point that her facility is having
difficulty controlling her. Daughter-in-law has been told that
pt's agitation is intermittently attributed to UTI, pneumonia,
etc but she is frustrated that she does not feel that pt has
improved at all despite treatment of multiple infections. In the
past week, the patient has become physical with nursing staff.
The daughter-in-law reports that pt has been hallucinating,
seeing people and hearing voices over the past several weeks to
months. Documentation from facility notes increasing paranoia.
Psych was consulted at the facility and has been adjusting her
seroquel dosing. It also appears that pt was treated for UTI
recently with meropenem, last dose ___ with repeat culture from
___ at her facility negative.
With regards to her MM, she has a long history of plasma cell
disorder dating back to ___. Her evaluation at the time
included bone marrow biopsy which showed ___ plasma cell,
suboptimal core. FISH staining was negative for cytogenetic
abnormalities, and since she had no other evidence of MM (no
anemia, renal failure or hypercalcemia), she was managed with
serial measurements of monoclonal proteins. However, in ___, pt suffered a fall and has been steadily declining since
then with significant weight loss (at least 30 pounds), back
pain, and urinary incontinence. She eventually had imaging that
showed cord compression at the T12 level so she was transferred
to ___ in ___, evaluated by neurology, neuro-onc and spine
surgery and underwent T12 extracavitary corpectomy. Pathology
showed plasma cells. MRI of C, T, L spine at the time also
commented on marked heterogenous signal intensity which may be
consistent with diffuse involvement of myeloma. Her post-op
course was complicated by wound dehiscence necessitating
surgical debridement and closure at the beginning of ___.
Past Medical History:
SAH, s/p b/l Aneurysm clipping. With frontal craniotomy.
Residual aphasia.
HTN
Hyperlipidemia
Right knee replacement
VP shunt
Multiple myeloma
T12 extracavitary corpectomy for removal of tumor ___
Social History:
___
Family History:
Multiple family members, particularly cousins with brain
aneurysms requiring clipping, some of who had strokes.
No history of cancer in the family.
Physical Exam:
ADMISSION PHYSICAL:
Vitals- 97.6 144/79 69 20 100% RA
General- Alert, no acute distress, interactive
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, palpable
nodules on abdomen, likely due to heparin injections
GU- no foley
Ext- warm, well perfused, 2+ pulses, trace edema
Neuro- pt unable to reliably follow commands, CN grossly intact,
able to move all extremities antigravity except RLE (horizontal
movement), A&O x 1
Skin: scattered echymoses on right arm and over abdomen, back
with well healing surgical wound, no surrounding redness or
drainage, no fluctuance, small area of ulceration on right
coccyx, as well as superficial ulceration on buttocks
bilaterally
DISCHARGE PHYSICAL:
Vitals- T 98 BP 120s/60s HR ___ RR 18 sat 100% RA
General- Alert and more calm this AM.
HEENT- Sclera anicteric. MMM.
Neck- supple
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. multiple ecchymoses.
GU- foley draining yellow urine
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 grossly intact, moving all extremities
symmetrically. AO to self only. Unable to follow commands or
participate in full neuro exam. More calm this AM and responding
appropriately to some questions.
Skin - scattered echymoses on right arm and over abdomen, back
with well healing surgical wound, no surrounding redness or
drainage, no fluctuance, small area of ulceration on right
coccyx, as well as superficial ulceration on buttocks
bilaterally
Pertinent Results:
ADMISSION LABS:
___ 09:20PM BLOOD WBC-11.1* RBC-3.35* Hgb-10.5* Hct-32.5*
MCV-97 MCH-31.4 MCHC-32.4 RDW-16.9* Plt ___
___ 09:20PM BLOOD Neuts-70.9* ___ Monos-5.4 Eos-0.1
Baso-0.4
___ 09:20PM BLOOD Glucose-79 UreaN-21* Creat-0.4 Na-138
K-4.7 Cl-106 HCO3-23 AnGap-14
___ 07:20AM BLOOD ALT-18 AST-21 LD(LDH)-434* AlkPhos-51
TotBili-0.2
___ 09:20PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
___ 09:20PM BLOOD VitB12-948* Folate-14.1
___ 09:20PM BLOOD TSH-1.5
___ 09:31PM BLOOD Lactate-1.8
___ 07:20AM BLOOD PEP-AWAITING F IgG-625* IgA-372 IgM-37*
IFE-PND
MICRO:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PROTEUS MIRABILIS. QUANTITATION NOT AVAILABLE.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
CT HEAD ___: IMPRESSION: No acute intracranial process. No
change from prior.
CXR ___: Left basilar opacity potentially atelectasis given low
___ ___ ng volumes however infection cannot be excluded.
MRI BRAIN ___: A localizer sequence was obtained. Two attempts
at
sagittal T1-weighted images were made, both degraded by
patient's motion. The exam was subsequently discontinued
because the patient was trying to climb off the table. No
diagnostic information was obtained.
Brief Hospital Course:
___ yo female with complicated past medical history who presents
with subacute to acute altered mental status.
.
# encephalopathy: Per conversation with HCP, pt has not been
herself since surgery in ___, though admittedly has gotten
progressively worse since then and is now exhibiting aggressive
behaviors at her facility, also concern for visual and auditory
hallucinations, along with paranoia. Pt has had multiple
medication changes recently, i.e. uptitrated seroquel, on and
off antibiotics, also on narcotic pain medications. Pt also on
steroids, which can cause AMS/psychosis. HCP also concerned that
pt is depressed, which can certainly present as AMS in elderly.
Neurology and psychiatry were consulted and both agreed
encephalopathy likely ___ delirium and/or progression of
underlying dementia +/- depression. CT negative for any acute
processes. Given unlikely CNS infection or acute intracranial
process given symptoms and time course held on LP and MRI. CXR
negative. TSH, B12, folate all within normal limits. Oncology
consulted and did not think CNS involvement of myeloma was
likely (CNS myeloma extremely rare, especially in pt like Ms.
___ with limited disease burden). Per recommendations from
neurology and psychiatry, we held her narcotics, increased
seroquel to 25mg BID + 100mg qhs, and started her on citalopram
10mg daily. With permission from oncology and radiation
oncology, we also initiated a decadron taper. Pt improved
greatly with these measures.
# UTI: Urine cx showed > 100,000 E coli sensitive to cipro and
ceftriaxone, but not to bactrim. UCx also with unclear # of CFU
of proteus. Attempted ceftriaxone IV, but pt would not tolerate
IV. Now giving ceftriaxone IM. Chose to avoid cipro as this
can worsen her encephalopathy. Pt to complete 5d course of CTX
for complicated UTI to end on ___
# multiple myeloma: Pt received ___ tx of XRT today (___). Plan
for 2 additional treatments, which have been scheduled. Pt will
f/u with Dr. ___ in oncology re: initiation of
chemotherapy. Family is aware that someone will need to
accompany pt to appt with Dr. ___ to consent for chemo.
# hyperglycemia: Secondary to decadron. Well controlled on
sliding scale insulin with BG 115-175.
# HTN: continued atenolol, diltiazem, losartan
# HLD: continued statin
# h/o CVA: continued aggrenox
Transitional issues
- UTI: on ceftriaxone IM as she could not tolerate maintaining
an IV. E coli resistant to bactrim, sensitive to cipro but we
avoided cipro as it could precipitate worsening encephalopathy.
Pt should receive final dose ceftriaxone 1g IM in 2.1ml normal
saline on ___
- encephalopathy: Increased quetiapine to 25mg BID during the
day and 100mg qhs. Started pt on citalopram 10mg on ___. This
can be increased to 20mg in one week.
- multiple myeloma: Steroid taper. Pt received 3mg of decadron
on ___ and will go to 2mg on ___. Dr ___
(___) should manage further tapering and management of
decadron. Pt received ___ of 5 radiation treatments today (___).
She should follow up with radiation oncology for remaining 2
treatments. She should also follow up with Dr. ___ at
___ listed below for initiation of chemotherapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Vitamin D 1000 UNIT PO BID
4. Multivitamins 1 TAB PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Senna 2 TAB PO BID
8. Losartan Potassium 50 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY
11. Omeprazole 20 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Acetaminophen 650 mg PO Q6H:PRN pain or fever
14. Allopurinol ___ mg PO DAILY
15. Atorvastatin 20 mg PO DAILY
16. Dexamethasone 4 mg PO DAILY
17. Dipyridamole-Aspirin 1 CAP PO BID
18. OxycoDONE (Immediate Release) 5 mg PO BID
19. Ascorbic Acid ___ mg PO BID
20. Zinc Sulfate 220 mg PO DAILY
21. QUEtiapine Fumarate 50 mg PO QHS
22. QUEtiapine Fumarate 25 mg PO DAILY
23. Ondansetron 4 mg PO Q6H:PRN N/V
24. TraZODone 25 mg PO Q6H:PRN agitation
25. QUEtiapine Fumarate 25 mg PO TID:PRN agitation
26. HumaLOG (insulin lispro) 100 unit/mL Subcutaneous qACHS
27. TraZODone 25 mg PO HS
28. Acetaminophen 975 mg PO Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Please transition to PRN when pain better controlled.
2. Allopurinol ___ mg PO DAILY
3. Ascorbic Acid ___ mg PO BID
4. Atenolol 25 mg PO DAILY
hold for SBP < 100, HR < 55
5. Calcium Carbonate 500 mg PO BID
6. Diltiazem Extended-Release 180 mg PO DAILY
hold if SBP < 100, HR < 55
7. Dipyridamole-Aspirin 1 CAP PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Heparin 5000 UNIT SC TID
10. Losartan Potassium 50 mg PO DAILY
hold for SBP < 100
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
Hold for loose stool.
14. QUEtiapine Fumarate 100 mg PO QHS
hold if sedated
15. QUEtiapine Fumarate 25 mg PO BID
please give about 6 hours apart during the day as pt should
receive 100mg qhs. hold if sedated
16. Senna 2 TAB PO BID
Hold for loose stool.
17. Vitamin D 1000 UNIT PO BID
18. Zinc Sulfate 220 mg PO DAILY
19. CeftriaXONE 1 g IM DAILY
please dilute in 2.1ml normal saline or 1% lidocaine if
available. last dose should be given ___. Citalopram 10 mg PO DAILY
Please uptitrate to 20mg daily if tolerated in 1wk (___)
21. Ondansetron 4 mg PO Q6H:PRN N/V
22. Atorvastatin 20 mg PO DAILY
23. Dexamethasone 2 mg PO DAILY
Further management per Dr. ___.
24. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: encephalopathy, urinary tract infection
Secondary diagnoses:
multiple myeloma
hyperglycemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted for altered mental status and agitation. A CT head
showed no evidence of a stroke or other acute changes. We
attempted to obtain an MRI of the brain but you were not able to
tolerate this. Neurology, oncology and psychiatry were
consulted and all felt that your current mental status is either
due to delirium (temporary confusion that is reversible) or a
natural progression of your dementia. Delirium may be caused by
steroids, recurrent urinary tract infections, or medication
changes. As such, we began to taper your steroids. We also
increased your dose of quetiapine and started you on
anti-depressant called citalopram.
For your multiple myeloma, please follow up with Dr. ___
at the appointment listed below for chemotherapy. You should be
contacted at ___ House regarding completion of your
radiation therapy.
Followup Instructions:
___
|
10010920-DS-10 | 10,010,920 | 24,676,144 | DS | 10 | 2150-10-06 00:00:00 | 2150-10-07 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
rash, leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with no significant PMH who presents with
rash and leg swelling. He is visiting from ___ and is
Portugeuse speaking only. He got Tdap and MMR vaccines on ___
prior to coming to the ___ for a visit. Just prior to leaving
___, he noticed a rash on his neck that was pruritic and
erythematous. He thought it was irritation from the hot weather
and came to the ___ during the week of ___. The rash was
progressing, so he went to ___ urgent care on ___. At that time,
there was concern for viral xanthem and he was referred to
dermatology. He saw Dr. ___ on ___ and due to concern for
syphilis vs. measles-like syndrome, RPR was sent as was measles,
mumps and rubella serology. Fluocinonide cream was prescribed
for the leg swelling. Pt presented to the ED due to concern for
worsening leg swelling. Echo ws negative for an acute
cardiomyopathy. UA showed trace protein. Patient was admitted
for further workup and for transaminitis.
In the ED, initial vitals: 100.8 97 158/89 18 99%
- Exam notable for: erythematous rash on neck, chest and groin
- Labs notable for: ALT 126, AST 182, RPR + 1:64. Lactate 2.2
On arrival to the floor, pt reports no discomfort. Rash is
nonpainful. Denies rhinorrhea, corrhyza or mucosal lesions.
ROS: 11 point ROS is positive per HPI otherwise negative.
Past Medical History:
GERD
Social History:
___
Family History:
NC
Physical Exam:
ADMMISSION:
===========
Vitals- 98.6 87 137/86 16 97% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
SKIN: erythematous papules on neck, behind ears, over scalp,
chest and groin. Few scattered papules on back. One crusted
lesion on R neck.
DISCHARGE:
==========
Vitals- 99.5, 98.7, 118/59, 93, 16, 99%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
SKIN: erythematous papules on neck, behind ears, over scalp,
chest and groin. Few scattered papules on back. One crusted
lesion on R neck.
Pertinent Results:
ADMISSION:
==========
___ 02:45PM ALT(SGPT)-116* AST(SGOT)-96* LD(LDH)-206 ALK
PHOS-96 TOT BILI-0.4
___ 03:40AM URINE HOURS-RANDOM
___ 03:40AM URINE HOURS-RANDOM
___ 03:40AM URINE UHOLD-HOLD
___ 03:40AM URINE GR HOLD-HOLD
___ 03:40AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:40AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:40AM URINE MUCOUS-RARE
___ 02:44AM LACTATE-2.2* K+-4.1
___ 02:00AM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-131*
POTASSIUM-7.3* CHLORIDE-98 TOTAL CO2-23 ANION GAP-17
___ 02:00AM estGFR-Using this
___ 02:00AM ALT(SGPT)-126* AST(SGOT)-182* ALK PHOS-93 TOT
BILI-0.3
___ 02:00AM LIPASE-37
___ 02:00AM proBNP-99*
___ 02:00AM TOT PROT-7.7 ALBUMIN-3.9 GLOBULIN-3.8
CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-2.0
___ 02:00AM CRP-41.1*
___ 02:00AM WBC-10.0 RBC-4.37* HGB-13.4* HCT-41.1 MCV-94
MCH-30.7 MCHC-32.7 RDW-14.4
___ 02:00AM NEUTS-73.4* LYMPHS-14.8* MONOS-5.6 EOS-5.4*
BASOS-0.8
___ 02:00AM PLT COUNT-315
DISCHARGE:
==========
___ 06:15AM BLOOD WBC-14.2* RBC-4.47* Hgb-13.7* Hct-41.7
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.3 Plt ___
___ 06:15AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-137
K-4.3 Cl-101 HCO3-29 AnGap-11
___ 06:15AM BLOOD ALT-108* AST-72* LD(LDH)-192 AlkPhos-105
TotBili-0.6
___ 06:15AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9
___ 02:00AM BLOOD HCV Ab-NEGATIVE
___ 04:45PM BLOOD HIV Ab-NEGATIVE
___ 02:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
___ 10:03 am SEROLOGY/BLOOD
RPR w/check for Prozone (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:64.
Reference Range: Non-Reactive.
TREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE.
IMAGING:
========
___ CXR
FINDINGS:
The lungs are well inflated and clear. The cardiomediastinal
silhouette, hila contours, and pleural surfaces are normal.
There is no pleural effusion or pneumothorax.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ is a ___ with no significant PMH who presents with
rash and leg swelling.
# Syphilis, leg swelling: In the setting of transaminitis,
positive RPR, concerning for secondary syphilis. Leg swelling
has unclear relation but began in this setting. He was treated
with a test dose of penicillin 500mg on ___ and tolerated this
without difficulty. He received 2.4 million units of penicillin
IM on the morning of ___, was observed for several hours and
then discharged home. FTA-abs are still pending at the ___ lab
at the time of discharge.
# Tachycardia: Had episode of tachycardia to 150s while
ambulating, asymptomatic. Received 1 L NS with resolution.
# GERD: continued omeprazole
TRANSITIONAL ISSUES:
-will be returning to ___, but will need follow up to ensure
resolution of symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Fluocinonide 0.05% Cream 1 Appl TP BID
Discharge Medications:
1. Fluocinonide 0.05% Cream 1 Appl TP BID
2. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: secondary syphilis
Secondary: GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with a rash and leg swelling. Your
rash was found to be caused by syphilis infection. You were
given a test dose of penicillin and treated with a full dose
once you tolerated the test. Your leg swelling is of uncertain
cause, but may be related to the syphilis. You should follow up
with your doctor in ___. Make sure to use condoms when having
sex as this will protect you against syphilis and other
infections.
Wishing you the best,
Your ___ Care Team
Followup Instructions:
___
|
10010997-DS-9 | 10,010,997 | 20,783,870 | DS | 9 | 2139-05-02 00:00:00 | 2139-05-07 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R IF pain
Major Surgical or Invasive Procedure:
PROCEDURE: Irrigation, washout and debridement right index
finger distal interphalangeal joint.
History of Present Illness:
___ year-old right-hand dominant nurse at ___ with severe RA on methotrexate who underwent excision
of
distal right IF mass just proximal to eponychial fold concerning
for mucus cyst on ___ at ___. She noted some drainage
from
the incision starting in the past ___, she had worsening pain
therefore went to ___ earlier today where they
cultured purulent discharge and GPCs in clusters and pairs were
observed on gram stain, gave vancomycin and zosyn, and was
superficially washed out and digital block performed for pain
control. She was transferred to ___ for further management.
She
denies fevers or chills, only increasing pain, drainage, and
swelling of the digit.
Past Medical History:
RA
Social History:
___
Family History:
non contributory
Physical Exam:
***
Pertinent Results:
___ 02:26PM WBC-8.9 RBC-3.94 HGB-12.5 HCT-37.7 MCV-96
MCH-31.7 MCHC-33.2 RDW-13.1 RDWSD-45.1
Brief Hospital Course:
This is a delightful ___ female nurse ___
___ who is on immunosuppressants for rheumatoid
arthritis. She underwent excision of a draining mucous cyst by
Dr. ___ ___ unfortunately she developed an infection at
the surgical site. She was admitted to the hospital yesterday
and underwent bedside I&D x2.
The patient was formally admitted to hand service for ongoing
observation as well as IV antibiotic
treatment. She was placed on vancomycin and Unasyn. Her
cultures from the OSH grew pan sensitive enterococcus and MSSA
(resistant to b lactams) she was discharged on levofloxacin. She
will follow up with Dr. ___ in clinic as
scheduled.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Levofloxacin
Discharge Disposition:
Home
Discharge Diagnosis:
R IF wound infection
Discharge Condition:
AVSS, AOx3
Discharge Instructions:
You were admitted to the ED with a wound infection. Please
follow this instructions for postoperative care:
1. Soak your wound four times daily in warm soapy water. After
this, replace the dressing.
2. Take your antibiotics as prescribed
3. Only take narcotic pain medications for sever pain and do not
drive while taking these medications
Followup Instructions:
___
|
10011126-DS-22 | 10,011,126 | 26,463,677 | DS | 22 | 2155-11-24 00:00:00 | 2155-11-30 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of prostate cancer (s/p chemo on Thurday),
recent aortic valve Enterococcus faecalis endocarditis, and
chronic uteral stent with intermittent hematuria who presents
with fevers. He underwent his first dose of chemo on ___
(___) as treatment of his prostate cancer. He was in his
ususal state of health until last night, at which point he
developed chills and sweats. He has also had some worsening
abdominal pain. He denies any chest pain, cough, or shortness of
breath.
In the ___, initial vs were: 100.6 130 138/64 16 98% RA. Labs
were remarkable for a very dirty UA and a lactate of 2.9. CT
ABD/PEL showed moderate-severe left hydronephrosis despite left
sided ureteral stent placement, as well as obstructing bladder
mass at the UVJ junction on that side as well, and some
stranding surrounding that left kidney. CXR normal. He was seen
by urology while in the ___, who recommended admission to
medicine for antibiotics and possible stent removal/exchange. ID
was also consulted, and agreed with this plan. Of note, on
admission to the ___ he triggered for tachycardia to the 130s. He
was given 2L NS bolus, and his heart rate normalized.
Additionally, he was started on vanc/cefepime, and given tylenol
for fever.
On the floor, he denies any fevers, chills, but had experienced
these earlier today. He does endorse intermittent hematuria and
dysuria, but none since two days ago. His highest fever today
was 101.1.
Past Medical History:
CAD with single coronary artery stent around ___
HTN
H/O atrial fibrillation developed during his recent
hospitalization
Osteoarthritis
Hyprelipidemia
DVT RUE
hemoptysis on Coumadin
peptic ulcer disease
nephrolithiasis
inguinal hernia repair
Social History:
___
Family History:
Mother: died of MI
Father: lung cancer and diabetes, nephrolithiasis
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:99.3, 117/76, 84, 20, 99%RA pain ___
General: NAD, pleasant
HEENT: NC/AT, MMM
Neck: supple
CV: RRR, no M/R/G
Lungs: CTAB
Abdomen: +BS, soft/non-tender/non-distended. No rebound or
guarding, no palpable masses
GU: condom cath in place
Neuro: A+Ox3, CN ___ grossly intact
Skin: no rashes
DISCHARGE PHYSICAL EXAM:
***
***
***
Pertinent Results:
ADMISSION LABS:
___ 10:50AM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-LG
___ 10:38AM LACTATE-2.9*
___ 10:30AM GLUCOSE-161* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-19* ANION GAP-24*
___ 10:30AM ALT(SGPT)-17 AST(SGOT)-39 ALK PHOS-184* TOT
BILI-0.5
___ 10:30AM LIPASE-21
___ 10:30AM ALBUMIN-4.2
___ 10:30AM WBC-6.5 RBC-3.64* HGB-11.4* HCT-32.0* MCV-88
MCH-31.2 MCHC-35.6* RDW-14.0
IMAGING:
- CXR (___): IMPRESSION: No acute cardiopulmonary process.
- CT ABD/PEL (___):
Brief Hospital Course:
___ with history of prostate cancer (s/p chemo on ___ at OSH),
recent aortic valve Enterococcus faecalis endocarditis, and
chronic ureteral stent with intermittent hematuria who presents
with fevers, likely pyelonephritis and now with Neutropenia.
# Pyelonephritis/Sepsis from Urinary source: Resolved. Initially
septic with UA indicative of UTI.Risk factors for pyelonephritis
include chronic incontinence from prior TURP, bladder mass
causing obstruction and hydronephrosis. Complicating matters is
a left ureteral Double J stent, which will likely need to be
removed and/or replaced. All culture data is negative so far
(urine with mixed flora). Patient is currently neutropenic,
however, has been afebrile and was not admitted with neutropenia
and so will not treat as neutropenic fever . Vancomycin and
Cefepime discontinued ___ and now on ciprofloxacin monotherapy
which he was discharged on to complete 14 day course.
.
# Neutropenia: Related to recent chemotherapy, currently C1D7
and so likely reached nadir and now uptrending. He is afebrile
and doing well with PO Cipro to cover Pyelonephritis. Received
neupogen ___, will receive dose on ___ at ___.
- Neupogen 480mcg SC x5days (___)
#Back Pain: likely combination of chronic back pain. received
oxycodone x1, already receiving lidocaine patch, will add
tramadol.
-lidocaine patch
-tramadol
-consider muscle relaxant, already on lorazepam qhs
# Prostate Cancer: Pt has now undergone first cycle of chemo on
___. He had previously been trialed on Zytiga,
but failed this, as his PSA rose substantially despite therapy.
Per the patient, on last check on ___ his PSA was 100 (had
previously been ___. At this time he was started on chemo.
Discussed case with outpatient Oncologist Dr. ___ and
___ on ___.
# Prostate Cancer: Pt has a history of locally invasive prostate
cancer with bladder mets, and has now undergone first cycle of
chemo on ___. He had previously been trialed on Zytiga,
but failed this, as his PSA rose substantially despite therapy.
Per the patient, on last check on ___ his PSA was 100 (had
previously been ___.
CHRONIC ISSUES:
# HTN: Continued lisinopril, metoprolol
# A-fib: Rate well controlled. CHADS 2 score of 1. Continued
aspirin, metoprolol.
# CAD: Continue aspirin, metoprolol.
# GERD: His home medication nexium is not on formulary, so he
was treated with omeprazole instead.
# Anxiety: Continued ativan home regimen.
TRANSITIONAL ISSUES:
-Pt should receive neupogen from his ___ provider
-___ with outpatient PCP
-___. diff assay was negative, patient notified over phone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clotrimazole *NF* 1 % Topical TID
Apply to affected hands and foot
2. Lotrisone *NF* (clotrimazole-betamethasone) ___ % Topical
QHS
Apply to affected areas
3. NexIUM *NF* (esomeprazole magnesium) 20 mg Oral daily
4. Hydrocortisone Cream 1% 1 Appl TP BID
apply to affected areas
5. Lisinopril 10 mg PO DAILY
please hold for SBP<90
6. Lorazepam 0.5 mg PO QPM
Please give at 1600. Please hold for RR<12 or sedation.
7. Lorazepam 2 mg PO HS
Please give at 2355. Please hold for RR<12 or sedation
8. Metoprolol Succinate XL 100 mg PO DAILY
Please hold for SBP<90, HR <60
9. Aspirin 325 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
please hold for loose stools
11. Lactinex *NF* (lactobacillus acidoph & bulgar) 1 million
cell Oral TID
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lorazepam 0.5 mg PO QPM
5. Lorazepam 2 mg PO HS
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
Last dose on ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth q12 Disp #*20
Tablet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) apply 1 patch to affected areas
daily Disp #*10 Unit Refills:*0
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
11. clotrimazole *NF* 1 % Topical TID
12. Hydrocortisone Cream 1% 1 Appl TP BID
13. Lactinex *NF* (lactobacillus acidoph & bulgar) 1 million
cell Oral TID
14. Lotrisone *NF* (clotrimazole-betamethasone) ___ % Topical
QHS
15. NexIUM *NF* (esomeprazole magnesium) 20 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Urosepsis, pyelonephritis
Secondary: prostate cancer, hypertension, atrial fibrillation,
anxiety, gastroesophageal reflux disorder, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for evaluaion of your fevers.
While you were here you were found to have an infection in your
urine, which extended up to your left kidney. You were treated
with antibiotics, and you improved. Additionally, you were seen
by urology, who felt that your ureteral stent should be removed
once you finish antibiotics.
Your white blood cell count dropped so we started you on a
medication called Neupogen. We spoke with Dr. ___ will
see you in her clinic on ___ to receive your 4th dose of
neupogen. Please continue to take antibiotics until ___.
Please call your PCP or return to the hospital if you develop
worsening abdominal pain, fevers, or bloody bowel movements.
Followup Instructions:
___
|
10011126-DS-23 | 10,011,126 | 24,701,479 | DS | 23 | 2156-02-26 00:00:00 | 2156-03-07 20:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Percocet / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man whose PMH includes HTN, HL, CAD, atrial
fibrillation, anxiety, GERD, low back pain, aortic valve
endocarditis ___, and metastatic prostate cancer s/p
brachytherapy, TURP, & ongoing chemotherapy (last dose ___,
followed at ___, recently discharged (___) from ___ on
levofloxacin for atypical pneumonia. Developed N/V over ___s dysuria, chronic urinary incontinence unchanged.
Found
to be hypotensive at BID-N. Labs notable for bandemia 15% &
hypocalcemia, transferred here for further mgmt. CXR neg, UA
showed UTI.
Treating empirically with CTX pending urine cx. N/V improved
with
antiemetics so he tried clear liquids and tolerated well. He was
hungry and wanted full liquids, which he also tried but later
vomited. No abd pain or diarrhea but reports heartburn, notes he
did not get his Nexium today. Quite anxious about his condition,
worried about losing more weight. Has been ambulating
comfortably, chronic back pain at baseline.
Past Medical History:
CAD with single coronary artery stent around ___
HTN
H/O atrial fibrillation developed during his recent
hospitalization
Osteoarthritis
Hyprelipidemia
DVT RUE
hemoptysis on Coumadin
peptic ulcer disease
nephrolithiasis
inguinal hernia repair
Social History:
___
Family History:
Mother: died of MI
Father: lung cancer and diabetes, nephrolithiasis
Physical Exam:
Admit:
EXAM: VS afeb 112/66 ___ 100% RA
GEN: NAD, well-appearing
EYES: conjunctiva clear anicteric
ENT: moist mucous membranes, few sm white plaques on buccal
mucosa
NECK: supple
CV: RRR s1s2 II/VI SEM
PULM: CTA
GI: normal BS, ND, soft, nontender
GU: erythematous patchy rash along shaft of penis
EXT: warm, no ___ edema
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands
PSYCH: appropriate, pleasant
ACCESS: PIV
FOLEY: none
DC
XAM: VS afeb 104/62, 70, 95% RA
GEN: NAD, well-appearing
EYES: conjunctiva clear anicteric
ENT: moist mucous membranes, few sm white plaques on buccal
mucosa
NECK: supple
CV: RRR s1s2 II/VI SEM
PULM: CTA
GI: normal BS, ND, soft, nontender
GU: erythematous patchy rash along shaft of penis with
ulcerated lesion on foreskin over glans
EXT: warm, no ___ edema
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands
PSYCH: appropriate, pleasant
ACCESS: PIV
FOLEY: none
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
___ 06:40 3.5* 2.88* 8.6* 25.3* 88 30.0 34.2 15.8 29*
___ 06:50 3.1* 2.81* 8.6* 24.8* 88 30.6 34.6 16.1 32*
___ 10:30 4.6 2.84* 8.8* 25.5* 90 31.0 34.5 16.4* 38
UreaN Creat Na K Cl HCO3 AnGap
___ 06:50 8 0.4* 137 4.2 ___
___ 10:30 15 0.5 138 3.7 ___
___ 10:30AM BLOOD ALT-23 AST-39 LD(LDH)-706* AlkPhos-1621*
TotBili-0.6
___ 05:20AM URINE RBC-16* WBC-87* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
___ CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
RUQ US
MPRESSION:
1. Multiple scattered isoechoic hepatic lesions, the largest in
the right
lobe measuring 2.0 cm, suspicious for metastases. Further
evaluation with
contrast-enhanced MR or multiphasic CTA is recommended.
2. Splenomegaly.
3. Unremarkable gallbladder without stones.
4. No evidence of abdominal aortic aneurysm.
Brief Hospital Course:
___ was hypovolemic and nauseated in the context of a UTI for
which culture grew S. Epi. He did well with ceftriaxone and was
transitioned to cefpodoxime on discharge. He has macerated
penis rash with some ulceration that needs careful skin care.
We started miconazole for fungal superinfection and monitored
his ability for self-care which was appropriate. We did attempt
a foley to maintain a dry area however this was difficult and
swiwftly aborted - it may reflect obstructive disease. As
discussed previously, he does have liver metastases which is a
new finding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NexIUM (esomeprazole magnesium) 40 mg Oral Daily
2. Lisinopril 10 mg PO DAILY
3. MethylPHENIDATE (Ritalin) 5 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. pramipexole 0.125 mg Oral QHS
6. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) Dose is Unknown
Oral BID
7. Senna 2 TAB PO BID
8. Multivitamins 1 TAB PO DAILY
9. TraZODone 50 mg PO HS:PRN insomnia
10. Acetaminophen 500 mg PO BID
11. Bisacodyl ___AILY:PRN constipation
12. Docusate Sodium 200 mg PO BID
13. Gabapentin 300 mg PO BID
14. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
15. Metoprolol Tartrate 12.5 mg PO BID
16. Metoclopramide 10 mg PO TID
17. Morphine SR (MS ___ ___ mg PO Q8H pain
18. Citalopram 20 mg PO DAILY
19. Lorazepam 1 mg PO Q6H:PRN anxiety
20. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO BID
2. Bisacodyl ___AILY:PRN constipation
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 200 mg PO BID
5. Gabapentin 300 mg PO BID
6. Lidocaine 5% Patch 2 PTCH TD DAILY:PRN pain
7. Lorazepam 1 mg PO Q6H:PRN anxiety
8. MethylPHENIDATE (Ritalin) 5 mg PO BID
9. Metoclopramide 10 mg PO TID
10. Metoprolol Tartrate 12.5 mg PO BID
11. Morphine SR (MS ___ ___ mg PO Q8H pain
12. pramipexole 0.125 mg Oral QHS
13. Senna 2 TAB PO BID
14. TraZODone 50 mg PO HS:PRN insomnia
15. Miconazole Powder 2% 1 Appl TP TID
RX *miconazole nitrate [Miconazorb AF] 2 % Apply to penis three
times a day Disp #*1 Unit Refills:*0
16. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp
#*1 Unit Refills:*0
17. Lisinopril 10 mg PO DAILY
18. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
19. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 0 unknown ORAL
BID
20. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron [ZOFRAN ODT] 8 mg 1 tablet,disintegrating(s) by
mouth q8 Disp #*45 Tablet Refills:*0
21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 10 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
22. Multivitamins 1 TAB PO DAILY
23. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
24. Polyethylene Glycol 17 g PO DAILY
25. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# urinary tract infection
# chemotherapy-induced nausea/vomiting
# hypovolemia
Secondary diagnoses:
# prostate cancer with metastases to bone and probably liver
# candidal rash
# Penis ulcer
# chemotherapy-induced thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were admitted with a urinary tract infection.
You fared well with antibiotics. Nausea improved over the
hospitalization and was somewhat worse in the setting of reflux.
You have a penis rash with some ulceration that will need
careful skin care - keep as clean dry as possible and use the
new powder.
Please resume all your previous medications.
New medication: Cefpodoxime - continue until completed
: Miconazole powder, apply to penis as directed
: Zofran - use for nausea as needed
: Nystatin swish - for thrush
: Pyridium - for urinary burning
Followup Instructions:
___
|
10011189-DS-12 | 10,011,189 | 29,477,116 | DS | 12 | 2188-02-26 00:00:00 | 2188-02-26 17:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope, Visual Changes, Tinnitus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M ___ M with history of ?TIA, HTN, HLD, who
presents with episodes of altered consciousness.
Occurred ___ in the morning while sitting, he describes
feeling out-of-body in that his perception was "off," and then
his vision in both eyes narrowed circumferentially and then
expanded. He sat down in a chair, and continued to have series
of
about 6 brief episodes of this. He then loses memory of what
happened. Per sister, her other brother witnessed this and
stated
he was not speaking but remained sitting up without fall or
convulsions, loss of bowel or bladder function. Directly prior
to
these episodes he could hear a "whooshing sound" in his ear. He
recovered quickly from the events without any weakness numbness
or balance issues. He does say his chest felt "tight" prior to
the episodes. He did have palpitations, lightheadedness, chest
pain, shortness of breath.
He reports they also occurred about 4 months ago, and again 6
months prior to that. They did occur in the setting of poor PO
intake and possibly taking an extra dose of his Amlodipine.
There was no clear positional component to his symptoms.
He denies melena, hematochezia. He does have a history of
"ulcers" diagnosed 6 weeks ago in ___. He had an EGD there. He
does not recall being told if he had H. pylori. He was put on
several medications, he believes antibiotics for a total of 3
weeks to which he was compliant. also reports he intermittently
notices blood on his toilet paper and that a lump extrudes at
times when he strains when having bowel movements.
He recently moved to ___ from ___ within the last two weeks.
He is living with his sister. He used to drink heavily but has
not had alcohol in "many years." He denies other drug use.
He denies fevers, chills, nausea, diaphoresis, any recent cough,
abdominal pain, shortness of breath. He denies dyspnea on
exertion.
In the ED, initial VS were: 98.1 67 115/70 19 100% RA
Imaging showed:
NCTH with no acute intracranial abnormality
CXR wnl
Neuro were consulted and recommended to admit to medicine for
syncopal/cardiac
work-up
On arrival to the floor, patient reports he is feeling well. He
is concerned that he had a small amount of blood on the toilet
paper when having a bowel movement upon arrvial. He is very
worried about this. He does strain when having bowel movements.
Past Medical History:
? PUD
Psoriasis
HTN
HLD
? TIA
? CAD
? "arrhythmia"
Social History:
___
Family History:
mother- uterine cancer
father- kidney cancer
maternal grandmother kidney cancer
no family history of strokes or seizure
Physical Exam:
EXAM ON ADMISSION
======================
tele sinus, rates ___
VS: 96.4 AdultAxillary 91 / 58 60 18 94 Ra
GENERAL: NAD, laying comfortably in bed. barrel-chested
HEENT: AT/NC, EOMI, PERRL,pink conjunctiva, MMM
NECK: no JVD
HEART: Distant heart sounds, RRR, S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Rectal: deferred per patient
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CNII-XII, strength, sensation grossly intact
SKIN: warm and well perfused, no excoriations. hyperpigmented
patches to back.
EXAM ON DISCHARGE
===========================
Vitals: 98.0, 130/76, hr 64, RR 17, 97 Ra
Telemetry: sinus with rates 50-60's
General: Alert, oriented, no acute distress, well appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: normal WOB on room air
CV: RRR, no murmur, no gallop
Abdomen: soft, NT/ND
Ext: warm, no edema
Neuro: Moving all extremities. Able to walk the halls with a
normal gait.
Skin: No rash or lesion
Pertinent Results:
ADMISSION LABS
=========================
___ 03:14PM BLOOD WBC-6.3 RBC-4.38* Hgb-13.2* Hct-39.8*
MCV-91 MCH-30.1 MCHC-33.2 RDW-12.3 RDWSD-40.7 Plt ___
___ 03:14PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-20* AnGap-16
___ 04:28PM BLOOD ___ PTT-31.1 ___
___ 03:14PM BLOOD cTropnT-<0.01
___ 05:28AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:14PM BLOOD CK(CPK)-102
___ 05:28AM BLOOD ALT-27 AST-21 AlkPhos-96 TotBili-0.6
___ 05:28AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.3
___ 03:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 04:34PM BLOOD Lactate-0.8
___ 04:45PM URINE Blood-TR* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS
===========================
___ 05:12AM BLOOD WBC-5.5 RBC-4.40* Hgb-13.2* Hct-40.8
MCV-93 MCH-30.0 MCHC-32.4 RDW-12.3 RDWSD-42.5 Plt ___
___ 05:12AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-140
K-4.6 Cl-103 HCO3-27 AnGap-10
___ 05:12AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3 Iron-115
MICROBIOLOGY
===========================
___ 4:45 pm URINE
URINE CULTURE (Preliminary):
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL
REPORTS
===========================
CTA Head and Neck ___
Right MCA aneurysm measuring 5 x 4 x 3 mm. The aneurysm has a
slightly
lobulated/irregular appearance.
No significant ICA stenosis by NASCET criteria.
There is poor opacification of the left vertebral artery at its
origin, this may be secondary to its tortuous origin or be
related stenosis. Rest of the vertebral arteries and basilar
artery are widely patent with no significant stenosis.
Lobular/tubular structure just posterior to the suprasternal
notch which seems to connect to the left brachiocephalic vein
which most likely represents an anomalous venous structure.
However correlation with neck ultrasound is advised.
NCCT Head ___
No acute intracranial abnormality.
CXR ___
No acute cardiopulmonary abnormality.
EEG ___
This is a normal awake and asleep EEG with no epileptiform
discharges or features.
EKG ___
Sinus Bradycardia
Brief Hospital Course:
___ from ___, reported hx of possible CAD, possible hx of TIA,
possible hx of "arrhythmia," HTN, HLD, who presented to the ED
with transient episode of alteration in consciousness, visual
changes, and tinnitus.
He reports episodes of symptoms similar to this occurring about
6 months ago, and again a few months before that, while in ___.
No etiology had previously been identified.
On arrival to the floor, orhostatics were positive. He received
IV fluid and Amlodipine was stopped. Even after stopping
Amlodipine, blood pressures remained low-normal, so it was
discontinued.
He had a workup for this while in house, including telemetry
monitoring (no tachy- or bradyarrthymia was seen), CT of the
Head, EEG, and EKG, all of which were normal or unremarkable.
Neurology was consulted in the Emergency Room, and recommended a
CTA of the Head and Neck. This was negative for acute pathology
in the posterior circulation to explain his presenting symptoms,
but did show an incidental Right MCA aneurysm measuring 5 x 4 x
3 mm.
He had no further symptoms or episodes while in house, and was
feeling well on the day of discharge. Ultimately, given the lack
of other etiology identified, his symptoms were felt to most
likely be due to orthostatic hypotension in the setting of
Amlodipine, but he will need further monitoring as an outpatient
for recurrence of symptoms and consideration of further workup.
CHRONIC ISSUES
========================
# HLD - Atorva 20mg daily
# HTN - holding amlodipine given hypotension and positive
orthostatics, as above
# CAD (per report) - Aspirin 81mg
# GERD - omeprazole 40mg daily
TRANSITIONAL ISSUES
========================
[ ] NO HEALTH INSURANCE at the time of discharge. Patient is
having ongoing discussions with the Financial Department at
___ for arranging insurance. Once insurance arranged, he will
be contacted by ___ Health Care Associates and see Dr. ___
___ in clinic
[ ] have STOPPED Amlodipine given orthostatic hypotension on
admission and normal BP's without it
[ ] incidental Right MCA aneurysm measuring 5x4x3mm found on CTA
of Head and Neck
[ ] mild normocytic anemia with normal iron studies, B12,
Folate. Follow up as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope - likely from antihypertensive medication
Incidental finding of R MCA Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure meeting you at ___. You were admitted to
our hospital after developing dizziness, passing out, visual
symptoms, and ear ringing. We did multiple tests.
We found that your blood pressure was low, and for this we gave
you IV fluids and stopped your Amlodipine.
The EEG of the brain did not show any seizures. Your Head CT
did not show anything to explain your symptoms. It did show a
finding of an aneurysm in one of the arteries of your brain.
This was NOT what was causing your symptoms, but you will need
to follow up on this as an outpatient to for further monitoring.
Please stop your Amlodipine, and continue your other
medications.
It was a pleasure, we wish you the best,
___ Medicine Team
Followup Instructions:
___
|
10011427-DS-20 | 10,011,427 | 20,219,031 | DS | 20 | 2136-04-08 00:00:00 | 2136-04-09 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
optiflux dialyzer / lisinopril
Attending: ___
Chief Complaint:
Dislodged HD line
Encephalopathy
Sepsis
Major Surgical or Invasive Procedure:
___ CVL Insertion Note
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
===========================
Ms. ___ is a ___ year old F w/ EtOH cirrhosis complicated by
hepatic encephalopathy, recurrent ascites with weekly large
volume paracentesis, and hepatorenal syndrome on TuThSa HD who
was transferred from ___ for a dislodged
central
line and imaging showing free air in the peritoneal space. She
presented there after waking up with blood in her bed overnight.
CXR showed air in her peritoneum. Her HD line was found to be
dislodge and was removed. She was given vancomycin and cefepime
and transferred to ___ for further evaluation.
Of note, she was recently admitted to BI for altered mental
status. It was felt that she had hepatic encephalopathy.
Infectious workup was negative. She was started on lactulose and
rifaximin with improvement in her mental status. She was also
diagnosed with gout in her R ___ DIP and started on a prednisone
taper. It was recommended that she go to rehab, but was
discharge
home with ___ on ___.
In the ED, vitals were notable for hypotension with BPs in
___. Exam was notable for an unwell-appearing woman with
bibasilar crackles, bilateral lower extremity edema, an
abdominal
fluid wave, asterixis, and disorientation. Labs were notable for
hypotatremia, anemia, thrombocytopenia, and coagulopathy. CXR
was
normal. CT abd/pelvis showed "The air appears to communicates
with an umbilical defect. No portal venous gas or pneumatosis to
suggest bowel ischemia. In the setting of recent paracentesis
and
lack of convincing evidence of bowel ischemia, the
pneumoperitoneum could be secondary to the paracentesis and less
likely from bowel perforation. No acute processes." She was
started on Zosyn and Flagyl. Transplant Surgery was consulted
who
had low suspicion for intraabdominal process. Hepatology
recommended treatment with antibiotics, lactulose, and rifaxmin.
They also recommended diagnostic paracentesis, which was not
performed as there was reportedly no tappable pocket.
Upon arrival to the floor, she feels well. She denies any
fevers,
chills, night sweats, headaches, N/V, diarrhea, black or red
stools, abdominal pain, chest pain, easy bleeding, or confusion.
She is unsure of her home medications.
Past Medical History:
- CV: HLD, HTN
- GI: Esophageal stricture, GERD, Childs B EtOH Cirrhosis
(MELD-Na 15) decompensated by encephalopathy, ascites
- MSK: arthritis
Past Surgical History
- Appendectomy
Social History:
___
Family History:
- No family history of liver disease
- Father had a cancer of unknown origin
- Mother is in her ___
- No family history of liver disease
- Father had a cancer of unknown origin
- Mother is in her ___
Physical Exam:
VS: 97.___
GENERAL: Chronically ill-appearing woman laying in bed. Alert
and
interactive in no acute distress
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
CHEST: HD line site C/D/I with line removed
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, mild distention, non-tender, normoactive bowel
sounds, +fluid wave
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP and radial pulses bilaterally
NEURO: Alert and oriented to place, year, date; states month is
___. CN II-XII intact. Moving all 4 extremities with purpose,
no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION Labs:
___ 09:05PM BLOOD WBC-10.8* RBC-2.51* Hgb-8.7* Hct-27.0*
MCV-108* MCH-34.7* MCHC-32.2 RDW-20.1* RDWSD-79.3* Plt Ct-52*
___ 09:05PM BLOOD ___ PTT-30.4 ___
___ 09:05PM BLOOD Glucose-133* UreaN-72* Creat-4.6*#
Na-129* K-4.0 Cl-95* HCO3-16* AnGap-18
___ 09:05PM BLOOD ALT-28 AST-33 AlkPhos-112* TotBili-1.5
___ 09:05PM BLOOD Albumin-3.0*
___ 05:24AM BLOOD calTIBC-222* Ferritn-262* TRF-171*
DISCHARGE Labs:
___ 06:13AM BLOOD WBC-5.8 RBC-2.68* Hgb-8.8* Hct-28.1*
MCV-105* MCH-32.8* MCHC-31.3* RDW-23.2* RDWSD-88.3* Plt Ct-58*
___ 02:24AM BLOOD Neuts-83.4* Lymphs-9.0* Monos-6.7
Eos-0.0* Baso-0.2 NRBC-0.7* AbsNeut-3.35 AbsLymp-0.36*
AbsMono-0.27 AbsEos-0.00* AbsBaso-0.01
___ 06:13AM BLOOD Glucose-134* UreaN-35* Creat-4.5*# Na-135
K-3.9 Cl-96 HCO___ AnGap-16
MICROBIOLOGY:
___ 10:51 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM.
Identification and susceptibility testing performed on
culture #
___ (___).
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0540.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 10:51 am BLOOD CULTURE Source: Line-tlcl.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC OF 2 MCG/ML test result performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
HD Line Report ___:
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image
showing catheter
with tip terminating in the right atrium.
INDICATION: ___ year old woman with etoh cirrhosis HRS on line
holiday for vre
bacteremia, needs ___ dialysis on ___, can she get line on
___ AM, thank
you // can she get tunneled line in am of ___ for pm dialysis
on ___,
thanks
FLUOROSCOPY TIME AND DOSE: 2:01 min, 7.7 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the
risks,
benefits and alternatives to the procedure, written informed
consent was
obtained from the patient. The patient was then brought to the
angiography
suite and placed supine on the exam table. A pre-procedure
time-out was
performed per ___ protocol. The left upper chest was prepped
and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal
jugular vein
was compressible and accessed using a micropuncture needle.
Permanent
ultrasound images were obtained before and after intravenous
access, which
confirmed vein patency. Subsequently a Nitinol wire was passed
into the right
atrium using fluoroscopic guidance. The needle was exchanged
for a
micropuncture sheath. The Nitinol wire was removed and a short
Amplatz wire
was advanced to make appropriate measurements for catheter
length. The wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the
upper
anterior chest wall. After instilling superficial and deeper
local anesthesia
using lidocaine mixed with epinephrine, a small skin incision
was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was
selected. The
catheter was tunneled from the entry site towards the venotomy
site from where
it was brought out using a tunneling device. The venotomy tract
was dilated
using the introducer of the peel-away sheath supplied. Following
this, the
peel-away sheath was placed over the ___ wire through which
the catheter was
threaded into the right side of the heart with the tip in the
right atrium.
The sheath was then peeled away. The catheter was sutured in
place with 0 silk
sutures. Steri-strips were also used to close the venotomy
incision site.
Final spot fluoroscopic image demonstrating good alignment of
the catheter and
no kinking. The tip is in the right atrium. The catheter was
flushed and both
lumens were capped. Sterile dressings were applied. The patient
tolerated the
procedure well.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image
showing catheter
with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled
dialysis line.
The tip of the catheter terminates in the right atrium. The
catheter is ready
for use.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of ETOH cirrhosis
c/b HE, recurrent ascites with weekly large and hepatorenal
syndrome on HD (___), undergoing transplant work up, who was
transferred from ___ on ___ for a dislodged
HD line that was removed, hospital course c/b encephalopathy,
VRE bacteremia and concern for endocarditis. Patient was
admitted to ___, at which time she was started on daptomycin.
Repeat blood cultures were obtained, and the last positive blood
culture was on ___ growing enterococcus that was resistant to
vancomycin. The patient continued on IV therapy, and she was
clinically improving, denying any fevers, chills, chest pain,
palpitations, and throughout her hospitalization had no stigmata
of endocarditis. The source of the infection was likely due to
her HD line.
ID was consulted, and the recommendations included continuing
daptomycin, removing her HD line, and getting a TEE to determine
the course of antibiotic therapy. The patient had her HD line
removed, was on a line holiday, with replacement of her HD line
48 hours after removal. Patient had no issues with removal,
blood cultures were persistently negative, and her TEE did not
show any evidence of endocarditis. She was stable throughout her
time in the hospital. The patient had initially NG tube
placement, but prior to discharge given intolerance of NG tube
the patient and care team elected to remove the NG tube. The
patient tolerated oral feedings well, with the caveat that her
nutrition will have to be closely monitored. Patient was
discharged after her dialysis on ___, needing 2 additional
doses of daptomycin for her VRE bacteremia.
TI:
VRE Bacteremia
[]last 2 dapto doses on ___ and ___ after HD
Cirrhosis/transplant w/u
[]will need q6month HCC screening
[] please schedule pt to have eval for fistula
[] Continue to assess nutritional status and p.o. intake.
Patient briefly on NG tube while in hospital. Patient did not
want NG tube as outpatient.
PCP:
[] recheck vitamin d levels
ACUTE ISSUES:
==============
#Septic shock
#VRE bacteremia, stable
The patient was admitted with septic shock with VRE bacteremia
with 4 out of 4 blood cultures positive, requiring
norepinephrine/vasopressin. Patient was hemodynamically stable,
and transferred to the floor. Her last blood culture was
positive on ___ growing enterococcus resistant to
vancomycin sensitive to daptomycin. The source of the infection
was likely line infection although diarrheal illness was
initially considered. TTE was initially performed with a
possible vegetation, although later TEE was reassuring for no
signs of endocarditis. ID was consulted this hospitalization and
provided recommendations for infection management. She had a
line holiday for her HD line, with replacement of her HD line on
___, for which she continue daptomycin with dialysis. Her CK
levels were unremarkable. The patient was maintained on
Midodrine. She was scheduled to complete 2 weeks of daptomycin
treatment, with the last 2 courses to be infused via her midline
as an outpatient.
#Dislodged HD catheter
#ESRD on ___ HD
#Hepatorenal syndrome
The patient had HD line placed upon arrival to the ICU, was
stable on hemodialysis. She was maintained on midodrine,
continued hemodialysis through her tunneled HD line, and was
continued on her home Nephrocaps and sevelamer.
#Encephalopathy, resolved
The patient's encephalopathy was likely multifactorial although
there was a large component from her VRE bacteremia.
Encephalopathy improved with antibiotics and lactulose, the
patient was awake and alert oriented x3 and did not have any
asterixis on exam. Her mental status was stable over the course
of his hospitalization.
#ETOH Cirrhosis
C/b HE, recurrent ascites with weekly large and hepatorenal
syndrome on HD (___), undergoing transplant work up. MELD
27, Childs Class B. Currently decompensated by ascites.
- V: Moderate ascites on exam. paracetensis on ___ removed 4.3
liters of fluid
- I: VRE treatment as above, otherwise no new infections
- B: No signs of acute bleeding, continued pantoprazole
- E: None on exam. Continued rifaximin and lactulose
- S: will need q6month ___ screening
#Acute on chronic macrocytic anemia
Baseline Hgb ___, downtrended <7 requiring 1u pRBC. OSH EGD in
___ showed no varices. No evidence of active bleeding. Likely
multifactorial from chronic illness and cirrhosis.
- Trended CBC
- Continued home pantoprazole
- Maintained active T&S
- Transfused for Hgb <7 or HD instability
#Concern for pneumoperitoneum
Seen on outside hospital CXR. CT shows improvement in free air
and tracking to umbilical deficit. Per Surgery and Radiology,
most likely secondary to recent paracentesis. Abdominal exam has
remained benign throughout her hospitalization.
- Trended abdominal exam
#Malnutrition
- Nutrition consulted
-The patient was initially on tube feeds while she was on the
floor, she was tolerating p.o. intake well and her NG tube was
DC'd the night prior to her discharge. The patient tolerated
dinner and breakfast well.
CHRONIC ISSUES:
================
#Thrombocytopenia
Likely ___ underlying cirrhosis.
# Vitamin D deficiency
- Continued vitamin D supplements
- Recheck vitamin D level as outpatient
CORE MEASURES:
# FEN: No IVF, replenish electrolytes, regular diet
# PPX: Subcutaneous heparin (hold for plt <50), lactulose
# ACCESS: PIV, HD line
# CODE: Full code
# CONTACT: ___ (Husband) ___
# DISPO: ET pending abx plan, TEE, line holiday
Medications on Admission:
1. Vitamin B Complex w/C 1 TAB PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Midodrine 30 mg PO TID
5. Mirtazapine 15 mg PO DAILY
6. PredniSONE 10 mg PO DAILY
7. rifAXIMin 550 mg PO BID
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Thiamine 100 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Daptomycin 350 mg IV QTUTHUR (___)
RX *daptomycin 350 mg 350 mg IV on ___ and ___ Disp #*2
Vial Refills:*0
2. Midodrine 25 mg PO Q6H
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Mirtazapine 15 mg PO DAILY
6. rifAXIMin 550 mg PO BID
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Simvastatin 20 mg PO QPM
9. Thiamine 100 mg PO DAILY
10. Vitamin B Complex w/C 1 TAB PO DAILY
11. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
VRE bacteremia
Dislodged HD catheter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital because your dialysis line was
dislodged, and you were found to have a bacterial infection.
While you were in the hospital, you had IV antibiotics started,
and your blood cultures eventually showed that there was no
bacterial growth and you started to feel better. You also had a
paracentesis performed to take fluid from your belly.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol, and you should try to keep your
liver as healthy as possible. See below for all our recommended
strategies.
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. Best wishes to you
and your family.
- Your ___ Care Team
Followup Instructions:
___
|
10011466-DS-18 | 10,011,466 | 21,473,984 | DS | 18 | 2191-08-30 00:00:00 | 2191-08-31 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of RIGHT
SIDED ABDOMINAL PAIN. Patient presents with 2 days of right
lower quadrant pain. Patient states noticed it while
walking. Patient's noticed intermittent pain worsens.
Patient had no relief with Pepto-Bismol. Patient denies
fevers or chills. Patient reports some anorexia.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 97.8 HR: 90 BP: 124/86 Resp: 14 O(2)Sat: 100
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Right lower quadrant pain without Rovsing sign
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Pertinent Results:
___ 06:10AM BLOOD WBC-8.9 RBC-5.59 Hgb-12.5* Hct-42.0
MCV-75* MCH-22.4* MCHC-29.8* RDW-14.2 Plt ___
___ 10:43PM BLOOD WBC-6.6 RBC-5.71 Hgb-12.9* Hct-42.3
MCV-74* MCH-22.7* MCHC-30.6* RDW-14.3 Plt ___
___ 06:10AM BLOOD Plt ___
___ 10:43PM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
___: US of appendix:
ReportFINDINGS: Non-visualization of a normal or abnormal
appendix. Several loops
Preliminary Reportof peristalsing bowel are noted.
___: cat scan of abdomen and pelvis:
Appendix demonstrates dilation of the midportion to 8 mm with
tapering distally. No adjacent fat stranding, but air is not
seen distal to the focal dilation. Acute appendicitis is
improbable with these findings.
Brief Hospital Course:
The patient was admitted to the hospital with abdominal pain.
Upon admission, he was made NPO, given intravenous fluids and
underwent imaging. Cat scan imaging showed a large appendix
with a maximum diameter of 8 mm and a small amount of fat
stranding. The patient underwent serial abdominal examinations
and his white blood cell count was closely monitored. As the
patient's abdominal pain resolved, he was introduced to clear
liquids and advanced to a regular diet. There was no recurrence
of pain, nausea or vomiting. The patient's vital signs remained
stable and he was afebrile. The patient was discharged home on
HD #1 in stable condition. An appointment for follow-up was
made with his primary care provider.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right sided abdominal
pain. You were placed on bowel rest. Your abdominal pain has
slowly resolved. You are now preparing for discharge home with
the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
___
|
10011668-DS-28 | 10,011,668 | 24,061,001 | DS | 28 | 2141-04-20 00:00:00 | 2141-04-20 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
TEE ___
attach
Pertinent Results:
ADMISSION LABS
==============
___ 05:04PM BLOOD WBC-6.1 RBC-4.03 Hgb-12.3 Hct-38.0 MCV-94
MCH-30.5 MCHC-32.4 RDW-13.6 RDWSD-46.5* Plt ___
___ 05:04PM BLOOD Neuts-62.5 ___ Monos-5.7 Eos-3.1
Baso-1.0 Im ___ AbsNeut-3.80 AbsLymp-1.64 AbsMono-0.35
AbsEos-0.19 AbsBaso-0.06
___ 05:04PM BLOOD ___ PTT-36.0 ___
___ 05:04PM BLOOD Glucose-84 UreaN-12 Creat-0.6 Na-141
K-5.0 Cl-104 HCO3-24 AnGap-13
___ 10:07PM BLOOD ALT-16 AST-33 AlkPhos-99 TotBili-2.3*
DirBili-0.4* IndBili-1.9
___ 05:14AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7
OTHER PERTINENT LABS
====================
___ 05:14AM BLOOD ___
___ 05:42AM BLOOD ___ PTT-150* ___
___ 04:55AM BLOOD ___ PTT-62.0* ___
___ 05:03AM BLOOD ___ PTT-45.4* ___
___ 05:05PM BLOOD ___
___ 05:50AM BLOOD ___ PTT-105.1* ___
___ 05:10AM BLOOD ___
___ 05:14AM BLOOD LD(LDH)-452*
___ 05:04PM BLOOD cTropnT-0.19*
___ 08:29PM BLOOD CK-MB-9 cTropnT-0.25*
___ 10:07PM BLOOD CK-MB-7 cTropnT-0.29*
___ 05:14AM BLOOD CK-MB-5 cTropnT-0.16*
___ 05:19PM BLOOD CK-MB-3 cTropnT-0.06*
___ 05:14AM BLOOD Hapto-<10*
___ 05:42AM BLOOD CRP-4.0
___ 06:16AM BLOOD SED RATE-Test
DISCHARGE LABS
===============
___ 05:10AM BLOOD WBC-3.8* RBC-3.76* Hgb-11.6 Hct-36.0
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.9 RDWSD-48.8* Plt ___
___ 05:10AM BLOOD ___
___ 05:10AM BLOOD Glucose-100 UreaN-19 Creat-0.8 Na-138
K-4.9 Cl-103 HCO3-24 AnGap-11
___ 05:10AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
MICRO
=====
___ 7:33 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======
___ CXR
Moderate pulmonary vascular congestion/edema. More focal
nodular opacity at
the right lung base could be due to volume overload, but
pulmonary nodule or
consolidation is not excluded. Recommend repeat chest
radiographs after
diuresis.
___ TTE
TTE ___. Probable large thrombus on the left atrial aspect of
the bileaflet mitral valve adjacent to the posterior annulus
with no significant mitral regurgitation and normal
transvalvular gradients. Moderate global left ventricular
hypokinesis.
___ TEE
Normally functioning mechanical mitral prosthesis. No
thrombus/mass. The
interatrial septum is intact, but may have had prior repair or
chairi attachments to the right atrial side of the septum (see
clips ___.
___ Cardiac Cath
No angiographically apparent coronary artery disease. Normal
left-side filling pressures.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Discharge Weight: 71.9kg
[ ] Discharge INR 2.6
[ ] Please repeat lab to check INR this week by ___, given
lab script.
[ ] Patient presented with atypical chest pain and NSTEMI,
underwent LHC which showed no lesions. Her chest pain is quite
atypical so she was trialed on GI cocktails and pain medications
with little effect. She was ultimately trialed on Isurdil which
strangely resolved her chest pain. She was discharged on Imdur.
[ ] Patient presented with subtherapeutic INR. She was bridged
with heparin and ultimately resumed her home warfarin regimen.
INR seems to be labile as an outpatient. Please continue to
monitor INR closely.
[ ] Patient with TTE showing reduced EF 35-40% down from 60% in
___. She presented with fluid overload requiring IV diuresis.
She was not transitioned to PO diuretics as she was euvolemic
and not net positive without its addition. Advised patient to
weigh herself daily. Please follow weights as patient may need
addition of PO Lasix as an outpatient.
BRIEF HOSPITAL COURSE
======================
Ms. ___ is a ___ woman with a history of mechanical
mitral valve replacement(on Coumadin) in ___ rheumatic
disease c/b MSSA endocarditis in ___, HTN, HLD, non-ischemic CM
w/ EF 45%, and long-standing history of atypical chest pain, who
presents with recurrent chest pain, also with evidence of volume
overload and elevated troponins. In terms of chest pain, patient
ultimately underwent LHC on ___ showing no lesions. She
continued to have chest pain despite GI cocktail and pain
regimen. She was trialed on Isurdil which actually resolved her
pain. In terms of fluid overload, patient was treated with IV
diuresis and discharged in euvolemic condition. In addition,
patient's course was complicated by subtherapeutic INR and
concern for mitral valve thrombus, however, TEE showed no
thrombus and she was bridged with heparin to goal INR on
discharge.
CORONARIES: ___ clean coronaries/ ___ with clean
coronaries.
PUMP: EF 35-40% as of ___
RHYTHM: NSR
===============
ACTIVE ISSUES:
===============
#NSTEMI
#Atypical Chest pain
Patient has a longstanding history of atypical chest pain for
which she has undergone previous work-up including diagnostic
LHC in ___ showing clean coronaries and no obstructive CAD. Her
___ stress test revealed a poor exercise tolerance, resting
hypertension, and a blunted blood pressure response, as well as
a decrease in her heart rate (90s to ___ but no ischemic ECG
changes or wall motion abnormalities were appreciated. Her
current symptoms are consistent with prior presentations. EKG
does show similar STD in lateral leads and TWI in V4-V6 which
are stable compared to prior EKGs. However, the big difference
is that she had significantly elevated troponins on admission
trending up to 0.25 and since downtrending. Initially, this was
thought to be possibly a type II MI iso decompensated heart
failure but unusually high
troponins and normal renal function. It was less likely a type I
NSTEMI given such clean coronaries on LHC in ___. Now with TTE
showing global hypokinesis, decreased EF to 35-40%. Therefore,
patient underwent repeat LHC on ___ given continuing ___
chest pain which again showed no angiographically apparent
coronary artery disease and normal left-side filling pressures.
Patient failed GI cocktails and typical pain regimens.
Therefore, she was trialed on Isurdil 10mg TID which did relieve
her pain. This could represent microvascular changes given her
history of rheumatic heart disease, however is still atypical.
Will discharge on Imdur given its success and tolerance.
#Heart Failure with Reduced Ejection Fraction (35-40%)
#Hypoxemia
Patient had a most recent EF of 45%, although repeat TTE in
___ stress echo showing recovered EF of 60%. Echo this
admission showed EF of 35-40%. CXR showed moderate pulmonary
vascular congestion also with BNP ___. Possible trigger was
dietary indiscretion given high salt diet. Patient received IV
diuresis. She was not transitioned to a standing oral regimen as
she was improved to baseline euvolemic, not reaccumulating fluid
off diuretics. Patient continued on home losartan and
metoprolol. Patient euvolemic and saturating well on room air
upon discharge. Weight on discharge 71.9kg. Please continue to
monitor weights and volume exam. ___ need addition of loop
diuretic in future.
#History of Mitral Valve Replacement
#Indirect Hyperbilirubinemia
Patient has a mechanical bileaflet mitral valve replacement
secondary to rheumatic mitral stenosis ___, later complicated
by Staph aureus endocarditis ___ TR. Patient presented
subtherapeutic on coumadin, INR 1.6 (goal 2.5-3.5). She has been
subtherapeutic recently as an outpatient as well. Patient with
positive hemolysis labs. TTE showed concern for MV thrombus, but
TEE shows confirmed no thrombus. She was bridged with heparin
until her INR was therapeutic and she was discharged on her home
regimen. Please ensure INRs are checked regularly and warfarin
dosing is titrated accordingly.
================
CHRONIC ISSUES:
================
#HLD
Patient continued on home atorvastatin 80mg PO QPM
#Depression
Patient continued on home celexa 20mg PO QD. Please monitor QTc
as was elevated at start of admission. QTc on discharge 449.
# CODE STATUS: Full Code
# CONTACT: Name of health care proxy: ___
Relationship: boyfriend Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO 6X/WEEK (___)
2. Warfarin 6 mg PO 1X/WEEK (___)
3. Atorvastatin 80 mg PO QPM
4. Metoprolol Succinate XL 300 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
3. Citalopram 20 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Metoprolol Succinate XL 300 mg PO DAILY
6. Warfarin 4 mg PO 6X/WEEK (___)
7. Warfarin 6 mg PO 1X/WEEK (___)
8.Outpatient Lab Work
Z95.2
lab: INR
when: any day between ___.
Please fax results to ___ attn: ___
___, MD
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Atypical Chest Pain
Acute on Chronic Heart Failure with Reduced Ejection Fraction
SECONDARY DIAGNOSES
===================
Subtherapeutic INR with mechanical heart valve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had chest pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had imaging of your heart.
- You were given medications for your chest pain
- You had a procedure to look at your valve replacement better
which was normal
- You had a procedure to look at the blood vessels of your heart
which was normal
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-Please weigh yourself every morning. Call your doctor if you
gain more than 3 lbs in one day.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10011938-DS-19 | 10,011,938 | 24,772,774 | DS | 19 | 2132-01-30 00:00:00 | 2132-01-31 16:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___
right-handed woman with a history of complex partial seizures
was
brought to the ED by EMS due to concern for seizure at home.
She reports that her father passed away 2 weeks ago after a
fairly lengthy illness. This is caused her a great deal of
stress and other social difficulties. Since that time she has
been having several episodes per day, which are of a new
semiology for her. She describes these as follows: A feeling of
swelling and numbness of the tongue, which is accompanied by
difficulty forming words. She feels that she is able to think
of
the words she wants to say but is unable to get her mouth to
produce them. She is able to understand people if they did
speak
to her. She feels quite certain that the tongue
numbness/swelling as well as the difficulty speaking come on at
the same time. Episodes last between 1 and 2 minutes, after
which she is completely back to normal. Her husband has
apparently seen his episodes, and there is no associated
abnormal
eye movements, oral or facial automatism, or abnormal movement
of
the limbs. She has had the episodes while seated, and has been
able to maintain her posture; she is unsure if she is ever had
them while standing. These episodes have been happening between
5 and 10 times per day for the last 2 weeks. She is unable to
identify any particular triggers, and feels that they come on
randomly.
These episodes actually started at rehab, where she has been for
the last several days after she tripped and fell and sustained a
left ankle injury at home. Other than this, there have not been
any recent changes to her medical status. She is not certain of
the medicine she takes, but denies any changes in the doses or
frequency of her antiseizure medications. Her medications are
currently administered by visiting nurse. She reports that she
was not sleeping very well at rehab, but denies any significant
loss of sleep. She also denies any recent infections fevers,
etc.
Today, her visiting nurse apparently noted her to have one or
more of these episodes, and recommended she be brought to the ED
for evaluation.
Regarding her seizure history, she has been followed by Dr.
___ quite some time. Seizure started in the ___. Her
typical semiology consists of a visual aura of flashing lights,
followed by a head deviation to the right lasting a minute or
so.
This is been followed by a postictal cry as well as difficulty
speaking for several minutes. Apparently, there also sometimes
strange behaviors such as starting to make a pot of coffee. She
has never had a generalized seizure. Prior medications include
Dilantin, which was stopped for unclear reasons. She is
currently on a regimen of levetiracetam, phenobarbital, and
lamotrigine which she reports she tolerates well. She feels
like
her last seizure was around ___ years ago.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies loss of vision, blurred
vision, diplopia, vertigo, tinnitus, hearing difficulty,
dysarthria, or dysphagia. Denies focal muscle weakness,
numbness,
parasthesia. Denies loss of sensation. Denies bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- COPD
- Epilepsy, complex-partial; followed by Dr. ___ seizures
characterized by head turn to the right with impaired ability to
speak but maintains awareness; this lasts for ___ minutes,
followed by emotional crying, and then headache and nausea. Last
seizure was > ___ years ago.
- AVM, Left frontal, s/p Proton beam radiation at ___ in ___
and again ___
- PCom aneurysm s/p clipping at ___ in ___
- HLD
- Lumbar disc herniation, presented with left sciatic pain but
none recently
- Anemia (iron deficiency)
- Eosinophilia
Social History:
___
Family History:
No family history of neurologic disease.
Both parents had COPD. Father had colon cancer.
Physical Exam:
Admission Physical Examination:
Vitals: T: 98.2 p: 79 R: 18 BP: 137/66 SaO2: 94% room air
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Breathing comfortably on room air
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Spells WORLD backward as DLOW. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Pt was able to name both high
and low frequency objects. Able to 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 finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5- ___ ___- 5 5 5 5
R 5- ___ ___- 5 5 5 5
-Sensory: There is a circumferential, length dependent loss of
pinprick and temperature sensation below the upper shin. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on finger to nose bilaterally.
-Gait: Not tested
=================================================
Discharge Physical Exam:
24 HR Data (last updated ___ @ 500)
Temp: 97.3 (Tm 98.3), BP: 166/75 (119-166/72-80), HR: 64
(64-74), RR: 18 (___), O2 sat: 94% (94-97), O2 delivery: 2 L
General: elderly woman lying comfortably in recliner, NAD
HEENT: NC/AT, EEG leads in place
Cardiac: warm, well-perfused
Pulmonary: no increased work of breathing
Abdomen: soft, ND
Extremities: wwp, CAM boot on LLE
Skin: no rashes or lesions noted.
Neurologic:
- Mental status: Awake, alert, oriented to self, ___, date.
Able to relate history without difficulty. Attentive to
interview. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 4->2 brisk. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to voice. Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 5 5 5 5 5 5 * *
R 5 5 4- 5 5 5 5 5 3+ 5
L wrapped in dressing in CAM boot
- Sensory: No deficits to light touch bilaterally.
- Reflexes: deferred
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: unable to assess
Pertinent Results:
Admission Labs:
___ 05:59PM BLOOD WBC-9.8 RBC-3.65* Hgb-10.7* Hct-34.1
MCV-93 MCH-29.3 MCHC-31.4* RDW-13.9 RDWSD-47.3* Plt ___
___ 05:59PM BLOOD Neuts-65.5 Lymphs-16.4* Monos-5.9
Eos-11.2* Baso-0.7 Im ___ AbsNeut-6.40* AbsLymp-1.61
AbsMono-0.58 AbsEos-1.10* AbsBaso-0.07
___ 06:45PM BLOOD ___ PTT-28.4 ___
___ 05:59PM BLOOD Glucose-87 UreaN-24* Creat-1.4* Na-139
K-4.8 Cl-100 HCO3-24 AnGap-15
___ 05:59PM BLOOD ALT-6 AST-7 AlkPhos-160* TotBili-0.3
___ 05:59PM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0
Discharge Labs:
___ 06:00AM BLOOD WBC-9.9 RBC-3.23* Hgb-9.3* Hct-30.3*
MCV-94 MCH-28.8 MCHC-30.7* RDW-13.4 RDWSD-46.5* Plt ___
___ 06:00AM BLOOD ___ PTT-27.9 ___
___ 09:39AM BLOOD Glucose-90 UreaN-32* Creat-1.3* Na-142
K-5.4 Cl-104 HCO3-25 AnGap-13
___ 09:39AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1
___ 06:05AM BLOOD calTIBC-218* Ferritn-76 TRF-168*
___ 05:59PM BLOOD Phenoba-26.0
CXR AP Lat ___: FINDINGS:
No focal consolidation is seen. There is minimal basilar
atelectasis. Left upper hemithorax scarring is noted. There is
mild pulmonary vascular
congestion. No pleural effusion or pneumothorax is seen.
Cardiac silhouette as mildly enlarged. There is mild prominence
the main pulmonary artery, would suggest a component of
underlying pulmonary hypertension.
IMPRESSION:
Mild pulmonary vascular congestion. Mild prominence of the main
pulmonary
artery suggest component of underlying pulmonary hypertension.
CTA Head Neck ___: IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Stable large left frontal AVM with arterial feeders from the
left MCA and venous drainage into the superior sagittal sinus.
3. Approximately 20% stenosis by NASCET criteria of the proximal
bilateral
internal carotid arteries.
4. Mild-to-moderate multifocal atherosclerotic calcifications of
the head and
neck vasculature with no evidence of occlusion.
TIB/FIB (AP AND LAT) LEFT ___:
IMPRESSION:
Diffuse osteopenia is noted. There is a healing subacute spiral
fracture
through the distal tibial metadiaphysis, which demonstrates
fibroosseous
bridging and callus formation. There is a healed fracture
through the distal fibular diaphysis. Multiple well corticated
ossific densities inferior to the medial malleolus most likely
represent sequela from remote trauma. There are mild
degenerative changes of the medial patellofemoral compartment
and
tibiotalar joint.
FOOT AP,LAT & OBL LEFT PORT ___: FINDINGS:
Diffuse osteopenia is noted. No acute fracture or dislocation
is seen. There are sclerotic changes along the second, third
and fourth metatarsal necks,
which most likely represent subacute/chronic fractures. Mild
degenerative
changes are seen in the hindfoot and midfoot. There is a small
plantar
calcaneal spur. There is a small skin defect along the
posterior aspect of the calcaneus. There is no adjacent
cortical erosion, focal osteopenia or
periosteal reaction.
IMPRESSION:
1. Small skin defect along the posterior aspect of the
calcaneus. No
radiographic evidence of osteomyelitis. If there is high
clinical concern for osteomyelitis, further evaluation may be
performed with MRI with contrast or nuclear medicine bone scan.
2. Sclerotic changes along the second, third and fourth
metatarsal necks,
which most likely represent subacute/chronic fractures.
3. Please see separate report from concurrently performed
radiographs of the left tibia and fibula for additional
findings.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of epilepsy,
was well controlled on levetiracetam/lamotrigine/phenobarbital
who presented with new onset of episodes of tongue
numbness/swelling sensation, as well as aphasia. EEG shows
multiple left frontal brief seizures ___ long. Patient may be
having breakthrough seizures due to UTI and soft tissue
infections. She also has a L heel ulcer and a R groin abscess
s/p I&D by ACS.
#Epilepsy
-cvEEG monitoring showed numerous of electrographic seizures
daily (>80-90). Did not improve on addition of Ativan bridge,
vimpat, klonopin. However, there was decrease in clinical
seizures on fycompa 6mg such that there were no further clinical
events x24 hours prior to discharge.
- Continued home AEDs (LEV 1000mg BID, PHB 97.2mg BID, LTG 200mg
TID)
- vimpat 250mg BID (started ___ - ineffective - weaned off.
- trialed ativan bridge which was not improving EEG, so it was
stopped after 2 days
- stopped klonopin on ___ after short, ineffective trial
- prednisone 60 mg on ___, 40 mg on ___, 20 mg ___. Back to
home dose of 5 mg daily on ___. per outpatient epileptologist,
Dr. ___
- started Fycompa at 2 mg QHS and uptitrated to 6 mg QHS. Plan
to increase to 8mg QHS in 1 week as outpatient.
#R groin abscess- with purulent drainage
- consulted ACS; s/p I+D
- doxycycline and Keflex on ___ to complete 10 day course
- BID wet to dry dressing changes per ACS
#Heel ulcer, R buttock ulcer
- wound care consulted
- podiatry consulted
- please see wound recs
#multiple L tibia/fibula fractures, subacute in ___
- x-ray shows multiple subacute healing fractures
- spoke with patient's outpatient ortho, Dr. ___
- weight bearing as tolerated if CAM boot in place with walker
per OP ortho
- ___ consulted; recommended rehab
#UTI
- urine culture grew E. coli resistent to cipro and ampicillin.
sensitive to cephalosporins
- s/p ceftriaxone x1 in ED
- macrobid stopped; covered by Keflex and doxy for ulcers
- repeat UA negative
#Gross hematuria - painless, 2 episodes
- UA negative for blood, 1 RBC
- recommended outpatient follow-up with Urology
Chronic Issues:
#HTN
- Lisinopril 10 mg held. BPs mostly 120s-140s. Please restart as
appropriate.
===========================================
Transitional Issues:
[] f/u on healing of R groin ulcers/abscesses, R buttock ulcer,
L heel ulcer.
[] Continue daily/BID wound dressing changes
[] antibiotics through ___ unless continuing concern for
infection
[] increase Fycompa to 8 mg QHS on ___
[] follow-up in 1 week with ___ RN
[] follow up with Dr. ___ surgeon) within 2 weeks
of discharge.
[] follow up with urology for painless hematuria within 1 month
[] monitor blood pressure and restart home lisinopril 10 mg as
appropriate.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. sevelamer CARBONATE 800 mg PO TID W/MEALS
2. PredniSONE 5 mg PO DAILY
3. Famotidine 20 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath
5. LevETIRAcetam 1000 mg PO BID
6. LamoTRIgine 200 mg PO TID
7. PHENObarbital 97.2 mg PO BID
8. LORazepam 1 mg PO DAILY:PRN anxiety
9. Ferrous Sulfate 325 mg PO BID
10. HydrOXYzine 25 mg PO Q6H:PRN anxiety
11. Lisinopril 10 mg PO DAILY
12. Gabapentin 400 mg PO TID
13. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
Discharge Medications:
1. Cephalexin 500 mg PO QID
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*9 Capsule Refills:*0
2. Collagenase Ointment 1 Appl TP DAILY
3. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
4. Fycompa (perampanel) 6 mg oral QHS
RX *perampanel [Fycompa] 6 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
RX *perampanel [Fycompa] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*3
5. Polyethylene Glycol 17 g PO DAILY
6. Pramipexole 0.125 mg PO QHS
7. Sarna Lotion 1 Appl TP DAILY:PRN itching
8. Gabapentin 100 mg PO TID:PRN pain
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath
10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
11. Famotidine 20 mg PO DAILY
12. Ferrous Sulfate 325 mg PO BID
13. HydrOXYzine 25 mg PO Q6H:PRN anxiety
14. LamoTRIgine 200 mg PO TID
15. LevETIRAcetam 1000 mg PO BID
16. PHENObarbital 97.2 mg PO BID
17. PredniSONE 5 mg PO DAILY
18. sevelamer CARBONATE 800 mg PO TID W/MEALS
19. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until necessary for high blood
pressure.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure disorder
Secondary diagnoses:
Urinary tract infection
Right groin abscess
Left heel ulcer
COPD
Left tibia/fibular fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to
new episodes of tongue heaviness and difficulty speaking.
You were monitored on EEG, which showed that these episodes are
seizures. In addition, you had dozens of subclinical seizures
each day, which you do not notice.
We think you are having more seizures due to infections. You
were found to have a urinary tract infection which has been
treated with antibiotics.
You also had ulcers on your left heel and your right buttock. An
abscess was found in your right groin which needed to be lanced
and drained by the surgery team.
You were treated for 7 days with antibiotics called Keflex and
Doxycycline.
Take your medications as prescribed.
You were started on an additional anti-seizure medication:
Fycompa (perampanel) 6 mg at bedtime. On ___, increase to 8
mg at bedtime.
You are being treated on antibiotics through ___.
Keep taking cephalexin 500 mg four times a day. Stop after ___.
Keep taking doxycycline 100 mg twice a day. Stop after ___.
Your Lisinopril 10 mg daily was held temporarily while in the
hospital. Please see your PCP about whether you should restart
it for your blood pressure.
Continue all your other medications as prescribed.
Follow up with your PCP ___ ___ weeks of discharge.
You had a couple episodes of painless blood in your urine. This
may be completely benign but there is a possibility that
sometimes it is an early sign of bladder or kidney cancer. You
should see your PCP or ___ urologist within the next month to
follow up on blood in your urine.
Follow up with your orthopedic surgeon (Dr. ___ in 2 weeks.
He suggests calling his office to make an appointment.
Follow up with your neurologist within 2 months.
Thank you for the opportunity to care for you.
Sincerely,
The ___ Neurology Team
Followup Instructions:
___
|
10012206-DS-11 | 10,012,206 | 23,961,896 | DS | 11 | 2127-07-14 00:00:00 | 2127-07-14 15:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
floctafenine
Attending: ___.
Chief Complaint:
Acute pancreatitis
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
Laparoscopic cholecystectomy - Dr. ___ ___
History of Present Illness:
Pt.is ___ y/o male with hx of hypertriglyceridemia, HTN, OSA,
DMII, neuropathy, essential tremor, and prior diagnosis of acute
pancreatitis 3 weeks ago at ___ in ___ after experience abdominal pain, nausea/vomiting, and
several episodes of loose stools ___. CT at that time was
notable for mild acute pancreatitis/duodenitis, a high density
fluid collection posterior to the pancreatic tail, and a small
nonocclusive filling defect in SMV suspicious for thrombus.
Patient underwent IVF resuscitation and with an ___
hospital course and was subsequently discharged home.
Since discharge pt. states he as been unable to tolerate Po
intake eating solid food once in the past 10 days. While
traveling for a funeral the past couple of day his emesis,
abdominal pain, and diarrhea have intensified culminating in
evaluation at ___ where CT findings were again notable
for edema and inflammation around the pancreas, fluid collection
in both the tail(5.7x3.1cm) and head(2.9x2.2cm) of the pancreas,
as well fluid extending down the right abdomen.
On presentation, pt is not in acute distress, persistently
hypotensive 80-90 systolic despite receiving 3L at the OSH
endorsing continued abdominal pain, dry mouth, diarrhea, a
frustrating lack of PO intake. Pt denies nausea/vomiting today,
chest pain, LOC, prior MI, melena, or headache.
Past Medical History:
Past Medical History:
-DMII
-HTN
-HLD
-Acute Pancreatitis
-Neuropathy
-OSA
-Essential Tremor
Past Surgical History:
-Spinal Stimulator Placement
-C-spine Fusion
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals:98.5 PO 142 / 90 R Lying 92 18 98 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: hypotensive, regular rhythm
PULM: Clear to auscultation b/l, No wheezin
ABD: Soft,obese, nondistended, mild epigastric tenderness, no
rebound or guarding,
normoactive bowel sounds,
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 97.5 PO 141 / 83 104 20 97 RA
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs. NJT in place
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
IMAGING:
___: DUPLEX DOPP ABD/PEL PORT:
1. Patent hepatic vasculature.
2. Limited evaluation of the splenic vein and superior
mesenteric vein. The visualized portions of the splenic and
superior mesenteric veins appear patent.
3. Diffusely echogenic liver suggestive of a degenerative cyst
or intrinsic liver disease.
4. Heterogeneous collections adjacent to the spleen as on the
prior CT, likely sequela of known pancreatitis.
5. Cholelithiasis, without evidence of acute cholecystitis.
___: CTA Abdomen/Pelvis:
1. Multiple peripancreatic collections are unchanged from recent
prior.
2. Nonocclusive thrombus in the splenic vein. A second order
jejunal branch of the SMV is narrowed however remains patent.
___: Upper Endoscopic Ultrasound:
-Normal mucosa in the whole esophagus
-Normal mucosa in the whole stomach
-Multiple shallow nonbleeding clean-based ulcers in the examined
duodenum, expected in setting of acute pancreatitis
-EUS: markedly edematous and distorted pancreatic parenchyma in
setting of acute pancreatitis. Several acute pancreatic and
peripancreatic fluid collections identified. The CBD could not
be assessed due to distorted in anatomy in setting of acute
pancreatitis.
-Nasojejunal tube placed at the end of the procedure.
___: Portable Abdominal x-ray:
There is a nasojejunal tube which terminates in the expected
region of the
proximal jejunum in the left hemiabdomen. There are no
abnormally dilated
loops of large or small bowel. There is no free intraperitoneal
air, although evaluation is limited by supine technique. A
spinal cord stimulator device projects over the right side of
the abdomen. No acute osseous abnormalities are identified.
___: CT Interventional Radiology Procedure:
1. Sample 1: 3 cc of milky fluid was aspirated from the right
paracolic gutter collection.
2. Sample 2: 5 cc of straw-colored, blood tinged fluid was
aspirated from the peripancreatic collection.
IMPRESSION:
Technically successful CT-guided aspiration of the collections
as described above.
LABS:
___ 03:14AM LACTATE-0.7
___ 02:59AM GLUCOSE-108* UREA N-35* CREAT-1.5*
SODIUM-132* POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-14
___ 02:59AM ALT(SGPT)-12 AST(SGOT)-14 LD(LDH)-150 ALK
PHOS-50 TOT BILI-0.2
___ 02:59AM LIPASE-150*
___ 02:59AM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-3.1
MAGNESIUM-1.5*
___ 02:59AM TRIGLYCER-412*
___ 02:59AM WBC-15.2* RBC-3.53* HGB-10.3* HCT-31.6*
MCV-90 MCH-29.2 MCHC-32.6 RDW-15.2 RDWSD-50.1*
___ 02:59AM NEUTS-83* LYMPHS-15* MONOS-1* EOS-1 BASOS-0
AbsNeut-12.62* AbsLymp-2.28 AbsMono-0.15* AbsEos-0.15
AbsBaso-0.00*
___ 02:59AM HYPOCHROM-1+* ANISOCYT-1+* MACROCYT-1+*
___ 02:59AM PLT SMR-HIGH* PLT COUNT-587*
___ 02:59AM ___ PTT-27.7 ___
___ 08:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:50PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:50PM URINE RBC-6* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:50PM URINE HYALINE-5*
___ 08:49PM LACTATE-1.0
___ 08:39PM GLUCOSE-100 UREA N-39* CREAT-1.7* SODIUM-131*
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-21* ANION GAP-15
___ 08:39PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-52 TOT
BILI-0.2
___ 08:39PM LIPASE-168*
___ 08:39PM ALBUMIN-3.6
___ 08:39PM WBC-17.5* RBC-3.53* HGB-10.4* HCT-31.2*
MCV-88 MCH-29.5 MCHC-33.3 RDW-15.3 RDWSD-49.2*
___ 08:39PM NEUTS-68 ___ MONOS-3* EOS-3 BASOS-0
MYELOS-1* AbsNeut-11.90* AbsLymp-4.38* AbsMono-0.53 AbsEos-0.53
AbsBaso-0.00*
___ 08:39PM RBCM-WITHIN NOR
___ 08:39PM RBCM-WITHIN NOR
Brief Hospital Course:
Mr. ___ is a ___ y/o male with hx of hypertriglyceridemia,
HTN, OSA, DMII, neuropathy, essential tremor, and recent
diagnosis of acute pancreatitis at ___ in
___ after experiencing abdominal pain,
nausea/vomiting, and several episodes of loose stools ___.
He was discharged from ___ and then later
presented at ___ in ___ with
abdominal pain and emesis. CT findings at ___ were
again notable
for edema and inflammation around the pancreas, fluid collection
in both the tail(5.7x3.1cm) and head(2.9x2.2cm) of the pancreas,
as well fluid extending down the right abdomen. The patient was
transferred to ___ in hypovolemic shock and was
admitted to the Acute Care Surgery service on ___. Blood
culture from ___ grew staphylococcus coagulase negative and
he was started on vancomycin. Repeat blood cultures were sent
which were negative and vancomycin was discontinued.
The patient was transferred to the ICU and was made NPO with IVF
for hydration. Gastroenterology was consulted for endoscopy.
Abdominal ultrasound revealed gallstones and his pancreatitis
was thought to be due to gallstone pancreatitis. On ___,
CTA was done to evaluate for SMV thrombus and a nonocclusive
thrombus was seen in the splenic vein. The patient was started
on a heparin drip which was later transitioned to warfarin with
lovenox bridging.
On ___, the patient went for upper endoscopy with
Gastroenterology which revealed multiple shallow nonbleeding
clean-based ulcers in the examined duodenum, a markedly
edematous and distorted pancreatic parenchyma in the setting of
acute pancreatitis, several acute pancreatic and peripancreatic
fluid collections. The CBD could not be assessed due to
distorted anatomy in the setting of acute pancreatitis. A
nasojejunal tube was placed so that the patient could receive
tube feedings. Tube feeds were initiated on ___ which the
patient tolerated. Tube feeds were later changed from
continuous to cycled.
On ___, the patient was taken to the operating room where he
underwent laparoscopic cholecystectomy. This procedure went
well (reader, please refer to operative note for details).
After remaining hemodynamically stable in the PACU, the patient
was transferred to the surgical floor. Pain was managed with a
hydromorphone PCA initially. On POD #2, the PCA was d/c'd and
oxycodone and acetaminophen were prescribed. The patient
continued on tube feeds which he tolerated.
Given that the patient lives in ___, follow-up care
appointments were arranged in his home state. Please see
discharge worksheet for further details. INR check ___ ___. All other INR check with primary care doctor in
___ Dr. ___.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating Tube feeds,
ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services
for tube feeds. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. atenolol-chlorthalidone 50-25 mg oral DAILY
2. DULoxetine 60 mg PO DAILY
3. Fenofibrate 145 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
7. Nortriptyline 25 mg PO QHS
8. PrimiDONE 50 mg PO TID
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Enoxaparin Sodium 90 mg SC Q12H
RX *enoxaparin 100 mg/mL 90 mg sc every twelve (12) hours Disp
#*30 Syringe Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*6 Tablet Refills:*0
4. Warfarin 5 mg PO ONCE Duration: 1 Dose
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day
Disp #*8 Tablet Refills:*0
5. atenolol-chlorthalidone 50-25 mg oral DAILY
6. DULoxetine 60 mg PO DAILY
7. Fenofibrate 145 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
11. Nortriptyline 25 mg PO QHS
12. PrimiDONE 50 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Non-occlusive thrombus in the splenic vein- 3 months Lovenox
and Warfarin
-___ fluid collections- negative gram stain on
aspiration
-Cholelithaisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to ___ and
underwent laparoscopic cholecystectomy. During your
hospitalization ___ also had the interventional radiology team
aspirate a sample of the ___ fluid collections seen
on the CT scan. These cultures were negative. ___ are recovering
well and are now ready for discharge. Please follow the
instructions below to continue your recovery:
*****ANTICOAGULATION: ___ have a partial splenic thrombus seen
on the CT scan. ___ are on a Lovenox bridge until your INR is
goal ___. ___ also need to take Warfarin for 3 months. Follow up
with primary care doctor ___ in ___
. Your PCPC will monitor your anticoagulation in the office for
INR checks .Avoid changes in diet with foods rich in Vit.K
(broccoli, spinach, cauliflower & ___ sprouts)
****Your health records were sent to Dr. ___
___ surgery clinic (___) )office at the
Medical ___. ___ is Dr.
___ assistant. The office will review your record
then contact ___ in the next ___ days to be assigned to Dr.
___ another surgeon for your post operative
appointment(s). ___ can call ___ if ___ have any
questions. This arrangement was coordinated on your behalf due
to preference to follow up in ___.
***VISITING NURSES***
___ will have ___ services for 1 week in ___ for
nutrition feeding education and supplies. This company will
connect ___ with ___ services in ___ if still
needed.
******FOLLOW UPS:
1) Primary care doctor- INR blood test goal INR (___), blood
sugar and medication reconciliation . Please go to your primary
care doctor ___.
2) ___- post operative
check from laparoscopic cholecystectomy and splenic vein
thrombus
3) ___ ___ at 3:30pm- post operative
and a one time INR check. Your primary care doctor will be
following all additional INR checks. Please go the ___
blood lab before your clinic appointment to have labs drawn.
Clinic number ___.
ACTIVITY:
o Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow ___ may shower and remove the gauzes over your
incisions. o Your incisions may be slightly red around the
stitches. This is normal.
o ___ may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless ___ were told
otherwise.
o ___ may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if ___ take it before your
pain gets too severe.
o Talk with your surgeon about how long ___ will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10012688-DS-17 | 10,012,688 | 23,145,708 | DS | 17 | 2179-10-22 00:00:00 | 2179-10-22 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
dizziness, gait unsteadiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of chronic
left ear pulsatile tinnitus of unclear etiology and GERD who
presents with 1 day history of dizziness and gait unsteadiness,
for whom neurology is consulted due to question of posterior
circulation etiology. History provided by patient.
Ms. ___ reports she was in her usual state of health until 4
___ yesterday. At that time, she got out of her car on the way
home from work, and felt significant dizziness. Reports that
this started suddenly. She describes her dizziness as a
combination of feeling disequilibrium, off-balance, and with
some
room spinning sensation. She reported that when she tried to
walk, it felt like she "drank 20 beers." She struggled walking
back into the house, but eventually was able to do so, and
immediately went to lie down the couch. She right on the couch
and rested for 1 hour, and then felt back to her baseline. Last
night, she spent most of the night with her father who was
hospitalized at ___ and felt fine. During that time
she was able to ambulate without any symptoms.
The patient woke up this morning feeling in her usual state of
health. She got to ___ at 10 AM for a tour of the
stadium, and felt fine walking around the park. She had a
breakfast sandwich and 2 beers with breakfast. Shortly after
the
game started at 1 ___, she went to the bathroom. After standing
for a few minutes after using the restroom, while washing her
hands, she felt the dizziness come back. Dizziness was similar
to yesterday, described as a combination of disequilibrium, gait
unsteadiness, with some room spinning component. It was more
severe than usual. She sat down and put her head in her hands,
covering her eyes. She felt significantly nauseous but did not
vomit. She sat in the chair but that it did not help. There
was
no difference or change positions. She tried to stand up, but
was swaying back and forth, not in any particular direction, and
unable to take steps. EMS was called and she was transferred to
___ emergency department for further
evaluation.
On the emergency department evaluation, vitals were notable for
elevated blood pressures with systolic blood pressures
180s-190s.
Shortly after being in triage, she took a 20 minute nap and felt
some transient improvement, but by 5:30 ___, symptoms resumed.
Currently, patient reports low-grade dizziness and room spinning
vertigo. When she sits upright or tries to walk, it becomes
unbearable. She cannot ambulate unless she has significant
assistance, which is far from her baseline. Her blood pressures
continue to be elevated to 170s-180s.
Of note, the patient has baseline, chronic left ear pulsatile
tinnitus. She reports her left ear always feels blocked. This
has been worked up in the past with MRI head and MRA's, which
she
reports been overall unrevealing. She believes that over the
last day, this left ear sensation has been somewhat more
prominent than usual. She otherwise denies any new symptoms,
including denying focal weakness, sensory changes, visual
changes, difficulties understanding or expressing speech.
Prior to the above, the only change to her routine is that she
has had significant stress recently due to her father being ill
with pneumonia. She stayed up late last night overnight in the
hospital caring for him. She otherwise denies any recent
illnesses, denies fevers/chills, denies any new or missed
medications.
On neuro ROS, the pt reports dizziness and gait unsteadiness.
Denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt reports nausea. Denies
recent fever or chills. No night sweats or recent weight loss
or
gain. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies vomiting, diarrhea,
constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-Chronic pulsatile tinnitus of the left ear
-GERD
Social History:
___
Family History:
Denies any family history of stroke or neurologic
conditions
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: 97.3F, heart rate ___, blood pressure 178-191/94-109, RR
18, O2 94% RA
Orthostatic vital signs in ED:
Supine HR 74, BP 181/104
Sitting HR 81, BP 178/109
Standing HR 73, BP 180/108
General: Awake, cooperative, 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: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. No skew. Head impulse test indeterminate. Normal
saccades. VFF to confrontation. Visual acuity ___ bilaterally.
V: Facial sensation intact to light touch.
VII: Mild left nasolabial fold flattening at rest, symmetric
upon
activation. Obtained previous license photos and photos from
phone; difficult to appreciate if this was present previously.
Symmetric smile after hearing a joke. Symmetric forehead wrinkle
and eyeclosure. Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2+ 2+ 3 2+
R 3 2+ 2+ 3 2+
Pectoralis jerks and crossed adductors present b/l
Plantar response was flexor bilaterally.
-Coordination: When attempting to sit up, there appears to be
truncal ataxia, more prominent upon standing. No intention
tremor. Normal finger-tap bilaterally. No dysmetria on FNF or
HKS
bilaterally. No overshoot on cerebellar mirroring.
-Gait: Stands without assistance, but sways back and forth with
a
wide base at rest. Falls backward when attempting to do
Unteberger testing. Requires one person assistance to ambulate.
Gait is wide-based, normal stride and arm swing. Cannot walk in
tandem.
DISCHARGE PHYSICAL EXAM
==========================
General: no acute distress
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, Tympanic membranes with no infection or effusion.
Neck: Supple, No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: no cyanosis, clubbing, edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. R gaze nystagmus. No
skew. Head impulse test indeterminate. Normal saccades. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: No nasolabial fold flattening. Smile symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2+ 2+ 3 2+
R 3 2+ 2+ 3 2+
Pectoralis jerks and crossed adductors present b/l
Plantar response was flexor bilaterally.
-Coordination: When attempting to sit up, there appears to be
truncal ataxia, more prominent upon standing. No intention
tremor. Normal finger-tap bilaterally. No dysmetria on FNF or
HKS
bilaterally. No overshoot on cerebellar mirroring.
-Gait: Stands without assistance, veers to left with eyes
closed. Requires one person assistance to ambulate.
Pertinent Results:
ADMISSION LABS
===============
___ 05:00PM BLOOD WBC-10.6* RBC-4.45 Hgb-13.7 Hct-40.7
MCV-92 MCH-30.8 MCHC-33.7 RDW-12.8 RDWSD-41.7 Plt ___
___ 05:00PM BLOOD Neuts-76.7* Lymphs-17.6* Monos-4.7*
Eos-0.3* Baso-0.4 Im ___ AbsNeut-8.11* AbsLymp-1.86
AbsMono-0.50 AbsEos-0.03* AbsBaso-0.04
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-142
K-4.3 Cl-105 HCO3-21* AnGap-16
___ 05:00PM BLOOD ALT-18 AST-21 AlkPhos-97 TotBili-0.3
___ 05:00PM BLOOD Lipase-29
___ 05:00PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD Albumin-4.5 Cholest-243*
___ 05:00PM BLOOD Triglyc-312* HDL-47 CHOL/HD-5.2
LDLcalc-134*
___ 05:00PM BLOOD TSH-2.8
___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
=================
___ 04:25AM BLOOD WBC-7.0 RBC-4.01 Hgb-12.3 Hct-37.0 MCV-92
MCH-30.7 MCHC-33.2 RDW-12.7 RDWSD-43.3 Plt ___
___ 04:25AM BLOOD Neuts-40.8 ___ Monos-7.8 Eos-3.4
Baso-0.3 Im ___ AbsNeut-2.87 AbsLymp-3.34 AbsMono-0.55
AbsEos-0.24 AbsBaso-0.02
___ 04:25AM BLOOD Plt ___
___ 04:25AM BLOOD ___ PTT-27.3 ___
___ 04:25AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-144
K-4.1 Cl-108 HCO3-25 AnGap-11
___ 04:25AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
IMAGING
===========
CT HEAD W/O CONTRAST Study Date of ___
FINDINGS:
There is no evidence of acute large territorial infarction,
hemorrhage, edema,or mass effect. The ventricles and sulci are
normal in size and configuration.There is no evidence of
fracture. Minimal mucosal thickening is seen within the right
sphenoid sinus posteriorly. The visualized portion of the
remaining paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No acute intracranial abnormality.
MR HEAD W/O CONTRAST Study Date of ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are normal
in caliber and
configuration. Normal flow voids are demonstrated bilaterally.
IMPRESSION:
1. Normal brain MRI.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of chronic left
ear pulsatile tinnitus of unclear etiology and GERD who
presented with 1 day history of dizziness and gait unsteadiness.
She was ruled out for acute stroke.
#Vestibulopathy of unclear etiology:
Initially presented with intermittent dizziness, described as a
combination of dysequilibrium, gait unsteadiness and room
spinning over one day. Her dizziness was positional and worse
with standing, she was unable to ambulate independently which is
a change from her baseline. She also developed new left ear
"fullness". Initial exam notable for unremarkable HINTS exam,
however did have truncal ataxia. Interval repeat examination was
notable for persistent gait unsteadiness (veered to left), and
right beating nystagmus on right gaze. Tympanic membranes had no
evidence of infection or effusion. Head CT and MRI with no
evidence of stroke. Etiology of her symptoms is unclear, has
mixed features. Peripheral vestibulopathy possible, lower
suspicion for vestibular neuritis (no preceding viral symptoms,
nausea, or vomiting), BPPV (negative ___, Menieres
(late age of onset). Stroke risk factors were checked: LDL 134,
A1C 5.9. Initiated atorvastatin 40 mg daily. At the time of
discharge, patient felt subjectively better although still
required some assistance with walking. ___ recommended discharge
home with ___ rehab.
TRANSITIONAL ISSUES:
=====================
[] A1C 5.9, prediabetic range, continue to monitor and consider
metformin initiation
[] LDL 134, started atorvastatin 40 mg daily
[] noted to be hypertensive throughout admission (in ED SBP
180s-190s, on floor 140-160s/60-70s), consider addition of
antihypertensive
[] please perform outpatient audiogram, consider VNG pending
audiogram results and evolution of symptoms (Scheduled for ENT)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Cetirizine 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4.Outpatient Physical Therapy
___ rehab
ICD-10: H81.90
Discharge Disposition:
Home
Discharge Diagnosis:
#Vestibulopathy of unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
You came to the hospital because you developed dizziness, ear
fullness, and unsteadiness when walking at home. These symptoms
were concerning for a stroke. We performed blood tests and
imaging of your brain and determined that you did not have a
stroke. We also performed examinations of your ears and found no
abnormalities. We believe your symptoms are related to a problem
in your inner ears, which is an area of your body that controls
balance. It is safe for you to return home. ENT also evaluated
you and recommended you follow up in their clinic on ___
at ___:30 AM for a hearing test.
While in the hospital, we found that your cholesterol levels
were high and we started you on a medication to lower your
cholesterol ("atorvastatin"). You will also have ___
rehab" sessions which will help you regain and improve your
balance.
Please continue to take your medications as prescribed and to
___ with your doctors as ___.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10012853-DS-9 | 10,012,853 | 22,539,296 | DS | 9 | 2176-06-08 00:00:00 | 2176-06-15 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
generalized weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ y/o woman with a PMH of atrial fibrillation on
warfarin, PE, CKD III, PVD, HTN, T2DM, neurogenic bladder and
multinodular goiter, who was referred by her PCP for generalized
weakness and decreased appetite. Per the daughter, ___, for
the past three days the patient has been feeling nauseated and
clear, watery NBNB vomiting ___. Normal BM today. The patient
has not been eating or drinking, has required her daughter to
help her walk to the bathroom, and has not been able to sit up
due to weakness.
Denies shortness of breath, chest pain, abdominal pain, blood in
stool or urine. Of note, the patient was started on methimazole
1 week ago for hyperthyroidism. She also had a CT scan on ___
for lung nodules, with a slightly increased size of the right
lower lob nodule of 6 mm (previously 5 mm). Remainder of nodules
unchaged from prior study in ___, but all nodules have
gradually increased from ___. In ___, she also had a
pneumonia, for which she was in a rehab facility for a week.
In the ED, initial vitals were: T 98.1F P 77 BP 100/43 RR 18 98%
Labs were notable for: Trop-T <0.01. Na 137, K 3.5, Cl 98, HCO3
28, BUN 33, Cr 1.5, Gluc 107, Ca 8.9, Mg 1.8, P 4.4, ALT 33, AST
33, AP 125, Tbili 0.5, Alb 3.1. WBC of 9.1, H/H of 10.2/33.4 Plt
419. INR of 2.6. ProBNP 1144. UA notable for small leuks,
moderate blood, positive nitrites, >300 protein, RBC 15, WBC 98,
few bacteria.
Thyroid studies were pending.
Patient was given:
___ 18:22 IV CeftriaXONE 1 gm
On the floor, Ms. ___ reported that she has not been "feeling
right" since ___, when she had her catheter changed; she
endorsed increased dysuria and urinary frequency. Denies
hematuria. Has also had light headedness, with no syncope or
falls. Denied fevers, chills, chest pain, shortness of breath,
abdominal pain, diarrhea, BRBPR, melena, hematochezia, and
constipation. Last BM was yesterday, with one well-formed stool.
Now she reports that she is feeling considerably better.
Past Medical History:
- T2DM (HbA1c 6.1% in ___, diet controlled)
- HLD
- CKD III
- PVD
- OA
- iron deficiency anemia
- paroxysmal atrial fibrillation
- pulmonary embolism
- stroke
- diverticulosis
- goiter (nontoxic multinodular)
- AAA (3.3 cm in ___, no further eval)
- cholelithiasis
- obesity
- lung nodules (as above)
- neurogenic bladder
- prolonged QT
Social History:
___
Family History:
Mother, aunt, and uncle all had CHF, unknown cause; no known hx
of CAD in her family. Daughter with heart arrhythmia on
amiodarone
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 97.4F BP 128/39 P 65 RR 18 O2 96%RA
General: Alert, oriented, pleasant woman in NAD.
HEENT: PERRL; EOMs intact. MMM, OP clear. Anicteric sclera.
Neck: Supple; large, palpable goiter; non-tender. No JVD.
CV: RRR, III/VI systolic murmur best heard over LUSB. No rubs or
gallops. Normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS; no organomegaly.
GU: Suprapubic catheter in place, draining dark urine.
Ext: Warm, well-perfused. 2+ pulses; trace edema. No clubbing or
cyanosis.
Neuro: A&Ox3. Preserved strength in upper and lower extremities
and distal sensation intact to light touch, gait deferred.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.7 145/55 56 18 95% RA
General: Alert, oriented, pleasant woman in NAD.
HEENT: PERRL; EOMs intact. MMM, OP clear. Anicteric sclera.
Neck: Supple; large, palpable goiter; non-tender. No JVD.
CV: RRR, III/VI systolic murmur best heard over LUSB. No rubs or
gallops. Normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS; no organomegaly.
GU: Suprapubic catheter in place, draining dark urine.
Ext: Warm, well-perfused. 2+ pulses; trace edema. No clubbing or
cyanosis.
Neuro: A&Ox3. CNII-XII grossly intact, moving all extremities
spontaneously, gait deferred.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:00PM BLOOD WBC-9.1 RBC-4.24 Hgb-10.2* Hct-33.4*
MCV-79* MCH-24.1* MCHC-30.5* RDW-17.4* RDWSD-49.2* Plt ___
___ 04:00PM BLOOD Neuts-77.7* Lymphs-8.3* Monos-12.8
Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.07* AbsLymp-0.75*
AbsMono-1.16* AbsEos-0.02* AbsBaso-0.04
___ 04:00PM BLOOD Glucose-107* UreaN-33* Creat-1.5* Na-137
K-3.5 Cl-98 HCO3-28 AnGap-15
___ 04:00PM BLOOD ALT-33 AST-33 AlkPhos-125* TotBili-0.5
___ 04:00PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD proBNP-1144*
___ 04:00PM BLOOD Albumin-3.1* Calcium-8.9 Phos-4.4 Mg-1.8
___ 04:00PM BLOOD TSH-<0.02*
___ 04:00PM BLOOD T3-92 Free T4-1.8*
___ 04:08PM BLOOD Lactate-1.4
___ 04:00PM BLOOD TSH-<0.02*
___ 04:00PM BLOOD T3-92 Free T4-1.8*
==============
DISCHARGE LABS
==============
___ 06:20AM BLOOD WBC-5.6 RBC-3.83* Hgb-9.3* Hct-29.9*
MCV-78* MCH-24.3* MCHC-31.1* RDW-17.5* RDWSD-49.1* Plt ___
___ 06:20AM BLOOD ___ PTT-36.6* ___
___ 06:20AM BLOOD Glucose-82 UreaN-20 Creat-0.8 Na-141
K-4.0 Cl-104 HCO3-25 AnGap-16
===============
IMAGING/STUDIES
===============
CHEST (PA & LAT) (___)
IMPRESSION:
Hyperinflated lungs. Mild pulmonary vascular congestion. No
focal
consolidation.
============
MICROBIOLOGY
============
___________________________________________________________
___ 10:33 pm URINE Source: Suprapubic.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
__________________________________________________________
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mrs. ___ is a ___ y/o woman with a PMH of atrial fibrillation on
warfarin and amiodarone, PE, CKD III, PVD, HTN, T2DM, and
multinodular goiter recently started on methimazole, who was
referred by her PCP for generalized weakness and decreased
appetite, who presented with symptoms and UA consistent with
UTI, no leukocytosis and no fever.
============
ACUTE ISSUES
============
#Complicated UTI. She had no fever or leukocytosis, and endorsed
symptoms of urinary urgency and frequency, in the setting of
suprapubic catheter for neurogenic bladder. She history of
Pseudomonas (pan-sensitive) and Klebsiella UTIs in the past,
with no CVA tenderness to suggest pyelonephritis. We avoided
ciprofloxacin owing to history of prolonged QT. There was no
evidence of pneumonia on plain film. She was treated with one
dose of ceftriaxone in the ED, and then was monitored off
antibiotics. Her urine culture grew GNRs, but this was thought
to represent colonization. She did well off of antibiotics and
was discharged without any further antibiotic treatment.
# Toxic multinodular goiter. Mrs. ___ was recently started on
methimazole 10 mg on ___. TSH 0.02 on ___ and she had a
palpable, painless goiter. Methimazole was held on admission
but was restarted in the setting of thyroid studies showing
suppressed TSH.
# ___ on CKD, stage III. The was thought to be pre-renal in the
setting of poor PO intake, and her creatinine improved from 1.5
to 1.1 with the administration of fluids.
# Generalized weakness. Her weakness had improved on admission
and was thought to represent infection vs. thyroid dysfunction
in the setting of starting methimazole. There was no evidence of
neurogenic or cardiovascular dysfunction. No syncope or loss of
consciousness. We opted to pursue UTI treatment, encouragement
of PO intake, and maintenance fluids as above.
==============
CHRONIC ISSUES
==============
# Neurogenic bladder. Suprapubic catheter, secondary to diabetic
nephropathy, with Foley change by urology approximately once per
month with annual cystoscopy.
# Tobacco use. Nicotine patch was offered but declined.
# T2DM. Diet-controlled. A1c of 6.1% in ___.
# Paroxysmal atrial fibrillation. In normal sinus rhythm.
Warfarin and amiodarone were continued.
# Hypertension. Home lisinopril, amlodipine and HCTZ were
continued.
# Hyperlipidemia. Home atorvastatin and aspirin were continued
# Iron deficiency anemia. Home ferrous sulfate 325 mg was
continued.
===================
TRANSITIONAL ISSUES
===================
# Anticoagulation. Next INR should be drawn on ___. Managed
by Dr. ___ at ___.
# CODE: FULL
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 1 mg PO 3X/WEEK (___)
2. Atorvastatin 40 mg PO QPM
3. Lisinopril 30 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Methimazole 10 mg PO DAILY
12. Warfarin 2 mg PO 4X/WEEK (___)
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcium Carbonate 500 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 30 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Warfarin 1 mg PO 3X/WEEK (___)
11. Warfarin 2 mg PO 4X/WEEK (___)
12. Methimazole 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- urinary tract infection
- toxic multinodular goiter
- acute kidney injury
===================
SECONDARY DIAGNOSES
===================
- neurogenic bladder
- tobacco use
- type 2 diabetes mellitus
- paroxysmal atrial fibrillation
- hypertension
- hyperlipidemia
- iron deficiency anemia
=================
PRIMARY DIAGNOSES
=================
- urinary tract infection
- toxic multinodular goiter
- acute kidney injury
===================
SECONDARY DIAGNOSES
===================
- neurogenic bladder
- tobacco use
- type 2 diabetes mellitus
- paroxysmal atrial fibrillation
- hypertension
- hyperlipidemia
- iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for weakness and concern for a
urinary tract infection. You were initially treated with
antibiotics, but because our suspicion that you had a urinary
tract infection was low since you didn't have a fever and your
bloodwork did not show signs of infection, we decided to
discontinue antibiotics and to observe you for 24 hours. During
that time, you continued to feel well, so we felt it was safe to
send you home.
Please take all of your discharge medications as prescribed. We
recommend that you make a follow-up appointment with someone
from your primary care physician's practice this week to make
sure you are still doing okay.
We wish you all the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
10013015-DS-4 | 10,013,015 | 24,173,031 | DS | 4 | 2121-08-12 00:00:00 | 2121-08-12 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Complete Heart Block
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ female with history of A. fib on
Coumadin, chronic kidney disease, COPD on 2L O2, severe
pulmonary hypertension who is presenting as a transfer from ___
___ for concern for 3rd degree heart block.
The patient was recently admitted to ___ in ___ for
syncope. She was walking through a store to buy medications for
her constipation and she became lightheaded, weak, and she fell
to the floor and hit her head. She endorsed epigastric pain
prior to event but no other prodrome of diaphoresis, nausea, or
tunnel vision. The event was thought to be due to pulmonary HTN
from
chronic COPD as her TTE showed elevated PA pressures as well as
a possible orthostatic component. She was given gentle fluids
and her Lasix was held but resumed at a decreased dose prior to
discharge. She was also given prednisone 30mg PO daily,
levaquin 250mg daily, and started on albuterol nebulizers. She
was discharged on 2L NC with plan to get outpatient PFTs.
She states that she has not been the same since discharge. She
used to be able to walk her dog around the block multiple times
but in the past month, she has been so short of breath she has
not been able to walk her dog at all. The most activity she is
able to perform is chores around the house. She has noticed
lower extremity swelling but no orthopnea, PND, nausea, or
vomiting.
She does not weigh herself as she does not have a scale but she
does not think she has gained weight. She manages all of her
medications on her own and does not think she missed any doses.
The patient was cooking dinner for herself the night prior to
admission when she developed a sharp chest pressure in the left
side of her chest. The pain progressed so she called EMS. She
denied any palpitations, shortness of breath, nausea, or
vomiting. The pain lasted about one hour. When EMTs arrived,
she was bradycardic to the ___.
On arrival to ___, her blood pressure was 82/39 with a heart
rate of ___. EKG was concerning for complete heart block. She
had minimal response to atropine so was started on transvenous
pacing without capture. She was then given pushes of
epinepherine then started on an epinepherine drip. Her lowest
blood pressure was 70/40. Labs were notable for a creatinine of
3.1, potassium of
6.2, ph on the VBG of 7.10 with a pCO2 of 34 and a bicarbonate
of 10. She was then given IVF boluses and started on a
bicarbonate drip. She was also given 1 amp of calcium gluconate
and 3mg of glucagon given concern for AV nodal blockage
overdose.
The patient was transferred to ___ for further management of
complete heart block. Blood pressure was 90/40 on transfer and
she was placed on epinepherine and norepinephrine. In the ED,
epinephrine and norepinephrine were weaned off and she was
placed on dopamine 2.5 mcg/kg/min.
In the ED,
- Initial vitals were:
97.3 66 100/58 12 96% 3L NC
- Exam notable for:
None documented
- Labs notable for:
WBC of 27.6, hgb of 8.5, plt of 338
Na of 141, K of 5.9, Cl of 115, HCO3 of 13, BUN 46, Cr of 2.8
ALT of 21, AST of 51, ALP of 89, Tbili of 0.4
VBG with ___
lactate of 1.9
- Studies notable for:
CXR with Apparent opacities projecting over the right lower lung
may partially be due to costochondral calcifications but cannot
exclude possible lung parenchymal opacities.
- Patient was given:
IV DRIP DOPamine 2.5 mcg/kg/min
500 cc IVF
IV Calcium Gluconate 1 gm
On arrival to the CCU, the patient endorses shortness of breath
mildly improved from prior. She denies any chest pain, nausea,
vomiting, palpitations, dysuria, urgency, frequency, or
diarrhea. She has been eating and drinking normally over the
past few days.
In speaking with renal this morning, they recommended 1L of
Nabicarb for his acidosis.
Past Medical History:
Cardiac History:
- type 2 diabetes
- hypertension
- dyslipidemia
- atrial fibrillation
- HFpEF
Other PMH:
- CKD stage III
- COPD
Social History:
___
Family History:
FATHER, ___ Cause: CVA (cerebral vascular accident).
MOTHER, ___ Cause: Colon cancer.
DAUGHTER, ___, Age ___ Cause: Diabetes mellitus.
SON, ___, Age ___ Cause: ___ syndrome.
SON, ___, Age ___ Cause: Hydrocephalus.
Physical Exam:
ADMISSION EXAM
===============
VS: Reviewed in Metavision
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP at 11 cm at 90 degrees.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. scattered
wheezes
throughout both lung fields
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. 2+ pitting edema of both lower
extremities bilaterally
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
================
24 HR Data (last updated ___ @ 516)
Temp: 97.6 (Tm 98.0), BP: 149/70 (109-149/43-70), HR: 83
(___), RR: 20 (___), O2 sat: 90% (84-93), O2 delivery: 3L,
Wt: 168.21 lb/76.3 kg
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
CARDIAC: RRR. No murmurs, rubs, or gallops.
LUNGS: Decreased breath sounds. No wheezing, no increased WOB or
use of accessory muscles
ABDOMEN: Soft, NTND. No palpable hepatomegaly or splenomegaly.
EXTREMITIES: 1+ pitting edema of both lower extremities
bilaterally to mid shin.
PULSES: Distal pulses palpable and symmetric.
NEURO: Alert, conversant, no gross focal deficits
Pertinent Results:
ADMISSION LABS
================
___ 11:59PM BLOOD WBC-27.6* RBC-3.71* Hgb-8.5* Hct-30.3*
MCV-82 MCH-22.9* MCHC-28.1* RDW-21.0* RDWSD-59.8* Plt ___
___ 11:59PM BLOOD Neuts-85.5* Lymphs-6.9* Monos-6.2
Eos-0.0* Baso-0.3 NRBC-0.3* Im ___ AbsNeut-23.60*
AbsLymp-1.90 AbsMono-1.72* AbsEos-0.01* AbsBaso-0.08
___ 11:59PM BLOOD ___ PTT-27.4 ___
___ 11:59PM BLOOD ALT-21 AST-51* CK(CPK)-67 AlkPhos-89
TotBili-0.4
___ 11:59PM BLOOD Albumin-3.4*
INTERVAL LABS
===============
___ 12:05AM BLOOD ___ pO2-72* pCO2-36 pH-7.16*
calTCO2-14* Base XS--15 Comment-GREEN TOP
___ 07:46AM BLOOD ___ pO2-133* pCO2-37 pH-7.37
calTCO2-22 Base XS--3 Comment-GREEN TOP
___ 05:37AM BLOOD Cortsol-15.3
___ 11:59PM BLOOD TSH-2.1
___ 05:55AM BLOOD calTIBC-300 Ferritn-31 TRF-231
___ 11:59PM BLOOD cTropnT-<0.01
___ 05:37AM BLOOD CK-MB-3 cTropnT-<0.01
MICROBIOLOGY
=============
___ 12:05 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
___ BLOOD CULTURE
NO GROWTH
___ URINE CULTURE
NO GROWTH - FINAL
MRSA SWAB - PENDING
___ BLOOD CULTURE
NO GROWTH TO DATE (PENDING)
___ BLOOD CULTURE
NO GROWTH TO DATE (PENDING)
IMAGING
==========
TTE (___)
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is normal leftventricular wall
thickness with a normal cavity size. There is normal regional
and global left ventricular systolic
function. Quantitative biplane left ventricular ejection
fraction is 73 %. Left ventricular cardiac index is depressed
(less than 2.0 L/min/m2). There is no resting left ventricular
outflow tract gradient. Diastolic
parameters are indeterminate. Mildly dilated right ventricular
cavity with moderate global free wall hypokinesis. Tricuspid
annular plane systolic excursion (TAPSE) is depressed. There is
abnormal interventricular septal motion c/w right ventricular
pressure and volume overload. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no
mitral valve prolapse. There is trivial mitral regurgitation.
The pulmonic valve leaflets are not well seen. The tricuspid
valve leaflets appear structurally normal. There is moderate
[2+] tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Moderate to severe pulmonary artery systolic
hypertension. Right ventricular cavity dilation with free wall
hypokinesis. Moderate tricuspid regurgitation.
RENAL U.S. Study Date of ___ 6:20 ___
1. Atrophic kidneys bilaterally. No hydronephrosis.
2. Small right pleural effusion.
CXR (___)
Heart size is top-normal. Mediastinum is stable. Right basal
opacities are minimal and unchanged, unlikely to represent
infectious process but attention on the subsequent radiographs
is recommended to this area. No pleural effusion or
pneumothorax is seen
___: CT chest w/o contrast:
1. No evidence of interstitial lung disease.
2. Moderate upper lobe predominant centrilobular emphysema.
3. Small bilateral pleural effusions with minor associated
atelectasis. ''
4. Coronary calcification.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Few small lung nodules measuring up to at most 4 mm. These
are very
likely benign, but noting emphysema may be appropriate to
consider follow-up
chest CT for surveillance in ___ year.
RECOMMENDATION(S): Follow-up chest CT is recommended for
surveillance of very
small, probably benign, lung nodules in ___ year.3.
___: RUQUS with duplex
1. Patent hepatic vasculature. No evidence for portal vein
thrombosis
2. Loss of diastolic flow in the main hepatic artery is likely
secondary to
hepatic congestion.
3. Cholelithiasis without cholecystitis.
4. Small right pleural effusion.
V/Q Scan:
FINDINGS:
Ventilation images demonstrate irregular tracer distribution in
both lung
fields.
Perfusion images demonstrate irregular tracer uptake in both
lung fields, worse
on the left compared to the right. All perfusion images are
matched but less
apparent than the defects noted on ventilation imaging.
Chest x-ray shows bibasilar infiltrates and pulmonary
congestion.
IMPRESSION: Ventilation images more apparent than perfusion
images, most
consistent with COPD/airways disease. No clear evidence of
pulmonary
thromboembolism.
DISCHARGE LABS
===============
___ 06:19AM BLOOD WBC-9.8 RBC-3.47* Hgb-8.1* Hct-28.6*
MCV-82 MCH-23.3* MCHC-28.3* RDW-22.3* RDWSD-65.3* Plt ___
___ 06:19AM BLOOD ___
___ 06:19AM BLOOD Plt ___
___ 06:19AM BLOOD Glucose-80 UreaN-44* Creat-1.7* Na-139
K-4.7 Cl-107 HCO3-22 AnGap-10
___ 06:10AM BLOOD ALT-12 AST-17 LD(LDH)-242 AlkPhos-100
TotBili-0.4
___ 06:00AM BLOOD ___
___ 05:37AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:19AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.1
___ 05:55AM BLOOD calTIBC-300 Ferritn-31 TRF-231
___ 06:47AM BLOOD ANCA-PND
___ 06:47AM BLOOD RheuFac-<10 ___ Cntromr-NEGATIVE
___ 06:47AM BLOOD C3-110 C4-23
___ 06:47AM BLOOD HIV Ab-NEG
___ 05:55AM BLOOD Vanco-13.6
Brief Hospital Course:
Ms. ___ is an ___ female with history of A. fib on
Coumadin, chronic kidney disease, COPD on 2L O2, severe
pulmonary hypertension who is presenting as a transfer from ___
___ for bradycardia likely due to metabolic disturbances in
the setting ___ from right sided heart failure/HFpEF, thought
related to new severe pulmonary hypertension.
Discharge Cr: 1.7
Discharge Weight: 168.21 lb (76.3 kg)
Discharge Diuretic: Furosemide 10 mg daily
Discharge Hgb: 8.1
ACUTE ISSUES:
=============
#Bradycardia
The patient presented with bradycardia in the setting of
electrolyte disturbance and acidosis as transfer from ___
___. Reportedly at the OSH her ECG was concerning for
possible atrial fibrillation w/ complete heart block and both
atropine and transcutaneous pacing were attempted prior to
transfer. Of note, on arrival to ___ she was noted to be in
atrial fibrillation w/ slow ventricular response and rates
___. Sequence of causality is unclear: ie, if patient was
bradycardic leading to decreased renal perfusion and thus an
acidosis or if patient was acidotic due to renal failure (or
other cause) leading to bradycardia. However, given lack of
other end organ damage, more likely the latter. Her troponins
were negative so unlikely to be ischemic in etiology. She is on
high doses of metoprolol and Diltiazem at home and denies taking
more medications than prescribed. On arrival, the pt was briefly
on a dopamine drip. In this setting, her metoprolol and
dilitiazem were held and her metoprolol was slowly reintroduced.
Her Bradycardia resolved.
#Pulmonary Hypertension
The patient had evidence of volume overload with elevated JVP
and lower extremity edema consistent with right sided heart
failure exacerbation. However with diuresis, the patient became
orthostatic. RHC showed severe pulmonary hypertension. Likely
group III iso oxygen dependent COPD but evaluation for other
causes was recommended by pulmonary. Group I work up included
___, ANCA, CCP, anti-centromere pending at time of discharge,
C3: 110, C4: 23, RF: <10, anti-RNP: negative, HIV: negative. She
is s/p RUQUS with doppler for portopulmonary HTN: No evidence of
porto-pulmonary HTN. Group III work up: was unable to acquire
full PFTs - (spirometry, DLCO, lung volumes), has appointment on
___. A Non con CT chest: demonstrated emphysema. Regarding
group IV workup, a VQ scan was performed without evidence of PE.
#HFpEF
Patient with new diagnosis of HFpEF with evidence of right-sided
HF likely secondary to COPD given elevated RV pressures on her
TTE, right axis deviation/low limb lead voltage on her EKG. She
is chronically on 3L but had an increased oxygen requirement
intitially. She was initially diuresed with IV Lasix but this
was ultimately held given mild ___. TTE this admission notable
for RV dilation w free wall hypokinesis. She was diuresed with
IV Lasix transitioned to torsemide. Held ACEi in the setting of
___. Received metoprolol as above, continued to hold diltiazem.
Imdur was discontinued given absence of angina. Continued with
IV Lasix lead to orthostatic hypotension and RHC was done to
evaluate for volume overload. PCWP was normal at 10 and CI was
normal at 2.82. PA pressure was ___ (47) consistent for severe
pulmonary hypertension as above. At discharge, diuretic was her
home dose of furosemide 10mg PO.
#Atrial Fibrillation
CHADS2VASC of 5 on warfarin. INR supratherapeutic on admission,
initially held diltiazem and metoprolol iso of bradycardia. High
doses of AV nodal blocking agents suggest that she has difficult
to control rates. She had intermittent bouts of AF w/ RVR to
150s while her nodal agents were being held. We restarted her
metoprolol and uptitrated to metoprolol tartrate 25mg q6H (her
home dose of metop) and consolidated to 100mg succinate prior to
discharge. Anticoagulation was continued with warfarin 3 mg
after correction of coagulopathy.
#Coagulopathy
On arrival pt's INR was supratherapeutic to 6.0 with prolonged
PTT and decreasing platelets. Possibly in the setting of
congestive hepatopathy vs. due to changes in her PO intake prior
to arrival. She was given PO vitamin K for three days, w/
normalization of her INR. Fibrinogen normal, blood smear showed
1+ schistocytes. Warfarin was restarted as above.
#Iron Deficiency Anemia
Pt w/ Hgb ___ this admission. Required intermittent pRBC. Her
iron studies are consistent w/ Fe deficiency anemia (Ferritin
31, TIBC 300, Fe 17). Stool guaiac positive, but brown. Likely
slow lower GI bleed iso supratherapeutic INR. INR reversed with
vitamin K and Hgb stabilized. She should undergo EGD and a
colonoscopy as an outpatient, but had adamantly refused
inpatient evaluation. She received IV iron repletion x3 days.
#Non-Anion Gap Metabolic Acidosis:
Patient with non anion gap metabolic acidosis with respiratory
acidosis. Bicarbonate is chronically around 18 but ph was 7.16
on presentation. Non anion gap metabolic acidosis likely due to
renal failure from worsening heart failure or injury due to
hypotensive event. She required small quantities of bicarb
initially before her pH normalized. Renal was consulted while
she was inpatient and improved without intervention.
___ on CKD: Patient has been seen by nephrologist with workup
notable for negative spep, upep. Baseline creatinine in ___
~1.5. Give exertional dyspnea, lower extremity dyspnea, and
volume overload, likely pre-renal from decreased effective
circulatory volume. Cr was 2.8 on admission and improved
initially with diuresis. Diuresis was restarted with increase in
Cr. on discharge Cr was 1.7.
#Positive blood cultures
#Leukocytosis
#Possible Cellulitis
She was briefly on vancomycin for possible GPC bactermia, but
given speciation as CoNS only in one bottle, suspect this may
have been contaminant. She had a full infectious workup which
was negative and we transitioned her to Keflex to complete a 5
day course for cellulitis (___).
CHRONIC ISSUES:
===============
#Diabetes mellitus: on levemir 10U SQ qhs so switched to
glargine 10mg qhs with sliding scale insulin while inpatient.
#COPD: Baseline 3L of home O2 with extensive smoking history.
Continued Advair.
#gout: continued allopurinol, dose reduced to every other day in
setting of worsening renal function.
#CODE: DNR/okay to intubate
#CONTACT/HCP: ___ ___ (son)
TRANSITIONAL ISSUES
=====================
[] Recommend performance of Full PFTs - spirometry, DLCO, lung
volumes, which are scheduled at ___ on ___.
[] Recommend follow up with a pulmonologist (she preferred to
see a provider closer to home as outpatient follow up in ___
will be challenging for her to keep.) If possible outpatient
follow-up should involve a local Pulmonologist (at ___) and PH
specialist at ___. She has had relatively extensive pulmonary
hypertension workup however still needs PFTs. We have scheduled
an appointment for her on ___ at ___ with a pulmonary
hypertension specialist.
[] Recommend referral to a cardiologist given her bradycardia
with heart block on admission and further titration of nodal
blockers.
[] Few small lung nodules measuring up to at most 4 mm. These
are very likely benign, but noting emphysema may be appropriate
to consider follow-up chest CT for surveillance in ___ year.
[] Pt w/ iron deficiency anemia this admission w/ Hgb ___. Her
stool was guaic positive, but pt did not have any BRBPR or
melena, so suspecting slow ooze. She was repleted with IV iron.
Consider EGD/Colonscopy as an outpatient.
[] Consider transition from colesevelam to a statin.
[] Consider continuing iron repletion as an outpatient.
[] Diuretic management: she was discharged on lasix 10mg PO with
notable lower extremity edema, further attempts at diuresis were
made during her hospital course with worsening of her kidney
function, absent of resolution of her edema and orthostasis.
[] INR management: She was supratherapeutic with INR of 6 on
admission please continue to monitor INR closely on discharge.
She was ultimately continued on her home dose of 3 mg daily.
[] Reduced allopurinol to every other day dosing due to
decreased CrCl, if Cr improves can consider increasing dose.
[] Monitor BP. Stopped ACE because she was normotensive at rest
and intermittently orthostatic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. fosinopril 10 mg oral DAILY
3. levemir 10 Units Bedtime
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. WelChol (colesevelam) 1875 mg oral BID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Diltiazem Extended-Release 240 mg PO DAILY
11. Warfarin 3 mg PO DAILY16
12. Vitamin D 1000 UNIT PO DAILY
13. Aspirin 81 mg PO DAILY
14. Furosemide 10 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
RX *allopurinol ___ mg 1 tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*0
2. levemir 10 Units Bedtime
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
4. Aspirin 81 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Furosemide 10 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 3 mg PO DAILY16
11. WelChol (___) 1875 mg oral BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Bradycardia
Pulmonary hypertension
SECONDARY DIAGNOSIS:
====================
Atrial fibrillation
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
- Your heart rates were extremely slow.
WHAT DID YOU DO FOR ME WHILE I WAS HERE?
- Your heart rates were monitored closely.
- We slowly restarted some your medications to control your
heart rates.
- You were treated with antibiotics for a possible skin
infection.
- Your blood was too thin, so we held a few doses of your blood
thinner until it normalized.
- You had a right heart catheterization which showed severe
pulmonary hypertension so you were seen by lung doctors .
After you leave:
================
- Please take your medications as prescribed.
- Please attend any outpatient follow-up appointments you have
upcoming.
- Your primary care doctor ___ refer you to a local
pulmonologist. We would also recommend that you follow up with a
pulmonary hypertension specialist here at ___. We have made an
appointment for you (see below) and there are pulmonary function
tests scheduled for the same day. If you feel that you do not
want to keep this appointment, please call the clinic to cancel.
- Please work with your primary care provider to monitor your
warfarin level or INR closely, if the level is too high it can
cause bleeding. If it is too low, it can increase your risk of a
stroke.
- Please ask your primary care doctor to assist you in finding a
pulmonologist close to your home. They can help further evaluate
the causes of your shortness of breath.
It was a pleasure participating in your care! We wish you the
very best!
Sincerely,
Your ___ HealthCare Team
Followup Instructions:
___
|
10013310-DS-17 | 10,013,310 | 22,098,926 | DS | 17 | 2153-07-21 00:00:00 | 2153-07-21 18:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Excedrin Migraine / Fluzone / glyburide / ibuprofen /
metformin / tizanidine
Attending: ___
Chief Complaint:
Right-sided weakness, aphasia
Major Surgical or Invasive Procedure:
Mechanical thrombectomy
PEG
History of Present Illness:
___ is a ___ woman ___
speaking with a history of diabetes, dilated cardiomyopathy,
hypertension, hyperlipidemia who presented initially to an
outside hospital with acute onset right-sided weakness and
aphasia.
And most of it is provided by EMS run sheets as well as the
history is limited, outside hospital records. Patient was
otherwise last known well at 0835 this a.m. when she was talking
on the phone with a relative. She got off the phone at that
time. Unclear how she was discovered, however she was noted to
have right-sided weakness right facial droop, and a aphasia.
She
was initially taken to an outside hospital. Initial ___ stroke
scale was 27 for the findings as above. She was given TPA at
1005, after CT confirmed no hemorrhage. Initial blood pressures
were less than 110. She was subsequently transferred to ___
for consideration for endovascular clot retrieval.
Per daughter, the patient lives alone without assistance.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
-Nonischemic cardiomyopathy (LVEF ___
3. OTHER PAST MEDICAL HISTORY
-Chronic low back pain
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAMINATION:
======================
General: Drowsy but awakens to voice
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Eyes open to voice. Does not follow commands.
no spontaneous speech output
- Cranial Nerves: PERRL 3->2 brisk. There is significant left
gaze deviation but the patient is able to cross her eyes to the
right. There is right facial droop. Visual fields difficult to
assess, no significant blink to threat on either side.
- Sensorimotor: Left upper extremity is antigravity for at least
10 seconds. Left lower extremity briskly withdraws to noxious
but does not clearly give good antigravity effort. Right lower
extremity withdraws slightly against gravity to noxious. Right
upper extremity slightly withdraws off of the bed to noxious.
- Reflexes: Plantar response flexor bilaterally
- Coordination/gait deferred
DISCHARGE PHYSICAL EXAMINATION:
===============================
GENERAL: Elderly female sitting in chair, NAD.
HEAD: NC/AT. Leftward gaze preference.
NECK: Supple.
CARDIAC: RRR, S1S2 w/o m/r/g.
RESPIRATORY: Normal effort, CTABL.
ABODMEN: Soft, NT, +BS.
EXTREMITIES: Warm, non-pitting edema of feet and lower shins,
intact pulses.
NEUROLOGIC: Moves limbs spontaneously.
Pertinent Results:
ADMISSION LABS:
===============
Labs:
___ 06:35AM BLOOD WBC:12.2* RBC:4.23 Hgb:10.0* Hct:33.3*
MCV:79* MCH:23.6* MCHC:30.0* RDW:18.8* RDWSD:52.8* Plt Ct:282
___ 06:35AM BLOOD Glucose:319* UreaN:47* Creat:1.2* Na:156*
K:4.0 Cl:113* HCO3:27 AnGap:16
___ 06:35AM BLOOD Calcium:8.7 Phos:2.1* Mg:2.8*
___ 02:12PM BLOOD Type:ART pO2:81* pCO2:35 pH:7.49*
calTCO2:27 Base XS:3 Intubat:NOT INTUBA
___ 01:28PM TSH-2.6
___ 01:28PM %HbA1c-8.6* eAG-200*
___ 01:28PM TRIGLYCER-151* HDL CHOL-42 CHOL/HDL-2.5
LDL(CALC)-35
DISCHARGE LABS:
===============
___ 06:33AM BLOOD WBC-6.9 RBC-4.36 Hgb-9.6* Hct-33.3*
MCV-76* MCH-22.0* MCHC-28.8* RDW-20.3* RDWSD-54.4* Plt ___
___ 06:33AM BLOOD Glucose-322* UreaN-36* Creat-1.0 Na-138
K-4.7 Cl-93* HCO3-29 AnGap-16
MICROBIOLOGY:
=============
___ URINE URINE CULTURE-FINAL NEG
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEG
URINE (___)
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
IMAGING:
========
CHEST XRAY (___)
Left lower lobe atelectasis has improved substantially. Small
bilateral pleural effusions are smaller. Moderate to severe
cardiomegaly and pulmonary vascular engorgement have both
improved. No pulmonary edema. No pneumothorax. Compared to
previous chest radiographs
TTE (___)
Mild to moderately dilated left ventricle with severe global
hypokinesis. No intracardiac thrombi identified (cardiac MRI may
be more specific for left ventricular thrombi and TEE for left
atrial appendage thrombus if this would change clinical
management). Severe mitral regurgitation. At least moderate
tricuspid regurgitation. Moderate to severe pulmonary
hypertension.
MR HEAD W/O CONTRAST (___)
1. Acute infarction involving the left MCA territory, ASPECTS of
1. There is involvement of the left occipital lobe. Evidence
of cortical micro hemorrhage on gradient images only within the
parietal, occipital, and temporal lobe. No evidence of
parenchymal hematoma
2. Chronic small right frontal lobe infarct.
LIVER OR GALLBLADDER US (___)
Unremarkable abdominal ultrasound.
CHEST (PORTABLE ___
Moderate cardiomegaly is chronic. Large heart obscures the left
lower lobe where there is at least some atelectasis. Lateral
view would be helpful to decide if there is pneumonia, and to
assess pleural effusions probably small to moderate on both
sides. No pulmonary edema. Pulmonary vasculature mildly
engorged.
___ UNILAT LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CXR
IMPRESSION:
Small bilateral pleural effusions and mild pulmonary edema.
___ ___
IMPRESSION:
Stable distribution of infarcts, with large left MCA late
subacute to chronic infarct, with areas of predominant cortical
mineralization, with possible smaller components of cortical
microhemorrhage, and interval volume loss. There is no gyral
expansion or edema. There is no parenchymal hematoma
Brief Hospital Course:
BRIEF SUMMARY:
==============
Ms. ___ is a ___ ___ speaking woman
with a history notable for IDDM, HTN, HLD, recent MI s/p stent
(___), and HFrEF (EF=20%)transferred from ___
after presenting with right-sided weakness and altered mental
status (LKW ___ am ___. t-PA administered at OSH at 10:05 AM
prior to transfer to ___. On arrival to ___ angiogram
revealed occlusion of the left MCA at the M2 bifurcation,
followed by mechanical thrombectomy with TICI 2b reperfusion of
the left MCA territory after 3 passes at 11:00 AM. Following
admission to Neuro ICU, exam was notable for somnolence and
bradypnea, prompting NCHCT that revealed diffuse left MCA
hyperdensity likely related to contrast administration.
Follow-up MRI 24 hours after t-PA administration revealed
microhemorrhages within the infarct bed affecting the parietal,
occipital, and temporal lobes. Given patient's recent MI s/p
DES, dual antiplatelets were subsequently resumed. ICU course
otherwise notable for period of sinus tachycardia, ascribed to
beta blocker withdrawal effect and somewhat improved on resuming
home metoprolol dose, as well as pulmonary edema which responded
to IV furosemide. She was transferred to the floor. Floor course
complicated by aspiration PNA requiring antibiotic treatment &
hyperglycemia requiring frequent adjustments in insulin regimen.
PEG placed ___ for long-term nutrition.
TRANSITIONAL ISSUES:
===================
[ ] CRITICAL TO DO: Please follow this insulin regimen, as
patient has been prone to significant hyperglycemia:
[ ] NPH 60U given at 7PM (NEEDS TO BE GIVEN EXACTLY 1 HOUR
BEFORE TUBE FEEDS ARE GIVEN)
[ ] Sliding scale at breakfast, lunch, dinner, and before
bedtime as written.
[ ] Fasting sugar should be checked before each meal & sliding
scale insulin should be administered based on this sugar value.
[ ] If fasting sugar is > 400 or < 70 please call the MD on call
to review insulin regimen.
[ ] If tube feeds are held, start D10 at same rate of tube feeds
[ } CRITICAL FOLLOW-UP: Needs ongoing titration of insulin
regimen. Please arrange follow up with her endocrinologist Dr.
___ who is her primary endocrinologist for many years
(daughter will arrange appointment). Pt used to be on Victoza in
the past and per daughter she had achieved good glycemic control
on that. Victoza is an outapatient treatment to consider if her
hyperglycemia cannot be controlled despite titration of insulin
doses.
[ ] Diuretic regimen: torsemide 40mg BID, D/C Weight: 65.1 kg,
143.52 lb on standing scale. Please weigh daily and call MD if
change in weight by 3 lbs.
[ ] CAD regimen: aspirin 81mg daily, clopidogrel 75mg daily,
rosuvastatin 40mg daily, isosorbide dinitrate 10mg 3x/day,
metoprolol succinate 150mg daily
[ ] D/C diet: pureed solids w/ nectar pre-thickened liquids &
aspiration precautions
[ ] Tube feeds as written
Continuous tubefeeding: Start ___ Glucerna 1.5 Cal; Full
strength
Tube Type: Percutaneous gastrostomy (PEG); Placement confirmed.
Starting rate: 90 ml/hr; Do not advance rate Goal rate: 90 ml/hr
Cycle?: Yes Cycle start: ___ Cycle end: 0800
Residual Check: Q4H Hold feeding for residual >= : 200ml
Flush w/ 30 mL water Per standard
Free water amount: 50 mL; Free water frequency: Q6H
ISSUES ADDRESSED:
=================
# Left MCA stroke:
MRI: "Acute infarction involving the left MCA territory. There
is involvement of the left occipital lobe. Evidence of cortical
microhemorrhage on gradient images only within the parietal,
occipital, and temporal lobe. No evidence of parenchymal
hematoma. Chronic small right frontal lobe infarct." Received
t-PA administration & mechanical thrombectomy. Suffered residual
deficits and required daily work w/ ___ & OT. Has Neurology f/u
___.
# Aspiration PNA c/b sepsis, resolved:
# Recurrent aspiration:
___ placed for TF. PEG ___. On medical floor, febrile w/
leukocytosis. Initial concern for UTI, started on empiric
amp-sulb ___. CXR suspicious for aspiration PNA, switched to
vancomycin and ceftriaxone. Ceftriaxone changed to ceftazidime
___, course was completed on ___. Repeat aspiration PNA w/
diet advancement required further treatment w/ ceftazadime for
course completed ___. No further PNA or anti-infectives since
that time. On d/c, PEG in place, diet on d/c pureed solids w/
nectar pre-thickened liquids & aspiration precautions w/ plans
to advance as tolerated at rehab.
# IDDM:
Hospital course complicated by hyperglycemia and difficult
control given intermittent tube feeds & NPO status. ___
followed.
# HFrEF, last EF 20% ___: Home diuretic is torsemide 20mg
BID, she suffered fluid overload when on ICU service & required
IV diuretics. Maintained on furosemide 40mg PO QD until appeared
overloaded on exam w/ lower extremity edema ___. Weight noted
to be 10-lb increased from ___ (no weights charted in
between). She was diuresed w/ furosemide 40mg IV (___)
w/ adequate response but creatinine increased to 1.2 on ___
(from baseline 0.9). Diuresis was held ___ given creatinine
increase to 1.2, creatinine remained @ 1.2 by ___, gave gentle
hydration w/ improvement in creatinine to 1.0 ___.
-Preload: D/c diuretic torsemide 40mg BID, d/c weight 65.1 kg,
143.52 lb.
-Afterload: Did not initiate b/c of previous attempts w/
hyperkalemia.
-NHBK: Was on metoprolol tartrate 25mg Q6H, increased to
metoprolol tartrate 37.5mg PO Q6H given ST, plan to continue w/
metoprolol succinate 150mg daily on d/c.
-Inotropy: None.
# CAD s/p recent RCA STEMI with DES: Continued DAPT + statin +
BB & isosorbide dinitrate.
# Normocytic anemia: Stable, monitored H/H, did not require
transfusions.
# Glaucoma: Continued home eye drops.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspart 10 Units Breakfast
Aspart 10 Units Lunch
Aspart 10 Units Dinner
Glargine 20 Units Bedtime
2. Torsemide 20 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO QPM
6. Isosorbide Dinitrate 10 mg PO TID
7. Clopidogrel 75 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. Omeprazole 40 mg PO BID
10. Metoprolol Succinate XL 75 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
13. Tizanidine 2 mg PO Q8H:PRN muscle spasm
14. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
15. Lidocaine 5% Patch 3 PTCH TD QAM
16. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
Discharge Medications:
1. Metoprolol Tartrate 150 mg PO DAILY
2. Multivitamins W/minerals Liquid 15 mL PO DAILY
3. NPH 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 150 mg PO DAILY
5. Aspirin EC 81 mg PO DAILY
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
7. Clopidogrel 75 mg PO DAILY
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
9. Isosorbide Dinitrate 10 mg PO TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Rosuvastatin Calcium 40 mg PO QPM
12. Torsemide 40 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Omeprazole 40 mg PO BID This medication was held. Do
not restart Omeprazole until until directed by your phsyician.
15. HELD- Tizanidine 2 mg PO Q8H:PRN muscle spasm This
medication was held. Do not restart Tizanidine until directed by
your physician.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Left MCA Stroke
___ Acquired Pneumonia
Insulin Dependent Diabetes
Coronary Artery Disease, s/p STEMI with DES
Acute on Chronic Systolic Heart Failure
Acute on Chronic Kidney Disease
SECONDARY DIAGNOSES
Chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___ and family,
It was a pleasure to care for you at the ___
___.
WHY WERE YOU ADMITTED:
-You had weakness on the right side of your body and trouble
speaking.
WHAT HAPPENED WHEN YOU WERE HERE:
-We found you had a stroke. We gave you medication to dissolve
the clot and you had a procedure to remove it too.
-You had an infection in your lungs that we treated with
antibiotics.
-We put a feeding tube in your stomach because we found you were
unable to swallow food safely.
WHAT SHOULD YOU DO WHEN YOU LEAVE:
-Please take all of your medications as below.
-Please make sure to follow up with your cardiologist for
ongoing monitoring of your heart at the appointment listed
below.
-Please weigh yourself or have someone weigh you every morning
on a standing scale. If your weight changes by 3 pounds then
call your doctor because this might mean you are gaining too
much fluid in your body.
-If you notice worsening shortness of breath, chest pain, leg
swelling, dizziness, or any other symptoms that concern you
please let us know right away.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10013502-DS-19 | 10,013,502 | 23,404,838 | DS | 19 | 2159-01-02 00:00:00 | 2159-01-03 10:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Foot ulcer pain and fever.
Major Surgical or Invasive Procedure:
___ line placement.
History of Present Illness:
Mr. ___ is a ___ male with DMII, Afib on coumadin
(cardioverted in ___, HTN, and obesity here with fevers and
diabetic foot ulcer. Patient noted this ulcer on the plantar
aspect of his right foot two weeks ago after he pulled off some
dead skin in that area. He has no feeling in either foot but has
noted increase pain over his baseline. He went to his podiatrist
(Dr. ___ at ___ 3 days prior to admission for some
bothersome ulcers on L toe when podiatrist noted this wound and
some associated red streaks extending up the foot. He debrided
the wound and started patient on Augmentin. Wound culture
reportedly sent at that time to patient's PCP at ___. The night
prior to admission, patient woke up with fever to 101 and has
been feeling generally unwell since debridement. The wound had
been draining some yellow pus.
In the ER, initial vitals 7 97.6 108 133/78 18 95% RA. Labs
notable for WBC 12.7 (66%N), ESR 23, CRP 7.5, lactate and Chem 7
normal. Foot XR showed no clear evidence of osteo. Blood
cultures were sent and he received vanc and unasyn.
Currently, patient has mild bilateral foot pain related to his
neuropathy.
REVIEW OF SYSTEMS:
(+) Per HPI dry cough, chronic abdominal pain and diarrhea
(-) Denies weight change, Denies headache, shortness of breath,
or wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies vomiting. Denies dysuria, frequency, or
urgency.
Past Medical History:
Neuropathy
Insomnia
Hypercholesteremia
Hypertension
DM (diabetes mellitus) type II
Atrial fibrillation s/p cardioversion ___
Social History:
___
Family History:
Mother had a large MI at age ___ and died from cancer/heart
failure at age ___. Uncle had an MI in his late ___. Father's hx
unknown.
Physical Exam:
EXAM ON ADMISSION:
VS: 97.8 124/68 92 18 96%RA 147.7kg
GENERAL: well appearing obese man in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, no JVD
LUNGS: +scattered wheezes bilat, no rales, resp unlabored, no
accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-distended, no rebound or
guarding, no masses, mild ttp over upper abdomen b/l
EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R
than L, numb feet b/l, 2cm in diameter shallow clean-based round
ulcer on plantar surface of R foot w/some faint red streaking to
dorsal surface of foot, two bandaged toes on L
EXAM ON DISCHARGE:
VS: 97.6 140/83 ___ 97%RA ___ 185
GENERAL: well appearing obese man in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, no JVD
LUNGS: clear to auscultation bilaterally, no rales, resp
unlabored, no accessory muscle use
HEART: regular, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, obese, non-distended, no rebound
or guarding, no masses
EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R
than L, numb feet b/l, 2cm in diameter shallow clean-based round
ulcer on plantar surface of R foot w/no erythematous streaking,
previous marks of streaking to dorsal surface of foot now
resolved, L toe lesions without erythema or purulence
Pertinent Results:
Labs on Admission:
___ 06:05PM BLOOD WBC-12.7* RBC-5.03 Hgb-15.2 Hct-44.8
MCV-89 MCH-30.3 MCHC-34.0 RDW-12.6 Plt ___
___ 06:05PM BLOOD Neuts-66.6 ___ Monos-5.5 Eos-1.5
Baso-0.7
___ 06:05PM BLOOD ESR-23*
___ 06:05PM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-16
___ 06:22PM BLOOD Lactate-1.6
___ 08:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.3*
___ 08:10AM BLOOD ALT-26 AST-27 AlkPhos-78 TotBili-0.5
___ 08:10AM BLOOD ___ PTT-42.0* ___
Labs on Discharge:
___ 02:35AM BLOOD WBC-6.2 RBC-4.59* Hgb-13.9* Hct-41.1
MCV-90 MCH-30.3 MCHC-33.9 RDW-12.3 Plt ___
___ 02:35AM BLOOD ___ PTT-38.9* ___
___ 02:35AM BLOOD Glucose-187* UreaN-10 Creat-0.9 Na-137
K-4.6 Cl-100 HCO3-27 AnGap-15
___ 02:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7
___ 02:35AM BLOOD Vanco-10.5
___ Blood cultures pending.
XR FOOT AP,LAT & OBL RIGHT Study Date of ___:
Soft tissue ulcer along the plantar and lateral aspect of the
foot at the
level of the midshaft of the metatarsals. No subcutaneous gas or
definite radiographic evidence for osteomyelitis. Please note
that MRI or bone scan is a more sensitive exam for the detection
of osteomyelitis.
CXR ___:
Low lung volumes, no pleural effusions. No parenchymal
abnormality, in particular no evidence of pneumonia. Borderline
size of the cardiac silhouette without pulmonary edema. No hilar
or mediastinal
abnormalities.
Brief Hospital Course:
___ with DMII c/b neuropathy here with a foot ulcer and fever.
.
# Neuropathic Foot ulcer: Despite debridement by podiatry and
oral antibiotics as an outpatient, patient developed fever and
cellulitis concerning for resistant organism. Wound culture from
OSH shows only skin flora ___ strep, diptherioids) but
the patient reports a history of MRSA ulcer infection. Wound had
some lymphangitic spread on admission but resolved with
vanc/unasyn, now on vanc/augmentin. Low levels of inflammatory
markers (see results) and foot XR without e/o osteomyelitis make
this unlikely. Patient has good pulses. Podiatry recommended wet
to dry betadine dressings and f/u with outpatient podiatry
provider. Has been afebrile throughout admission. Has PICC for
continued vanc/augmentin to complete total ___s
outpatient. Vanc trough 10.5 (therapeutic).
.
# Afib: Missed coumadin dose ___ night of admission; INR
___ -> ___ -> ___, below goal INR of ___. Was
cardioverted in ___, regular rate and rhythm on exam.
Continued coumadin and beta blocker. Patient will follow up in
___ clinic ___ to follow-up INR.
.
# Abdominal pain: Mild on admission and seemed resolved during
admission. On last admission, pt was felt to have diverticulitis
but current pain is located in the mid-epigastrium so
differential more likely to include gastritis, GERD,
gastroparesis, gallstones. Per patient he also has associated
chronic diarrhea. LFTs/lipase unremarkable ___.
.
# DM2: continued home insulin regimen and restarted metformin on
day prior to discharge. HgbA1c 8.5.
# HL: continued statin.
# HTN: continued BB, ACEi.
.
## Transitional Issues ##
1. pending studies at discharge - blood cx's drawn ___, no
growth to date, final pending
2. complete course of antibiotics for cellulitis with IV
Vancomycin and PO Augmentin for total 7 day course (___)
3. f/u with outpt podiatrist for 5 metatarsal base resection
4. f/u with ___ for INR monitoring and
Coumadin adjustment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Glargine 56 Units Breakfast
Glargine 30 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
3. Metoprolol Tartrate 100 mg PO BID
HOLD for SBP < 100, HR < 60
4. Warfarin 8.75 mg PO 2X/WEEK (MO,FR)
5. Lisinopril 10 mg PO DAILY
HOLD for SBP < 100
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain
8. Vitamin D 800 UNIT PO DAILY
9. Warfarin 10 mg PO 5X/WEEK (___)
10. Clonazepam 1 mg PO QHS:PRN insomnia
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Clonazepam 1 mg PO QHS:PRN insomnia
3. Glargine 56 Units Breakfast
Glargine 30 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Vitamin D 800 UNIT PO DAILY
7. Warfarin 8.75 mg PO 2X/WEEK (MO,FR)
8. Warfarin 10 mg PO 5X/WEEK (___)
9. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 750 mg 1500 mg(s) IV every twelve (12) hours Disp
#*20 Vial Refills:*0
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Neuropathic Diabetic Foot Ulcer c/b cellulitis
Seconadry Diagnosis:
Atrial Fibrillation s/p Cardioversion
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for treatment of cellulitis complicating an ulcer on your right
foot. You were started on antibiotics to treat this infection.
Your infection appears markedly improved and you are now safe to
return home.
You missed your ___ evening warfarin dose. Your INR was 1.6
(below your goal of ___ for two days (on ___ and ___. Please
follow up in ___ clinic and have your INR checked again on
___, they are aware and will be expecting you.
We made the following changes to your medication:
Please START Vancomycin
Please CONTINUE Augmentin
Followup Instructions:
___
|
10013502-DS-21 | 10,013,502 | 25,788,312 | DS | 21 | 2161-05-16 00:00:00 | 2161-05-16 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity stump infection.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history signficiant for
diabetes and neuropathy with right BKA who now presents with
purulent wound on stump.
BKA was performed ___ due to diabetic foot infection and
was well-healed and he was ambulating with a prosthesis. First
noticed stump swelling ___, went to ___ ED on ___
and was admitted for cellulitis, treated with IV abx and
discharged ___ on Bactrim. Went to wound clinic
at ___ ___ and was admitted for I&D at the
bedside and antibiotics, discharged ___. Wound was treated
with wicks and dry dressings. Again seen at ___ wound ___
___ and admitted ___ at ___, no surgical intervention,
again discharged on Bactrim. He has since been seen twice at
___ for followup assessment and wound care.
Inciting incident is unclear, although patient thinks it may be
due to a new carbon fiber prosthesis he has been using since
shortly before his problems began.
Past Medical History:
PMH:
- Neuropathy
- Insomnia
- Hypercholesteremia
- Hypertension
- Type II diabetes mellitus with neurological manifestations
- Chronic pain syndrome
- Pain medication agreement
- Adenomatous colon polyp
- S/P R BKA (below knee amputation) unilateral
- Diabetic ulcer of left foot
- MRSA cellulitis
- 1 episode of Afib resolved with cardioversion
PSH:
- R BKA
- I&D of wound above R BKA at bedside
- L shoulder surgery
- Open appendectomy (pediatric)
- Tonsillectomy (pediatric)
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP 144/80 HR 82 RR 16
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left Femoral palp, DP palp ,___ palp
Right Femoral palp,
Right anterior stump wound: 8 cm length x 1 cm maximal width x
superficial depth. Wound bed pink with no slough or necrosis.
Periwound area is red but no surrounding erythema.
Pertinent Results:
CT Right lower extremity
Thick periosteal reaction about the distal tibia and fibula
amputation
site. No cortical erosion or aggressive appearing periosteal
reaction. If there is concern for osteomyelitis, MRI can be
performed.
Soft tissue edema and fluid. About the amputation site without
absent
soft tissue abscess.
___ 07:15AM BLOOD WBC-5.9 RBC-4.25* Hgb-12.1* Hct-36.5*
MCV-86 MCH-28.5 MCHC-33.2 RDW-12.8 RDWSD-39.5 Plt ___
___ 07:05AM BLOOD Glucose-207* UreaN-10 Creat-1.0 Na-139
K-4.5 Cl-100 HCO3-28 AnGap-16
___ 07:05AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8
___ 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr. ___ is a ___ man with history signficiant for
diabetes and neuropathy with right BKA who now presents from PCP
office with purulent wound on stump.
BKA was performed ___ due to diabetic foot infection and
was well-healed and he was ambulating with a prosthesis. First
noticed stump swelling ___, went to ___ ED on ___
and was admitted for cellulitis, treated with IV abx and
discharged ___ on Bactrim. Since that time, he has had 2
admissions of short course IV antibiotics with return of
cellulitis when transitioned to an appropriate oral coverage for
his cultured MRSA at an OSH. Of note MRI at OSH was negative
for osteo andour CT showed no fluid/abscess at the site.
He was treated initially with IV vanco/cipro and flagyl and the
drainage and erythema quickly resolved. We open the wound at the
bedsite to facility drainage and wound packing but the wound is
superficial and does not tract. On the day prior to discharge,
we transitioned to oral clinda and augmentin with no return of
the erythema. We are concerned that the proximity of the bone
to the wound as seen on CT may be problematic for prothesetic
use.
We plan to follow him closely as an outpatient. He is discharged
to a friends house having declined to go to ___
transtional care house.
Medications on Admission:
- Percocet, ___, 1 tab Q4H PRN
- Oxybutynin ER 5'
- Gabapentin 900 mg TID
- Metformin 1,000''
- Aspirin 81'
- Vitamin D3 1,000u'
- Atorvastatin 20'
- Lisinopril 20'
- Metoprolol tartrate 100''
- Insulin Glargine 64 Units subcutaneously daily
- Insulin Aspart (NOVOLOG FLEXPEN) sliding scale
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Clindamycin 450 mg PO Q6H
5. Gabapentin 900 mg PO TID
6. Glargine 64 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Tartrate 100 mg PO BID
9. Lisinopril 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Oxybutynin 5 mg PO BID
12. Docusate Sodium 100 mg PO BID
HOLD FOR LOOSE STOOLS
13. Senna 8.6 mg PO BID:PRN constipation
14. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
not to exceed 8 tabs/day.
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
Right lower extremity stump infection.
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital with an right lower extrmity
stump wound with surrounding redness and infected appearing
drainage. Although there was no fever or other signs of
infection like elevated white blood cell count, we admitted you
to the hospital as this has been a reoccuring problem despite
oral antibiotics. You were started on IV antibiotics which
stopped the drainage and redness. We need a CT scan that showed
no pockets of fluid or infection. We then opened the area at
the skin to allow drainage and packing of the wound. You were
transitioned to oral antibiotics on the day prior to discharge
with little change in the appearance of your wound. We will now
follow you now very closely as an outpatient in the clinic.
Followup Instructions:
___
|
10013569-DS-10 | 10,013,569 | 27,993,048 | DS | 10 | 2167-12-25 00:00:00 | 2167-12-25 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Morphine / Codeine / Demerol / Iodine-Iodine
Containing
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
R thoracentesis
Right heart cath x2
Swan placement and removal x2
PICC line placement and removal
History of Present Illness:
___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p
renal transplant in ___, type 1 diabetes, CAD, hld, and recent
admission at ___ for CHF and possible RLL pneumonia, d/c on
___, recent admission to ___ for CHF exacerbation, now
representing with dyspnea, hypoxia, concern for CHF
exacerbation.
A summary of recent medical history is as follow: on ___ she
presented to ___ in ___ for CHF
exacerbation (BNP of 8265). Diuresis was limited due to change
in cr from 1.4 to 2.0 after several days of diuretics. OSH
report Pt was 100.7 kg on admission on ___ kg on
discharge on ___. She was discharged on torsemide 40mg po bid
(was on furosemide 120mg po qam and 80mg po qpm) and
spironolactone 25mg po bid (new). At home she has had worsening
dyspnea despite taking medications as prescribed. She reports
increasing edema, dyspnea, orthopnea. Pt denies fevers, chest
pain, cough, any myalgias. On admission ___ pt found to have
BNP 10902, CXR suggestive of volume overload w/ R pleural
effusion. She was diuresed with lasix 80mg IV for a few doses
and then discharged on PO torsemide 60mg qam and 40mg qpm with
plans to follow-up ___ outpt cardiologist for TTE showing
worsening EF (30->25%).
Pt now complaining that ___ night she started having SOB,
wheezing, and suprapubic pressure. She used nebs which helped
but did not completely resolve the pain. ___ came yesterday and
wanted to send the pt to her PCP, however she became very
dyspneic and fatigued, couldn't move her arms. The husband
called ___ and she was taken to ___ where the pt
had a u/a which was clean, BNP 12449. Unclear from paperwork
what was done for her there. She was transferred to ___ ED.
The pt was transferred to ___ and initial vitals in the ED
were 98.0 80 127/85 20 98% 2L. Labs revealed a K of 5.7, BUN/Cr
44/1.4, trop 0.02 and a BNP 11008. Her CXR prelim read was
significant for large right sided pleural effusion. She was
given furosemide 80 mg IV x1 but urine output was not recorded
due to difficulties measuring urine.
On the floor: 97.5 152/90 88 20 98%RA. The pt states she is
improved but not back to baseline. Pt denies medication
non-adherence, inc fluid intake or dietary indiscretion.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-CAD s/p CABG ___, s/p coronary angiography in ___ showing
native 3VD but patent vv grafts (2) and patent LIMA-LAD. T
-systolic CHF w/ EF 35-45% in ___
-pacemaker implanted, unclear type
-chronic kidney disease s/p transplant ___
-HTN
-hyperlipidemia
-PVD s/p b/l BKAs
-type 1 diabetes
-osteoporosis
-Peripheral neuropathy
Social History:
___
Family History:
-DM on mother's side.
Physical Exam:
On Admission:
VS: 97.5 152/90 88 20 98%RA
GENERAL: Hypervolemic, somewhat flat affect, setting in chair
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: R sided decreased breathsounds, no wheezes
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: firm, nontender, mildly distended, edematous
EXTREMITIES: bilateral BKA
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
On Discharge:
VS: Temp: 98.4/97.6 HR: 74-84, RR: 20, BP: 118-145/63-73, O2
sat: 100% RA
I/O:
24h: 1140/2150
8h: 300/100, BM x2
Wt: 83.9
Tele: a paced
___: ___
Gen: A&Ox3, pleasant, in NAD
HEENT: MM dry. OP clear. EOMI
NECK: Supple, No LAD. JVP difficult to assess
CV: RRR, no murmurs
LUNGS: air exchange symmetric, CTAB
ABD: NABS. Soft, NT, ND.
EXT: B/l BKA, trace thigh edema, trace left hand edema
Pertinent Results:
Admission labs:
___ 12:30AM BLOOD WBC-8.6 RBC-5.16 Hgb-13.2 Hct-44.7 MCV-87
MCH-25.5* MCHC-29.4* RDW-15.9* Plt ___
___ 12:30AM BLOOD Glucose-278* UreaN-44* Creat-1.4* Na-141
K-5.7* Cl-98 HCO3-28 AnGap-21*
___ 12:40AM BLOOD CK(CPK)-29
___ 12:30AM BLOOD ___
___ 07:45AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.2
___ 05:55AM BLOOD tacroFK-2.8*
Other Relevant Labs:
___ 12:30AM BLOOD ___
___ 12:30AM BLOOD cTropnT-0.02*
___ 07:45AM BLOOD CK-MB-5 cTropnT-0.01
___ 05:55AM BLOOD ___
___ 12:40AM BLOOD CK-MB-2 cTropnT-0.08*
___ 05:00AM BLOOD CK-MB-2 cTropnT-0.06*
___ 02:27PM BLOOD CK-MB-6 cTropnT-0.29*
___ 11:47PM BLOOD CK-MB-12* cTropnT-0.56*
___ 05:47AM BLOOD CK-MB-13* MB Indx-15.3* cTropnT-0.72*
___ 01:00PM BLOOD CK-MB-10 MB Indx-16.4* cTropnT-0.73*
___ 12:12AM BLOOD CK-MB-6 cTropnT-0.72*
___ 02:27PM BLOOD TSH-2.8
___ 05:55AM BLOOD Anti-Tg-LESS THAN Thyrogl-21
___ 03:30AM BLOOD ___
___ 05:45PM BLOOD RheuFac-11
___ 06:00AM BLOOD Digoxin-0.6*
Discharge Labs:
___ 06:20AM BLOOD WBC-6.1 RBC-4.16* Hgb-10.8* Hct-34.1*
MCV-82 MCH-25.9* MCHC-31.6 RDW-17.2* Plt ___
___ 06:20AM BLOOD Glucose-332* UreaN-102* Creat-2.2* Na-133
K-3.6 Cl-92* HCO3-25 AnGap-20
___ 06:20AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.1
>> Imaging:
___ CXR:
IMPRESSION: Enlarging right pleural effusion without pulmonary
edema. Recommend obtaining PA and lateral chest radiograph.
___ Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS.
___ Renal Transplant Ultrasound:
IMPRESSION:
Again the RIs are elevated compared to the previous examination
with diminshed diastolic flow. As well, there is increased peak
systolic velocity within the main renal artery.
CXR ___ IMPRESSION:
1. A left-sided pacemaker remains in place. A right subclavian
PICC line is unchanged. The right internal jugular Swan-___
catheter continues to be in the right pulmonary artery with the
tip somewhat distal and a pullback of 3-4 cm has been previously
conveyed to the house staff on ___ by Dr. ___,
but the position remains unchanged. The heart remains stably
enlarged. There has been some interval improvement in but there
is persistent mild pulmonary edema. No pneumothorax is seen.
No focal airspace consolidation is seen to suggest pneumonia.
There is likely a layering right effusion with patchy streaky
right basilar opacities likely reflectiing compressive
atelectasis.
___:
CARDIAC CATHETERIZATION:
COMMENTS:
1. Resting hemodynamics revealed elevated left and right-sided
filling
pressures. The RA pressure was elevated at a mean of 30 mmHg.
The mean
PA pressure was elevated at 46 mmHg. The wedge pressure was 30
mmHg.
2. The pulmonary artery oxygen saturation was low at 26%.
3. Cardiac index was 1.27 L/min/m2
FINAL DIAGNOSIS:
1. Severe pulmonary hypertension.
2. Marked elevation of the RA and PCW pressures.
3. Markedly reduced cardiac index.
4. Elevated PVR.
___:
ABD US: No ascites.
___:
RENAL TRANSPLANT US:
1. Elevated intrarenal artery resistive indices, unchanged from
___, with diminished or no diastolic flow. Increased peak
systolic velocity in the main renal artery, also unchanged.
2. Tiny right perinephric fluid is new from ___.
___ ___ BILATERAL: No evidence of bilateral lower extremity
DVT.
___:
CARDIAC CATHETERIZATION
COMMENTS:
1. Selective resting hemodynamics revealed markedly elevated
left sided
filling pressure with mean PCWP 32mmHg. Severe pulmonary
hypertension
with mean PA 55mmHg and PASP 85mmHg. Cardiac output was low
normal
while on milrinone and dopamine infusions with arterial
oxygenation
obtained from pulse oximeter and assumped oxygen consumption.
FINAL DIAGNOSIS:
1. Markedly elevated left sided filling pressures.
2. Severe pulmonary hypertension (predominantly secondary to
left sided
pressures).
3. Low normal cardiac output while on milrinone and dobutamine
infusions.
>> Micro:
BCX ___: neg
___ 3:58 pm URINE Source: Catheter.
URINE CULTURE (Final ___:
GRAM POSITIVE COCCUS(COCCI). ~5000/ML.
___ 1:33 pm PLEURAL FLUID PRO BNP.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 5:54 pm URINE Source: ___.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
___ 5:20 pm URINE Source: ___.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
(___).
.
___ 9:45 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated. Culture screened for
Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and
Respiratory Syncytial Virus..Detection of viruses other than
those listed above will only be performed on specific request.
Please call Virology at ___ within 1 week if
additional testing is needed.
Respiratory Viral Antigen Screen (Final ___: Negative for
Respiratory Viral Antigen. Specimen screened for: Adeno,
Parainfluenza 1, 2, 3, Influenza A, B, and RSV by
immunofluorescence. Refer to respiratory viral culture for
further information.
___ 11:32 pm URINE Source: ___.
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
UCX ___: negative
___ 6:00 pm CATHETER TIP-IV Source: right PICC .
WOUND CULTURE (Preliminary): No significant growth.
Brief Hospital Course:
___ woman w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p
renal transplant in ___, type 1 diabetes, CAD, hld, and recent
admission at OSH for CHF and possible RLL pneumonia, d/c on
___, recent admission ___ for the CHF exacerbation, and
presenting to ___ with worsening SOB and hypervolemia.
# Acute on chronic systolic CHF: Pt presented with dyspnea
likely flash pulmonary edema with unclear precipitant. Dyspnea
exacerbated by R pleural effusion. Symptoms improved with
diuresis, and with R thoracentesis with 1150cc fluid removed
___ have potential component of undiagnosed OSA she had
worsening hypoxia at night. Patient was initially aggressively
diuresed with IV lasix. However, patient developed fever and
hypotension on ___, so diuresis was discontinued (both lasix
and spironolactone). Patient remained very volume overloaded on
physical exam, and her creatinine worsened. The heart failure
service was consulted, she received right heart catheterization
___, which showed depressed cardiac index (1.2-1.9) and
elevated biventricular pressures as well as elevated PA
pressure, and she and was transferred to the CCU further
management with a swan in place. In the CCU, she was started on
milrinone and dopamine for inotropic support, and lasix drip for
diuresis. Her CI improved to > 2, however on ___ she was
found unresponsive in PEA after returning from the commode. She
has ROSC after 1 min of CPR, and then had evidence off unstable
A.fib/SVT. Dopamine and lasix were held temporarily, and were
restarted once she spontaneously converted to sinus rhythm. The
episode was attributed to vasovagal response and amiodarone was
subsequently discontinued without recurrence of atrial
fibrillation. She also received Metolazone 5mg BID to augment
diuresis; also acetazolamide. Her beta blocker, ACE-I, and
spironolactone were held in the setting of hypotension.
Pulmonary was consulted for evaluation of lung disease and
pulmonary hypertension and recommended above treatment and
outpatient PFTs. Dopamine weaned ___, lasix gtt weaned and
transitioned to PO torsemide ___, milrinone also weaned. Called
out ___. Coreg had been restarted. Digoxin started ___ for
inotropy. Her last CVP prior to removal of central line was 10.
Her creatinine subsequently rose to >3 on the floor on PO
torsemide so RHC repeated ___ which demonstrated markedly
elevated left sided filling pressures, severe pulmonary
hypertension, and low normal cardiac output while on milrinone
and dopamine infusions. She was transferred back the CCU where
she was continued on dopamine, milrinone and lasix drips with
___ again in place. Coreg discontinued and not restarted. Pt
diuresed for multiple days on this regimen and then milrinone
gtt was weaned. Swan was again discontinued and lasix gtt
stopped and transionted to PO torsemide. Pt called out to the
floor and dopamine subsequently weaned and discontinued. Pt's
creatinine remained stable off inotropic support. I/Os remained
even. When milrinone weaned off, hydralazine was uptitrated for
afterload reduction. Imdur continued at 60. As dopamine weaned,
hydral uptitrated further and Imdur subsequently uptitrated as
well. Spironolactone subsequently restarted. Prior to ___ CCU
transfer, Palliative care was consulted due to difficulty
managing pt's heart failure as it seemed pt may be inotrope
dependent in order to support renal functinon. Pt had multiple
meetings with the palliative care team to discuss such topics
and plan for future as prognosis relatively poor.
# Acute on chronic renal failure: Patient is s/p renal
transplant. Cr baseline 1.3-1.5. Pt with fluctuating renal
function during long hospital course. Initial ___ prior to ___
CCU transfer (Cr up to 3.4) thought ___ cardiogenic
hypoperfusion vs. infection/poor PO intake vs ATN in setting of
hypotension. Transplant US (___) showed increased resistive
index in the renal artery. FEUrea 18.3%, suggesting etiology was
pre-renal. She was treated with milrinone, dopamine, furosemide,
and Metolazone to augment urine output. Her ACE-I was held in
the setting of ___. She was continued on mycophenolate mofetil
and her tacrolimus was continued at goal trough of ___
initially. Pt's renal function improved on inotropic support and
with lasix gtt. Cr improved to 1.8-2. Cr again rose to 3.2 on PO
torsemide and pt subsequently returned on CCU on inotropic
support. Cr improved to 2 range and was maintained as this level
after wean of inotropes. At the time of discharge, her Cr was
2.2. Tacro levels were monitored through the admission at the
direction of Transplant Nephrology. Prior to discharge
Transplant Nephrology recommended increasing the dose of
tacrolimus. The patient will have tacro levels drawn by ___
after discharge.
# UTIs: Pt with fever and hypotension on ___, started on
vanc/cefepime. Found to have ucx +enterococcus (___). CXR
unchanged from prior. Bcx without growth. No diarrhea to raise
concern for cdiff. +Myalgias concerning for flu, but DFA was
negative for influenza. Pt initially started on vanc/cefepime,
but when urine culture came back she was started on ampicillin
for 7 day course for complicated UTI until ___. The patient
developed an additional pansensitive Klebsiella UTI during this
hospitalization. She was initially treated with ceftriaxone and
later switched to cefpodixime (___).
# Hyponatremia, resolved: Pt with intermitent hyponatremia,
hypervolemic in nature from CHF. Pt s/p tolvaptan ___. On day of
discharge Na was 133.
# New AFib, resolved prior to discharge: She was found to have
afib with RVR after her brief PEA on ___, and converted
spontaneously to sinus rhythm. She was treated with amiodarone
(loading IV, converted to PO load), which was subsequently
discontinued after no recurrent episodes of afib. She was also
started on a heparin bridge to coumadin, which also discontinued
after no recurrent episodes of afib.
# Hypertension: During this hospital stay lisinopril was held
due to ___. Carvedilol was held in the setting of hypotension
and inotrope use. Imdur and Hydralazine were used for afterload
reduction and the patient was normotensive on these medications.
# Type 1 Diabetes: Highly variable insulin regimen. Pt uses
___ levemir qhs plus tid sliding scale. Was getting 70 U
levemir at OSH but pt states this was causing severe
hypoglycemia. Due to persistent poor glycemic control per
patient's dictated regimen, ___ was consulted, and
recommended BID Lantus and humalog insulin sliding scale. Pt's
insulin regimen generally changed on a daily basis per ___
recommendations. Although there were attempts to control FSG
with BID lantus dosing the patient was eventually transition to
levemir (her home medication) along with ISS prior to discharge.
# Pulmonary Hypertension: Pulmonary consulted during CCU stay
and have no further recs. Recommend PFT's as outpatient.
# CAD s/p CABG: Continued home pravastatin, aspirin 81 daily.
# Back pain, chronic: Continued home tramadol. Added lidoderm
patch for better control of pain.
# GERD: Continued home pantoprazole.
# Neuropathy: Home dose of gabapentin was uptitrated during this
admission.
TRANSITIONAL ISSUES:
# CODE: Full, confirmed
# CONTACT: husband ___ ___.
# Dry Weight 73kg
- Please perform follow-up PFTs as outpatient to further
evaluated pulmonary HTN
- Please consider sleep study given evidence of night-time
hypoxia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
hold for sbp < 90 or HR < 60
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp < 90
4. Mycophenolate Mofetil 500 mg PO QAM
5. Mycophenolate Mofetil 1000 mg PO QPM
6. Pantoprazole 40 mg PO Q12H
7. Pravastatin 80 mg PO DAILY
8. Spironolactone 25 mg PO BID
hold for sbp < 90
9. Tacrolimus 0.5 mg PO Q12H
10. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Gabapentin 1200 mg PO HS
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
15. Vitamin D 50,000 UNIT PO MONTHLY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
2. Aspirin 81 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg three tablet(s) by mouth daily
Disp #*90 Tablet Refills:*2
5. Mycophenolate Mofetil 500 mg PO QAM
6. Mycophenolate Mofetil 1000 mg PO QPM
7. Pantoprazole 40 mg PO Q12H
8. Pravastatin 80 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain
11. Acetaminophen 1000 mg PO TID
12. Digoxin 0.0625 mg PO DAILY
RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth daily Disp
#*15 Tablet Refills:*2
13. HydrALAzine 50 mg PO Q8H
RX *hydralazine 50 mg one tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*2
14. Metolazone 5 mg PO BID
RX *metolazone 5 mg one tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
15. Torsemide 60 mg PO BID
RX *torsemide [Demadex] 20 mg three tablet(s) by mouth twice a
day Disp #*180 Tablet Refills:*2
16. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
17. Vitamin D 50,000 UNIT PO MONTHLY
18. Gabapentin 300 mg PO HS
RX *gabapentin 300 mg one capsule(s) by mouth hs Disp #*30
Capsule Refills:*2
19. Tacrolimus 2 mg PO Q12H
RX *tacrolimus 1 mg two capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*2
20. Levemir 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq one tablet by mouth daily Disp
#*30 Tablet Refills:*2
22. Outpatient Lab Work
Please check chem-7 and tacrolimus level twice weekly with
results to Dr. ___ at Phone: ___ and Fax:
___ and Dr. ___ at ___ fax and ___
fax.
ICD 9: 585.6
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic systolic heart failure
Acute on Chronic kidney injury
Diabetes Mellitus type 1
End Stage renal disease s/p transplant
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of ___ at ___.
___ had an acute exacerbation of your heart failure and needed
dopamine, milrinone and lasix intravenously to remove the extra
fluid. Your weight at discharge is 170 pounds. Weigh yourself
every morning, call Dr. ___ weight goes up more than 3 lbs
in 1 day or 5 pounds in 3 days.
___ heart stopped beating and ___ were transferred back to the
ICU, there was evidence of a heart rhythm called atrial
fibrillation and a medicine called amiodarone was started but
then stopped. ___ have not had further episodes of atrial
fibrillation.
Your kidney function worsened because of your heart but is now
improving. ___ will need to have your tacromilus level checked
twice a week with results to Dr. ___ at ___.
Followup Instructions:
___
|
10013569-DS-9 | 10,013,569 | 22,891,949 | DS | 9 | 2167-11-14 00:00:00 | 2167-11-17 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Morphine / Codeine / Demerol / Iodine-Iodine
Containing
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p renal
transplant in ___, type 1 diabetes, CAD, hld, and recent
admission at OSH for CHF and possible RLL pneumonia, d/c on
___, now presenting to ___ with worsening SOB. Pt reports
that she had been feeling dyspneic since ___. She initially
went to OSH ED and was diagnosed with acute bronchitis,
prescribed steroids and nebulizer, which helped her symptoms. Pt
feels that ever since then, she started to gain weight and
become more edematous. She finally went to another OSH ___
___ in ___) on ___, where she was treated for
CHF exacerbation based on her BNP of 8265. Per discharge
summary, her diuresis was limited by acute renal insufficiency
w/ increase in Cr from baseline 1.4 to 2.0 after several days of
diuretics. OSH report Pt was 100.7 kg on admission on ___ kg on discharge on ___. Pt was also noted to have
significant stool in abdomen w/out evidence of obstruction,
moderate R pleural effusion, and anasarca. Pt was given bowel
regimen and also treated with azithromycin for 3 days and
cefpodoxime 5 days on discharge (assuming they were started 2
days prior to discharge, but no mention in DC summary). She was
also discharged on torsemide 40mg po bid (was on furosemide
120mg po qam and 80mg po qpm) and spironolactone 25mg po bid
(new).
Pt states that since she has been at home, her dyspnea has
worsened. States that she has been taking her medications as
prescribed by feels more edematous and dyspneic, with worsening
orthopnea. Pt denies fevers, chest pain, cough, any myalgias.
In the ED, initial vitals were
97.9 78 134/71 32 100%
EKG showed v-paced rhythm at 73, difficult to compare to prior
since that was sinus rhythm, but diffuse T wave inversions were
also present at that time. BNP 10902, Troponin mildly elevated
to 0.09 but no chest pain symptoms and CK-MB flat. Other labs
benign and UA was bland. CXR suggestive of volume overload w/ R
pleural effusion. Pt was given nitroglycerin 0.4mg w/ some
improvement in dyspnea. Pt was also given aspirin 325 and renal
consult was called. Pt was previously admitted for CHF
exacerbations in the past, and per renal consult, Pt had a foley
placed and was given furosemide 40mg iv x 1 w/ admission to ET
service for further management.
On arrival to the floor:
97.3, 145/79, 76, 20, 96% 2L nc. Wt 100kg bed.
Pt states that she feels that her breathing is improved. Denies
fever, cough, myalgias, rhinorrhea. States that she was taking
all her medications as previously prescribed. Denies sick
contacts, though she was recently hospitalized.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-CAD s/p CABG ___, s/p coronary angiography in ___ showing
native 3VD but patent vv grafts (2) and patent LIMA-LAD. T
-systolic CHF w/ EF 35-45% in ___
-pacemaker implanted, unclear type
-chronic kidney disease s/p transplant ___
-HTN
-hyperlipidemia
-PVD s/p b/l BKAs
-type 1 diabetes
-osteoporosis
-Peripheral neuropathy
Social History:
___
Family History:
-DM on mother's side.
Physical Exam:
Admission:
97.3, 145/79, 76, 20, 96% 2L nc. Wt 100kg bed.
GENERAL: obese woman sleeping in mild respiratory distress
HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx
NECK: Supple, JVP difficult to discern
CARDIAC: RRR, normal S1, S2, no m/r/g
LUNGS: reduced breath sounds in R > L bases, bibasilar
inspiratory crackles, no wheezes
ABDOMEN: normal bowel sounds, obese, distended, Soft, non-tender
to palpation, no masses. 1+ pitting edema
EXTREMITIES: 2+ pitting edema in bilateral upper extremities to
elbows. Lower extremities s/p bilateral BKA. 2+ pitting edema to
abdomen.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge
VS 98.3 131/70 75 20 96%RA
GENERAL: A&Ox3, NAD, bilateral BKAs with prostheses
HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx
NECK: Supple, JVP difficult to discern
CARDIAC: RRR, normal S1, S2, no m/r/g
LUNGS: reduced breath sounds in R > L bases, no wheezes
ABDOMEN: normal bowel sounds, obese, distended, Soft, non-tender
to palpation, no masses. 1+ pitting edema
EXTREMITIES: 2+ pitting edema in bilateral upper extremities to
elbows. Lower extremities s/p bilateral BKA. 2+ pitting edema to
abdomen.
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
___ 07:30PM BLOOD WBC-8.3 RBC-4.78 Hgb-12.6 Hct-40.2 MCV-84
MCH-26.4* MCHC-31.4 RDW-15.7* Plt ___
___ 06:55AM BLOOD WBC-7.0 RBC-4.71 Hgb-12.3 Hct-41.1 MCV-87
MCH-26.0* MCHC-29.8* RDW-15.8* Plt ___
___ 07:30PM BLOOD Glucose-221* UreaN-61* Creat-1.5* Na-138
K-4.9 Cl-98 HCO3-23 AnGap-22*
___ 06:55AM BLOOD Glucose-46* UreaN-59* Creat-1.5* Na-142
K-4.3 Cl-100 HCO3-28 AnGap-18
___ 07:30PM BLOOD ALT-17 AST-20 CK(CPK)-43 AlkPhos-65
TotBili-0.4
___ 07:30PM BLOOD CK-MB-3 ___
___ 07:30PM BLOOD cTropnT-0.09*
___ 07:20AM BLOOD CK-MB-3 cTropnT-0.08*
___ 06:45AM BLOOD tacroFK-3.3*
___ 06:40AM BLOOD tacroFK-5.7
___ 07:30PM BLOOD Lactate-1.4
___ ECG: Atrial sensing and ventricular pacing which has
replaced regularly conducted beats. Clinical correlation is
suggested.
___ CXR: IMPRESSION: Enlarged cardiac silhouette and engorged
pulmonary hila with pulmonary vascular congestion may be due to
CHF. Right lower hemithorax opacity could be due to pleural
effusions with overlying atelectasis and/or consolidation,
elevation of the right hemidiaphragm. If patient able,
dedicated PA and lateral views would be helpful for further
evaluation.
___ TTE: There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is severely depressed (LVEF = 25
%). The right ventricular free wall thickness is normal. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, left ventricular contractile function is
further impaired.
Brief Hospital Course:
___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p
renal transplant in ___, type 1 diabetes, CAD, hld, and recent
admission at OSH for CHF and possible RLL pneumonia, d/c on
___, now presenting to ___ with worsening SOB and
hypervolemia.
___ Exacerbation: The pt presented with worsening dyspnea,
hypoxia, and weight gain. Most likely due to CHF exacerbation
given elevated BNP, known CHF w/ history of exacerbations,
clinical appearence of hypervolemia, and improvement with
diuresis. The pt seems to have had difficulty with volume status
since a prednisone taper in ___ for bronchitis. Pt was
recently discharged from OSH on torsemide 40mg po bid plus
spironolactone 25mg po bid, though previously taking furosemide
120mg po qam and 80mg po qpm. This is unlikely to be sufficient
diuresis and may explain her repeat CHF exacerbation. The pt was
treated initially with a few doses of lasix 80mg IV with
significant output, and then transitioned to torsemide 60mg qam
and 40mg qpm. The pt was successfully weaned from O2 and edema
decreased, though still present at discharge. Repeat TTE showed
worsening LVEF from 30% previously to 25%, without current ACS.
Pt scheduled for f/u with outpt cardiology and home ___ to help
with daily weights.
# Dyspnea: mainly due to sCHF exacerbation as above. Pt also
with some episodes of wheezing and mild hypoxia improved with
albuterol nebs. Started on advair (which pt has taken in the
past) and continued on home albuterol nebs.
# s/p renal transplant: Cr is close to baseline (1.3-1.5).
Prot/cr ratio 0.1. UA bland. No evidence of infection,
obstruction, or rejection. Hypervolemia most likely cardiac in
origin. Continued MMF 500mg po qam and 1000mg po qpm and
tacrolimius 0.5mg po q12h. Tacro level 3.3 and 5.7 (goal ___.
# Dysuria: Pt with pain at meatus, in the setting of foley in
place, possibly worse with urination. U/a with blood but without
e/o infection. Pain likely ___ trauma from foley.
# Hypertension: normotensive. Lisinopril has been held due to
___. Continued home carvedilol, isosorbide mononitrate
# Diabetes: highly variable insulin regimen. States ___ U
levemir qhs plus tid sliding scale based on carb counting.
During admission, treated with 30U glargine qhs (levemir is
non-formulary) and humalog sliding scale adjusted per pt carb
counting.
.
# h/o CAD s/p CABG: continued home pravastatin, aspirin 81 daily
# Back pain, chronic: continued home tramadol
# GERD: continued home pantoprazole
# neuropathy: continued home gabapentin, of note, pt taking
2400mg qhs at home, agreed to decrease to 1200mg qhs.
Transitional issues:
# ___ at home, pt refused ___ rehab, which was recommended by
___
# ___ to check weekly BMP, tacro levels
# Pt to f/u with outpt cardiologist re: decreased EF
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
hold for sbp < 90 or HR < 60
2. Vitamin D 50,000 UNIT PO MONTHLY
3. Torsemide 40 mg PO BID
hold for sbp < 90
4. Gabapentin 2400 mg PO HS
5. Levemir 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Start: In am
hold for sbp < 90
7. Mycophenolate Mofetil 500 mg PO QAM Start: In am
8. Mycophenolate Mofetil 1000 mg PO QPM
9. Pantoprazole 40 mg PO Q12H
10. Spironolactone 25 mg PO BID
hold for sbp < 90
11. Pravastatin 80 mg PO DAILY Start: In am
12. Tacrolimus 0.5 mg PO Q12H
13. Aspirin 81 mg PO DAILY Start: In am
14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
15. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain
16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
hold for sbp < 90 or HR < 60
3. Levemir 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp < 90
5. Mycophenolate Mofetil 500 mg PO QAM
6. Mycophenolate Mofetil 1000 mg PO QPM
7. Pantoprazole 40 mg PO Q12H
8. Pravastatin 80 mg PO DAILY
9. Spironolactone 25 mg PO BID
hold for sbp < 90
10. Tacrolimus 0.5 mg PO Q12H
11. Torsemide 60 mg PO QAM
RX *torsemide 20 mg 3 tablet(s) by mouth qAM Disp #*90 Tablet
Refills:*0
12. Torsemide 40 mg PO QPM
RX *torsemide 20 mg 2 tablet(s) by mouth qpm Disp #*60 Tablet
Refills:*0
13. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain
14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
15. Vitamin D 50,000 UNIT PO MONTHLY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
disk INH twice a day Disp #*1 Inhaler Refills:*0
17. Gabapentin 1200 mg PO HS
18. Outpatient Lab Work
On ___
Check basic metabolic panel, tacrolimus
.
Please fax results to ___ Attn Dr ___
19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CHF exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
It was a pleasure participating in your care. You were
admitted because of worsening shortness of breath and found to
have to have retained too much fluid. You were given IV
diuretics to help decrease this fluid and then restarted on oral
diuretics. You also had some shortness of breath with wheezing
that improved with nebulizers.
Physical therapy evaluated you and felt you would benefit from
___ rehab. However you opted to return home with ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
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Subsets and Splits