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10029108-DS-2

DS

2145-05-30 00:00:00

2145-05-31 19:29:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: lisinopril / banana Attending: ___ Chief Complaint: Rectal pain Major Surgical or Invasive Procedure: ___: Exam under anesthesia and incision and drainage of posterior perirectal abscess. History of Present Illness: ___ hx CAD/MI x2, DM presenting with ___ rectal pain described as burning in nature, exacerbated by sitting and with defection and notes subjective fever last night. WBC 9.1, CTAP with 2cm rim-enhancing collection in posterior midline at level of sphincters. No personal or family history of inflammatory bowel disease or colorectal cancer. No prior episodes. No change in bowel habits. At time of consultation, pt AFVSS with DRE notable for fluctuance and tenderness in the posterior midline, no blood or drainage. Past Medical History: PMH: DM2, HTN, glaucoma, HL, CAD/MIx2 PSH: Prostate needle-biopsy ___ Social History: ___ Family History: No family history of IBD, CRC. Father: CAD/PVD Physical Exam: Admission Physical Exam: Weight: VS: T 99.0, HR 101, BP 110/78, RR 16, SaO2 100%rm air GEN: NAD, A/Ox3 HEENT: EOMI, MMM CV: tachycardic PULM: CTAB BACK: No CVAT ABD: soft, NT/ND PELVIS: perianal exam - unremarkable. DRE: posterior midline fluctuance and tenderness at level of sphincters, no blood, no drainage. EXT: warm, well-perfused Discharge Physical Exam: Pertinent Results: ___ 10:20AM GLUCOSE-139* UREA N-15 CREAT-1.3* SODIUM-138 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 ___ 10:20AM WBC-6.4 RBC-3.53* HGB-11.1* HCT-34.0* MCV-96 MCH-31.4 MCHC-32.6 RDW-13.4 RDWSD-47.7* ___ 10:20AM PLT COUNT-155 ___ 04:17AM GLUCOSE-101* UREA N-18 CREAT-1.2 SODIUM-138 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 ___ 04:17AM WBC-7.9 RBC-3.54* HGB-11.1* HCT-34.0* MCV-96 MCH-31.4 MCHC-32.6 RDW-13.2 RDWSD-47.3* ___ 04:17AM PLT COUNT-149* ___ 11:05PM LACTATE-1.8 ___ 05:55PM GLUCOSE-81 UREA N-20 CREAT-1.3* SODIUM-140 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22* ___ 05:55PM WBC-9.1 RBC-4.23* HGB-13.1* HCT-40.2 MCV-95 MCH-31.0 MCHC-32.6 RDW-13.3 RDWSD-46.5* ___ 05:55PM NEUTS-71.6* ___ MONOS-6.6 EOS-1.1 BASOS-0.4 IM ___ AbsNeut-6.49* AbsLymp-1.81 AbsMono-0.60 AbsEos-0.10 AbsBaso-0.04 ___ 05:55PM PLT COUNT-175 ___ 05:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG ___ 05:40PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 05:40PM URINE MUCOUS-RARE Imaging: ___: CT Pelvis: 1. 2.0 cm rim enhancing midline fluid collection just posterior concerning forpossible perirectal abscess. 2. Sigmoid colon diverticulosis without evidence of diverticulitis. Enlarged prostate. Brief Hospital Course: Mr. ___ is a ___ year-old male who presented to ___ with complaints of rectal pain and received a CT pelvis which showed him to have a perirectal abscess. He was admitted to the Acute Care Surgery team for further medical evaluation. On ___, the patient was taken to the Operating Room and underwent incision and drainage of his perirectal abscess. He tolerated this procedure well (reader, please see operative note for further information). Post-operatively, the patient received IV antibiotics. on post op day 1, patient noticed to have some pain and induration just anterior to the incision, MRI showed small residual abscess, we took him back to the OR and another I&D (please refer to the operative note for more information). He tolerated this procedure well and transferred to the regular floor. The remainder of the ___ hospital course is summarized by systems below: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with oral pain medication once tolerating a diet. 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: The patient's diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, and he received antibiotics post-operatively.. 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: Polyethylene Glycol 3350:PRN, Gatifloxacin 0.5%'''', Prednisolone 1% q2h, Metformin 1000, HCTZ 25, Losartan 25, Toprol XL 50, Atorvastatin 80, Alphagan 0.1%, Cosopt 2% L eye'', Latanprost ___ 81 Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID 5. Lorazepam 1 mg PO Q4H:PRN Anxiety 6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN constipation 10. Hydrochlorothiazide 25 mg PO DAILY 11. Losartan Potassium 25 mg PO DAILY 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. gatifloxacin 0.5 % ophthalmic QID 15. Docusate Sodium 100 mg PO BID 16. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q3 Disp #*30 Tablet Refills:*0 17. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12 Disp #*2 Tablet Refills:*0 18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth q8 Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Perirectal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You presented to the ___ and were found to have an abscess. You were admitted to the Acute Care Surgery team for further medical management. On ___, you were taken to the Operating Room and underwent an incision and drainage of your abscess which you tolerated well. You were started on antibiotics to treat and prevent infection. Your pain is better controlled and you are tolerating a regular diet. You are now medically cleared to be discharged to home. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 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. 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. Followup Instructions: ___

10029295-DS-5

DS

2180-10-26 00:00:00

2180-10-26 11:13:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Crush injury with an open fracture dislocation to the right forearm. Major Surgical or Invasive Procedure: ___ 1. Open reduction, internal fixation of the of the radial forearm fracture. 2. Carpal tunnel release. 3. Fasciotomy of the forearm x3 compartments. 4. Irrigation and debridement over the crush injury to the mid forearm area over a 4 x 14 x 6 cm area. 5. Tenotomy of the ECU as well as EPL tendons due to severe necrosis to the muscle. 6. Open reduction, internal fixation of distal radioulnar joint dislocation. 7. Neurolysis of the ulnar nerve and median nerve in the forearm. 8. Exploration of the ulnar artery. 9. Neurolysis of the ___ and ___ digit radial digital nerves. ___ 1. Repeat irrigation and debridement of the right arm, both volar and extensor surface all the way down to bone. 2. Neurolysis of the median nerve in the forearm. 3. Open reduction, internal fixation of the distal radioulnar joint. 4. Placement of VAC dressing. ___ 1. Cystoscopy with clot removal ___ 1. Right forearm wound debridement, volar 21 x 6 cm, dorsal wound was 19 x 4 cm. 2. VAC dressing exchange. ___ 1. Cystoscopy for clot removal 2. Arterial bleed found in false urethral passage History of Present Illness: Mr. ___ is a ___ y/o RHD gentleman who was working with a metal lathe earlier today when his forearm got caught in the lathe. He was subsequently airlifted to the ___ ED from ___ for further management and care. He denies other injuries. Last meal was ~12:30 ___. He received Tetanus, Ancef, and Gentamicin in the ED bay. Past Medical History: GERD, Gout Social History: ___ Family History: Non-contributory Physical Exam: AVSS AAOx3, NAD Resp - RR, non-labored breathing CV - RRR Abd - Soft, NTND Ext - WWP Pertinent Results: ___ 06:05AM BLOOD WBC-9.0 RBC-2.62* Hgb-8.0* Hct-24.2* MCV-92 MCH-30.5 MCHC-33.0 RDW-14.7 Plt ___ Brief Hospital Course: The patient was admitted to the orthopaedic hand surgery service on ___ for a crush injury to the right forearm with an open fracture dislocation. He was taken urgently to the OR. He underwent open reduction internal fixation of the of the radial forearm fracture, carpal tunnel release, fasciotomy of the forearm x3 compartments, irrigation and debridement over the crush injury to the mid forearm area over a 4 x 14 x 6 cm area, tenotomy of the ECU as well as EPL tendons due to severe necrosis to the muscle, open reduction internal fixation of distal radioulnar joint dislocation, neurolysis of the ulnar nerve and median nerve in the forearm, exploration of the ulnar artery, neurolysis of the ___ and ___ digit radial digital nerves and wound vac placement. He was given a nerve block both pre and post-surgery, with a pain catheter left in place for pain control. A foley catheter was placed post-operatively for urinary retention. This was a traumatic placement with immediate bleeding. He continued to have pink urine throughout the following days with clot formation. He was then taken back to the OR on ___ and underwent a repeat irrigation and debridement of the right arm, both volar and extensor surface all the way down to bone, neurolysis of the median nerve in the forearm, ORIF distal radioulnar joint, and placement of VAC dressing. Post-operatively on ___ he was transfused 2 units PRBCs for Hct 20. Overnight on ___ he developed acute urinary retention, without successful flushing of the foley. He was then taken urgently by urology for cystoscopy and clot evacuation on the morning of ___. He was also transfused another 2 units PRBCs for Hct 17. Post-operatively he was started on continuous bladder irrigation. He was then taken back to the OR on ___ and underwent a repeat irrigation and debridement, with a vac change. IV gentamicin was discontinued at this time. Over the following days his Hct stabilized and his CBI was stopped on ___. Overnight he began to again form clots in his foley, irrigation was unsuccessful. He was then taken back to cystoscopy urgently on the morning of ___. At that time he was found to have an arterial bleed in a false urethral passage which was cauterized. Clots were evacuated and he then had clear urine. Upon return to the floor he had no further events of clot formation and his urine remained clear. The RUE was kept in strict elevation and dressed with dry sterile gauze and splinted. The extemity was closely monitored throughout his hospitalization. Neuro: A nerve block was placed both pre and post-operatively. The patient received Dilaudid IV with good effect and adequate pain control. Pain service was consulted who recommended a PO and IV course of dilaudid, PO gabapentin and PO tylenol. The patient was transitioned to oral pain medications with continued adeqaute pain relief. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: The patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. ID: The patient's temperature and incision was closely watched for signs of infection. He recieved a brief course of IV antibiotics, including Gent and Ancef, during his hospital course. He remained afebrile. He was transitioned to PO antibiotics for discharge. Prophylaxis: The patient was encouraged to get up and ambulate as early as possible. Physical therapy was consulted for mobilization. At the time of discharge, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Omeprazole Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*40 Capsule Refills:*0 2. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours Disp #*60 Tablet Refills:*0 3. Omeprazole 20 mg PO DAILY 4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 hours Disp #*80 Tablet Refills:*0 5. Gabapentin 300 mg PO Q8H RX *gabapentin 300 mg 1 capsule(s) by mouth every 8 hours Disp #*60 Capsule Refills:*0 6. Cephalexin 250 mg PO Q6H Duration: 10 Days RX *cephalexin 250 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Capsule Refills:*0 7. Bacitracin Ointment 1 Appl TP TID RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram Apply to urethral meatus while catheter is in place Once daily Disp #*1 Tube Refills:*0 8. Oxybutynin 5 mg PO TID RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth Three times a ___ Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Crush injury with an open fracture dislocation to the right forearm. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Personal Care: 1. Keep your splint on until follow-up. 2. Non weight bearing right arm. 3. Wound vac should remain to suction at all times until it is changed at your follow-up appointment on ___. 4. You are going home with a foley catheter and leg bag. Please perform flushes as needed. Please call urology to schedule an appointment for next week. Activity: 1. You may resume your regular diet. 2. DO NOT lift anything with your right arm. Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by tylenol. 4. Take Colace, 100 mg by mouth 2 times per ___, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. 6. You have been given a prescription for an antibiotic, Keflex. Take the entire course of the antibiotic as directed. 7. you have been given a prescription for Oxybutinin to prevent bladder spasms while your catheter is in place. Take this medication three times a ___. Stop taking the medication on ___, with a plan for a voiding trial on ___. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness,swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Physical Therapy: NWB RUE Treatments Frequency: Dressing, including the wound vac, should remain on until his follow-up appointment on ___. The wound vac will be changed in the clinic during his appointment. Please do not perform any dressing or vac changes at home. Foley with leg bag - flush as needed Followup Instructions: ___

10029429-DS-13

DS

2187-01-14 00:00:00

2187-01-14 16:35:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine / Penicillins Attending: ___. Chief Complaint: R distal femur periprosthetic fx Major Surgical or Invasive Procedure: Surgical fixation (open reduction, internal fixation), R distal femur History of Present Illness: ___ female hx of CHF (EF 65% last TTE ___, A. fib (on Eliquis) who presents after a mechanical fall after slipping on a raw vegetable on the ground at the grocery market. She denied head strike or loss of consciousness. She denied any presyncopal symptoms. She was brought to ___ where her initial evaluation and workup revealed a right periprosthetic distal femur fracture. She states that she last took her Eliquis the morning of her fall. She denies any other complaints including neck pain, chest pain, shortness of breath, pain in the left lower or bilateral upper extremities. She states that she ambulates with a cane and is functionally independent of ADLs and IADLs. Past Medical History: Hypertension CAD CHF Hyperlipidemia Hypothyroidism Atrial fibrillation Social History: ___ Family History: NC Physical Exam: Admission Physical Exam Vitals: AVSS General: Well-appearing female in mild distress due to her right thigh pain Neck: No C-spine tenderness or palpable step-offs, full passive range of motion of the neck Right lower extremity: - Skin intact - No deformity evident, moderate ecchymosis and swelling - Soft, but tender distal thigh and proximal leg - Full, painless ROM at bilateral hip, left knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Discharge Physical Exam VS: 98.2 PO 149/66 HR 63 RR 16 ___ 94 Ra General: Alert and oriented, NAD HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: JVP 6 cm. CV: Irregularly irregular, no MRG Lungs: Scattered crackles at bases, no wheezes, normal respiratory effort GI: soft, NT/ND Extremities: warm, well perfused, trace edema on the L ankle, 1+ edema on the RLE Neuro: No gross motor/coordination abnormalities Pertinent Results: Admission Labs ___ 12:45PM BLOOD Glucose-139* UreaN-33* Creat-1.0 Na-135 K-4.1 Cl-100 HCO3-25 AnGap-10 ___ 06:30AM BLOOD WBC-7.9 RBC-2.70* Hgb-7.9* Hct-24.9* MCV-92 MCH-29.3 MCHC-31.7* RDW-14.9 RDWSD-50.2* Plt ___ ___ 05:14AM URINE Hours-RANDOM UreaN-712 Creat-89 Na-<20 ___ 08:30AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM* Discharge Labs ___ 06:16AM BLOOD WBC-9.9 RBC-2.89* Hgb-8.7* Hct-25.9* MCV-90 MCH-30.1 MCHC-33.6 RDW-14.9 RDWSD-48.8* Plt ___ ___ 06:16AM BLOOD ___ PTT-28.1 ___ ___ 06:16AM BLOOD Glucose-110* UreaN-22* Creat-0.7 Na-139 K-3.8 Cl-99 HCO3-28 AnGap-12 ___ 06:16AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9 ___ Imaging VENOUS DUP EXT UNI (MAP No evidence of deep venous thrombosis in the left lower extremity veins. ___ Imaging KNEE (2 VIEWS) RIGHT Distal femur fracture. No definite involvement of the prosthesis radiographically. Brief Hospital Course: Ms. ___ is a ___ w/ HFpEF, afib on apixiban, CAD (60% LAD in ___, h/o sinus pauses and Mobitz I AVB, HTN, and hypothyroidism, admitted with R periprosthetic femur fracture (now s/p ___ ORIF). Course c/b bradycardia (now improved off carvedilol), CHF and cardiorenal ___ (both improved with diuresis), and anemia requiring 1u pRBCs. ACUTE ISSUES ADDRESSED ======================== #R periprosthetic distal femur fracture: The patient was found to have a right distal femur periprosthetic fracture and was admitted to the orthopedic surgery service. Given her elevated Chads2Vasc score, she was bridged from her home apixaban to a heparin drip for tight control of her anticoagulation status on the way to the operating room. The patient was taken to the operating room on ___ for open reduction with internal fixation, which the patient tolerated well. 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 her home anticoagulation was restarted. She received a blood transfusion for an asymptomatic low hematocrit which she tolerated without issue. Activity restrictions: touch down weight bearing in unlocked ___ knee brace on R side. ___ recommended: discharge to rehab. #Acute on chronic diastolic HF exacerbation: Likely ___ IV fluid administration and holding diuretics post-operatively. On Lasix 40mg BID at home. Admission weight 180lbs. Standing weight was not trended given patient's activity restriction. She was treated with IV diuresis with improvement which was transitioned to PO diuretics at discharge. ___: likely cardiorenal as this developed I/s/o volume overload. Cr improved with IV diuresis. #Bradycardia: likely ___ to carvedilol as bradycardia improved with discontinuation of medication. Patient has history of AVB 2nd degree type ___elay, previously with HR ___ and pauses on telemetry. The patient continued to have episodes of HR in ___ that were asymptomatic after discontinuation of beta blocker. Non-urgent cardiology follow up is recommended for continued surveillance of her asymptomatic bradycardia. #Oral bleeding: the patient had hemorrhage from the site of a recent tooth extraction after resuming her home Eliquis. If this issue recurs, she should see her outpatient oral surgeon promptly. CHRONIC ISSUES: =============== #Atrial fibrillation - continued home apixaban, stopped carvedilol as above #HTN - continued home amlodipine #HLD - continued home atorvastatin #GERD - continued home omeprazole #Depression - continued home citalopram #Hypothyroidism - continued home levothyroxine Transitional Issues ===================== [] R Distal Femur Periprosthetic Fracture: f/u with orthopedics team in 2 weeks (contact information listed above) [] TDWB RLE in unlocked ___ brace until ortho follow up. [] Consider treatment for presumed osteoporosis with Prolia or a bisphosphonate (unclear to this author from available records if she has had a bisphosphonate in the past). She is continued on vitamin D. [] Bradycardia: Stopped carvedilol. Because she also has paroxysmal a-fib, watch for any RVR or palpitations off her beta blocker. [] HFpEF: If possible to obtain accurate weights with her weight-bearing restrictions, please trend daily weights. Please check BMP in one week. Notify the rehab doctor if creatinine is 1.2 or higher, or if weight changes by five pounds or more. Titrate PO Lasix pending volume status. [] Tooth bleeding: Follow-up with surgeon who performed recent dental extraction PRN #CODE: Full, presumed #CONTACT: Name of health care proxy: ___ ___ number: ___ Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Carvedilol 6.25 mg PO BID 4. Citalopram 20 mg PO DAILY 5. Apixaban 5 mg PO BID 6. Furosemide 40 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226 mg-200 unit -5 mg-0.8 mg oral BID 10. Cholecalciferol ___ IU daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate Do not drink or drive on this medication. Please beware sedation RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth q4hrs Disp #*24 Tablet Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. Furosemide 80 mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Apixaban 5 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. Citalopram 20 mg PO DAILY 9. Fluticasone Propionate NASAL 1 SPRY NU BID 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226 mg-200 unit -5 mg-0.8 mg oral BID 13. Cholecalciferol 1000 IU daily (this was omitted in error by the discharging resident but was called in to the rehab) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ==================== R Distal Femur Periprosthetic Fracture Acute on chronic diastolic heart failure exacerbation SECONDARY DIAGNOSES =================== Anemia Constipation ___ Bradycardia Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? - 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. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had a surgery on your R leg. - You were treated with diuretics for fluid overload - You were given a blood transfusion for bleeding. - You had a kidney injury that improved with diuresis. - You had slow heart rate that improved with stopping carvedilol. - You had tooth bleeding that improved. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. - You also slow heart rate and had volume overload which was treated with diuresis. We wish you the best! Sincerely, Your ___ Team ACTIVITY AND WEIGHT BEARING: - Touchdown weight bearing in the right lower extremity in an unlocked ___ brace. 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 continue to take your apixaban as you were previously. 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. 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 Followup Instructions: ___

10029468-DS-6

DS

2169-01-16 00:00:00

2169-01-16 18:51:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Amoxicillin / Iodinated Contrast Media - IV Dye / iodine / Lupron / Lyrica / Migranal / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Percocet / piroxicam / Salsalate / Tegretol / Tylenol-Codeine / Ultram / Vicodin / iodoform / Tegaderm Attending: ___ Chief Complaint: motor vehicle accident Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female presenting to ___ after a motor vehicle accident. She was the restrained driver and was hit on the left driver's side while traveling at 35 mph. No loss of consciousness, no airbag deployment. She was seen at an outside hospital where FAST showed a pericardial effusion. She was transferred to ___ for further management. Past Medical History: PMH hypothyroidism PSH Anterior Fusion cervical spine Bilateral Salpingoophorectomy C section L tendon repair Occipital nerve stimulator (placed ___- checked ___ Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: HR 72, BP 124/72, RR 19, Sat 96% RA Gen: NAD Chest/CV: RRR, no tenderness to palpation Lungs: CTAB Abdomen: Soft, NT, ND Spine: Tenderness to palpation at base c-spine, lumbar spine DISCHARGE PHYSICAL EXAM Vitals: T97.9 (Tm 97.9), BP: 97/63, HR: 66, RR: 18, O2 sat: 96%, O2 delivery: Ra Gen: NAD, AAOx3 HEENT: MMM, tenderness to palpation left neck CV: RRR Resp: breaths unlabored, CTAB Abdomen: soft, nondistended, nontender Ext: WWP Pertinent Results: ___ 10:32PM ___ PTT-30.5 ___ ___ 10:32PM PLT COUNT-352 ___ 10:32PM NEUTS-41.6 ___ MONOS-10.2 EOS-0.9* BASOS-0.8 IM ___ AbsNeut-3.23 AbsLymp-3.57 AbsMono-0.79 AbsEos-0.07 AbsBaso-0.06 ___ 10:32PM WBC-7.8 RBC-3.87* HGB-13.5 HCT-39.8 MCV-103* MCH-34.9* MCHC-33.9 RDW-12.0 RDWSD-45.2 ___ 10:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG ___ 10:32PM LIPASE-36 ___ 10:32PM UREA N-11 ___ 10:38PM GLUCOSE-141* LACTATE-0.8 CREAT-0.9 NA+-141 K+-3.6 CL--109* TCO2-23 IMAGING: Outside Hospital Imaging 1) CT Head - No acute intracranial abnormality - Post surgical changes of bilateral mastoid occipital region noted with what appears to be implantable meshlike material. On the right, material thickened relative to left. Internal gas therefore infection cannot be excluded. - Neurostimulator device is positioned as above 2) CT C spine - No fracture seen - S/p anterior fusion at C5-6 with C5-6 disc age - Disc bulge at C6-7 - Posterior spinal stimulator electrodes - Bilateral craniotomies with possible infected mesh on right 3) CT Abdomen - Moderate sized anterior pericardial effusion -Electronic implanted device possibly a stimulator unit at posterior right lower thorax - Mild stranding seen about the paracolic gutters of uncertain etiology. ___ Imaging CT Chest: IMPRESSION: Essentially normal chest CT. No evidence of trauma. Brief Hospital Course: Ms ___ was admitted to the Acute Care Surgery service after being transferred from an outside hospital given concern for pericardial effusion. She was FAST + in the ED, but hemodynamically stable. She had no additional injuries on imaging obtained at the outside hospital. On the night of admission, she underwent chest CT which showed an essentially normal chest CT with no evidence of trauma. She remained hemodynamically stable. She was tolerating a regular diet and ambulating independently. She was seen by Neurosurgery given the previous neurosurgical procedures and concern for possible infection of the right sided neurostimulator mesh. On their evaluation, there was no evidence of infection or neurological deficits. She was instructed to follow up in ___ clinic and to follow up with her PCP. She was therefore discharged home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Topiramate (Topamax) 200 mg PO DAILY 4. BuPROPion XL (Once Daily) 300 mg PO DAILY 5. FLUoxetine 40 mg PO DAILY 6. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY Discharge Medications: 1. BuPROPion XL (Once Daily) 300 mg PO DAILY 2. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 3. FLUoxetine 40 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Topiramate (Topamax) 200 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: motor vehicle accident, no significant pericardial effusion 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 ___ after a motor vehicle accident due to concern over fluid around your heart. You had a CT of the chest which was normal. While in the hospital, you were also seen by Neurosurgery for your peripheral nerve stimulator. There were no signs of infection. It is recommended that you follow up with your neurosurgeon Dr ___ and with your primary care doctor after discharge. Please continue all of your home medications. Please come to the Emergency Department if you develop: * Fever > 101 degrees * Chills * Chest pain or shortness of breath * Dizziness, lightheadedness, or feeling faint * Any symptoms that concern you Thank you, Your ___ Surgery Team Followup Instructions: ___

10029484-DS-12

DS

2160-11-11 00:00:00

2161-01-04 21:13:00

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 Major Surgical or Invasive Procedure: none History of Present Illness: ___ year-old man with a histor of CAD, HTN, HLD, NIDDMII who presented after multiple syncopal episodes at home in the setting of 10 episodes of diarrhea. Patient was in usual state of healt until yesterday ___ when he awoke not feeling well. He ten ad 10 episodes of diarrhea with associated nausea and chills, after which syncopized x3 including once with + headstrike. Syncopal episodes were preceeded by dizziness and diaphoresis but witout chest pain palpitation. He states he did black out each time and does not know how long he passed out for. Notably, patiet as had similar episodes of sycnope in the setting of prior GI illness. Upon arrival to ___, patient with tachycardic to 100s but otherwise VSS. Labs notable for leukocytosis to 12.7, Chem-7 with anion gap 15 and Glu 427, UA with + glucose and ketones. Patient was started on insulin gtt and admitted to MICU for concern of DKA. In MICU, patient's anion gap quickly closed on insulin gtt, and he has been transitioned to lantus 10u with gentle ISS. For his syncope, EKG unchanged from prior and cardiac biomarkers negative. Diarrhea has been managed supportively with fluids, and stool C. dif sent and pending. VS at the time of transfer T97.5 HR 89 BP 144/64 RR 22 O296%RA. Patient reports feeling better. able to tolerate PO. no n/v. had 4 BM today, watery. denies f/c. abd slightly distended Past Medical History: 1. CAD status post PCI of the mid LAD for stable angina in ___ after a positive stress test. 2. Type 2 diabetes. 3. Hyperlipidemia. 4. Hypertension. Social History: ___ Family History: Significant for cardiac disease Physical Exam: Admission physical exam: Vitals: T97.5 HR 89 BP 144/64 RR 22 O296%RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes NECK: supple LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding BACK: no spinal processes tenderness, tenderness to the left paraspinal muscles EXT: no ___ edema NEURO: cranial nerves III-XII grossly intact, moving all four extremities Discharge physical exam: Vitals: 98.3 84 152/72 18 98%RA GENERAL: Well appearing man sitting up in chair in NAD HEENT: Sclera anicteric, moist mucous membranes LUNGS: CTAB, no wheezing, rales, rhonchi CV: RRR, normal S1 S2, no M/R/G ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding EXT: WWP, no ___ edema NEURO: AAOx3, motor and sensory exam grossly intact Pertinent Results: ADMISSION LABS ============== ___ 08:30PM BLOOD WBC-12.7*# RBC-4.66 Hgb-13.9* Hct-42.5 MCV-91 MCH-29.9 MCHC-32.8 RDW-12.8 Plt ___ ___ 11:13AM BLOOD ___ PTT-34.0 ___ ___ 08:30PM BLOOD Glucose-427* UreaN-28* Creat-1.5* Na-133 K-4.8 Cl-101 HCO3-17* AnGap-20 ___ 04:38PM BLOOD Albumin-3.7 Calcium-7.5* Phos-2.1* Mg-1.6 ___ 08:30PM BLOOD %HbA1c-7.7* eAG-174* ___ 11:13AM BLOOD PTH-112* ___ 11:13AM BLOOD 25VitD-33 . DISCHARGE LABS ============== ___ 06:55AM BLOOD WBC-3.4* RBC-3.95* Hgb-11.8* Hct-33.8* MCV-85 MCH-29.8 MCHC-34.9 RDW-12.4 Plt ___ ___ 06:55AM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-138 K-3.6 Cl-105 HCO3-23 AnGap-14 ___ 11:13AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 03:28AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 06:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.7 . PERTINENT RESULTS ================= CT abdomen: There is a 9 mm hypodensity in segment 2 of the liver which is too small to characterize. The liver otherwise enhances homogeneously without focal lesions or intrahepatic biliary dilatation. The gallbladder is unremarkable and the portal vein is patent. The pancreas, spleen and adrenal glands are unremarkable. The kidneys present symmetric nephrograms and excretion of contrast with no pelvicaliceal dilation or perinephric abnormalities. The small bowel is fluid-filled with some areas which are mildly dilated; however, without sharp transition point. Contrast reaches the mid sigmoid colon. There is no evidence of obstruction. The appendix is visualized and there is no evidence of appendicitis. The intraabdominal vasculature is unremarkable. There is no mesenteric or retroperitoneal lymph node enlargement by CT size criteria. No ascites, free air or abdominal wall hernia is noted. CT pelvis: The urinary bladder is unremarkable. There is no pelvic free fluid. There is no inguinal or pelvic wall lymphadenopathy. Osseous structures: No lytic or sclerotic lesions suspicious for malignancy is present. IMPRESSION: Fluid-filled small bowel with some mildly dilated loops, as can be seen in the setting of enteritis. No evidence of obstruction. . 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. Brief Hospital Course: ___ y/o M with PMHx significant for CAD, HTN, HLD, NIDDMII who presented after multiple syncopal episodes at home in the setting of 10 episodes of diarrhea. # AG acidosis: On admission, patient found to have anion gap 15 in the setting of BS 400s and UA with ketones suggestive of DKA. Although patient does have DM, he is not insulin dependent at baseline making him at lower risk of DKA. His acidosis is likely explained by his ___ GI illness with loss of HCO3 in the GI tract, but this would not explain the AG. Alternatively, the patient could have had an elevated lactate in the setting of hypovolemia with under perfusion as evidenced by his ___ on admission which has resolved with intravenous fluids. Patient was briefly on insulin drips. His Anion gap closed with fluid resuscitation. # Diarrhea: Likely a viral gastroenteritis given acute onset. Patient also no PPI as outpatient, raising the risk of C. diff which is therefore, also in the ddx. c. diff antigen returned negative. CT abdomen was also normal as well. Stool culture were negative as well. Diarrhea resolved prior to discharge. # Syncope: Patient wit ___ episodes of syncope at home in the setting of diarrhea so most likely etiology is ___ to hypovolemic and orthostasis. Without chest pain or palpitations changes to suggest ACS or arrhythmia as etiology, which is consistent with EKG unchanged from prior and cardiac biomarkers negative. No post-ictal symptoms to suggest seizures. Pt had no more episodes of ___ stay after IV fluid support. Pt had no pre-syncope symptoms prior to discharge. # Acute kidney injury: Unclear recent baseline, although most recent Cr from ___ in our system 1.1. pateint presented with Cr 1.5, likely ___ to pre-renal etiology. pt's creatinine improved to 1.0 with IV fluids. # HTN: pt's home metoprolol 25mg XL and lisinopril was initially held in the setting of orthostasis. It was resume prior to dishcarge and pt had no significant episodes of hypotension or hypertension prior to discharge. # HLD: continued on home dose simvastatin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 10 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. GlipiZIDE XL 10 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Gastroenteritis Diabetic Ketoacidosis Severe Dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It has been our pleasure caring for you at ___. You were admitted because you had severe diarrhea. In that setting, you were severely dehydrated, causing you to faint. You briefly stayed at the intensive care unit because your blood sugar was too high. Your diarrhea was likely due to an infection. We are glad to see that your diarrhea has improved and your blood sugar level has improved as well. You can resume your home regimen for diabetes control. Followup Instructions: ___

10030549-DS-7

DS

2141-11-28 00:00:00

2141-11-29 08:40:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: isoniazid Attending: ___. Chief Complaint: Right upper and lower limb weakness Major Surgical or Invasive Procedure: Cyber Knife to brain lesion History of Present Illness: Mr. ___ is a pleasant ___ HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy ___ w/ rapid met recurrence s/p C3 TIP ___ who p/w RLE weakness x ___ days. He acutely developed RUE weakness while walking up the stairs at 6PM tonight and fell back and hit his head. He called EMS and code-stroked by EMS. In the ED he was noted to have RUE and RLE weakness although subjectively improved. He was seen by neurology and found to have preserved strenght in the RUE but RLE weakness w/ R foot drop and sensory changes. NCHCT revaled a large hypodensity in the L frontoparietal region w/ c/f mass. He was seen by ___ who advised dex and no AEDs. He denied any headache, changes to vision, no N/V, no other acute complaints. REVIEW OF SYSTEMS: 12 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: Metastatic Penile SCC with sarcomatoid and acantholytic features Rheumatoid arthritis previously treated with Plaquenil, MTX, sulfasalaine, leflunomide Type 2 diabetes mellitus Asthma +PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin Osteoarthritis Right bundle branch block Ventral hernia Hypertension Hyperlipidemia Social History: ___ Family History: Mother ___ ___ Father ___ ___ blood cancer NO history of colon, lung or prostate cancer Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITAL SIGNS: 98.2 PO 120/70 7620 99 ra General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions NCAT CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, no ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength ___ LUE, ___ RUE/RLE with paresthesias RLE, ___ R ___, + R dysmetria , speech intermittent difficulty to understand due to aphasia, AOx3 PSYCH: Thought process logical, linear, future oriented but seems to have intermittent aphasia, off baseline from when i've met him before ACCESS: Chest port site intact w/o overlying erythema, PIV DISCHARGE PHYSICAL EXAM ======================= Vitals: ___ 2347 Temp: 97.9 PO BP: 112/59 HR: 59 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: NAD, lying comfortably in bed, sits up independently, fully cooperative with exam. HEENT: AT/NC, EOMI, PERLLA, MMM NECK: Supple, No LAD CV: RRR, S1/S2, no murmurs PULM: CTAB, breathing comfortably without use of accessory muscles, no wheezes, rales or crackles. ABD: Bowel sounds appreciated, abdomen soft, nondistended EXT: WWP. Chronic RA changes to BUE, mostly right hand. 2+ pulses appreciated in four limbs. SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: AOx3, Fluent speech, CN II-XII grossly intact. RUE with 4+/5 strength, no difference in sensation to light touch, stable from previous exam. RLE with ___ strength, mostly decreased in right foot plantar flexion but improved from baseline (and stable), reduced sensation to light touch throughout RLE. ACCESS: Port, no erythema, no skin breakdown, no tenderness. PIV. Pertinent Results: IMAGING ======= EEG (___) impression: This was normal continuous EEG recording. There were no epileptiform discharges or electrographic seizures. Single channel ecg showed an irregular heart rhythm. CT Head and Neck (___) impression: ECG (___) impression: Sinus rhythm Ventricular premature complex Right bundle branch block repolarization abnormality- nonspecific MRI Head w&w/o contrast (___) impression: 1. 1 cm ovoid enhancing lesion in the posterior with aspect of the left superior frontal gyrus with surrounding moderate vasogenic edema, raises concern for metastatic disease. Primary brain malignancy is also differential consideration. 2. No additional intraparenchymal lesions are identified. 3. There is T1 hypointensity in the C4 and C5 vertebral bodies which is incompletely assessed on this examination but can reflect osseous metastatic disease. Consider dedicated imaging of the cervical spine. 4. No acute infarct or hemorrhage. 5. Cerebellar tonsils are pointed and protrude below the foramen magnum by approximately 1 cm, which can reflect Chiari type configuration in the appropriate setting. Chest CT w/contrast (___) impression: No good evidence for intrathoracic malignancy. 3 mm solid nodule left lung apex is indeterminate but more likely a scar than a solitary metastasis. Recommendations for such incidental findings provided below. Benign air-filled cyst, right lower lobe. CT Abdomen and Pelvis w/Contrast (___) impression: 1. Lucent lesion in the T11 vertebral body with associated soft tissue, better characterized on the same day thoracic spine MRI, likely a metastasis. 2. Same date chest CT is reported separately. MRI Spine w&w/o contrast (___) impression: 1. Enhancing lesion involving the T11 vertebral body, raises concern for metastatic disease. No additional lesions are identified in the spine. 2. Severe bilateral neural foraminal narrowing at L3-L4, L4-L5 and L5-S1. 3. Severe spinal canal narrowing at L4-5 due to degenerative disease. 4. Additional multilevel multifactorial cervical and lumbar spondylosis as described above. CYTOLOGY ======== SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID DIAGNOSIS: CEREBROSPINAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes and monocytes. MICROBIOLOGY ============ ___ 8:35 pm URINE STROKE. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S LABS ==== ___ 04:52AM BLOOD WBC-5.8 RBC-3.71* Hgb-11.6* Hct-34.4* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.4 RDWSD-46.3 Plt ___ ___ 04:29AM BLOOD WBC-5.8 RBC-3.68* Hgb-11.6* Hct-34.1* MCV-93 MCH-31.5 MCHC-34.0 RDW-13.5 RDWSD-46.4* Plt ___ ___ 05:20AM BLOOD WBC-5.9 RBC-3.75* Hgb-11.6* Hct-35.3* MCV-94 MCH-30.9 MCHC-32.9 RDW-13.7 RDWSD-46.9* Plt ___ ___ 05:24AM BLOOD WBC-5.3 RBC-3.85* Hgb-12.0* Hct-36.3* MCV-94 MCH-31.2 MCHC-33.1 RDW-13.7 RDWSD-47.6* Plt ___ ___ 05:55AM BLOOD WBC-3.8* RBC-3.88* Hgb-12.1* Hct-36.4* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.7 RDWSD-47.5* Plt ___ ___ 06:06AM BLOOD WBC-4.3 RBC-3.81* Hgb-11.8* Hct-35.7* MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 RDWSD-47.8* Plt ___ ___ 04:11AM BLOOD WBC-4.2 RBC-3.67* Hgb-11.6* Hct-34.5* MCV-94 MCH-31.6 MCHC-33.6 RDW-13.8 RDWSD-47.4* Plt ___ ___ 04:15AM BLOOD WBC-4.8 RBC-3.73* Hgb-11.6* Hct-35.1* MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 RDWSD-47.1* Plt ___ ___ 05:20AM BLOOD WBC-4.7 RBC-3.68* Hgb-11.5* Hct-34.3* MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 RDWSD-47.8* Plt ___ ___ 05:30AM BLOOD WBC-5.3 RBC-3.78* Hgb-11.8* Hct-35.7* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.2 RDWSD-49.7* Plt ___ ___ 05:00AM BLOOD WBC-4.9 RBC-3.77* Hgb-11.6* Hct-35.1* MCV-93 MCH-30.8 MCHC-33.0 RDW-14.1 RDWSD-48.1* Plt ___ ___ 05:10AM BLOOD WBC-5.1 RBC-3.59* Hgb-11.2* Hct-33.8* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.4 RDWSD-49.9* Plt ___ ___ 06:04AM BLOOD WBC-6.5 RBC-3.42* Hgb-10.5* Hct-32.1* MCV-94 MCH-30.7 MCHC-32.7 RDW-14.6 RDWSD-50.7* Plt ___ ___ 04:52AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.6* Hct-32.1* MCV-95 MCH-31.3 MCHC-33.0 RDW-14.9 RDWSD-52.1* Plt ___ ___ 05:04AM BLOOD WBC-4.2 RBC-3.62* Hgb-11.2* Hct-34.3* MCV-95 MCH-30.9 MCHC-32.7 RDW-14.6 RDWSD-51.3* Plt ___ ___ 07:25PM BLOOD WBC-6.4 RBC-3.45* Hgb-10.8* Hct-33.5* MCV-97 MCH-31.3 MCHC-32.2 RDW-15.4 RDWSD-55.3* Plt ___ ___ 04:29AM BLOOD Neuts-72.9* ___ Monos-4.1* Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.25 AbsLymp-1.32 AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01 ___ 07:25PM BLOOD Neuts-51.4 ___ Monos-7.4 Eos-5.2 Baso-1.1* Im ___ AbsNeut-3.26 AbsLymp-2.20 AbsMono-0.47 AbsEos-0.33 AbsBaso-0.07 ___ 04:52AM BLOOD ___ PTT-27.3 ___ ___ 04:29AM BLOOD ___ PTT-52.9* ___ ___ 05:20AM BLOOD ___ PTT-25.5 ___ ___ 05:00AM BLOOD ___ PTT-25.6 ___ ___ 07:25PM BLOOD ___ PTT-29.1 ___ ___ 04:52AM BLOOD Glucose-180* UreaN-17 Creat-0.9 Na-133* K-4.7 Cl-94* HCO3-27 AnGap-12 ___ 04:29AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-132* K-4.7 Cl-94* HCO3-26 AnGap-12 ___ 05:20AM BLOOD Glucose-215* UreaN-15 Creat-0.8 Na-134* K-5.0 Cl-96 HCO3-25 AnGap-13 ___ 05:24AM BLOOD Glucose-175* UreaN-18 Creat-0.8 Na-135 K-4.8 Cl-98 HCO3-25 AnGap-12 ___ 05:55AM BLOOD Glucose-164* UreaN-22* Creat-1.0 Na-133* K-4.6 Cl-96 HCO3-24 AnGap-13 ___ 06:06AM BLOOD Glucose-112* UreaN-19 Creat-0.8 Na-133* K-4.8 Cl-96 HCO3-24 AnGap-13 ___ 04:11AM BLOOD Glucose-149* UreaN-22* Creat-1.1 Na-132* K-5.0 Cl-93* HCO3-24 AnGap-15 ___ 05:45PM BLOOD Glucose-258* UreaN-23* Creat-1.1 Na-133* K-4.6 Cl-95* HCO3-25 AnGap-13 ___ 04:15AM BLOOD Glucose-173* UreaN-22* Creat-1.1 Na-131* K-5.0 Cl-95* HCO3-24 AnGap-12 ___ 05:29PM BLOOD Glucose-225* UreaN-27* Creat-1.2 Na-129* K-5.5* Cl-92* HCO3-25 AnGap-12 ___ 05:20AM BLOOD Glucose-213* UreaN-20 Creat-1.0 Na-131* K-5.1 Cl-94* HCO3-25 AnGap-12 ___ 03:44PM BLOOD Glucose-158* UreaN-22* Creat-1.2 Na-131* K-5.7* Cl-92* HCO3-22 AnGap-17 ___ 05:30AM BLOOD Glucose-158* UreaN-22* Creat-1.1 Na-131* K-5.4 Cl-94* HCO3-26 AnGap-11 ___ 05:00AM BLOOD Glucose-227* UreaN-18 Creat-1.0 Na-133* K-5.1 Cl-97 HCO3-25 AnGap-11 ___ 05:10AM BLOOD Glucose-290* UreaN-18 Creat-1.0 Na-134* K-5.1 Cl-97 HCO3-26 AnGap-11 ___ 06:04AM BLOOD Glucose-239* UreaN-18 Creat-0.9 Na-138 K-4.8 Cl-101 HCO3-24 AnGap-13 ___ 04:52AM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-137 K-4.5 Cl-98 HCO3-25 AnGap-14 ___ 07:25PM BLOOD UreaN-10 ___ 04:29AM BLOOD ALT-32 AST-19 AlkPhos-95 TotBili-0.4 ___ 05:00AM BLOOD ALT-25 AST-24 LD(LDH)-167 AlkPhos-99 TotBili-0.3 ___ 07:25PM BLOOD ALT-12 AST-25 AlkPhos-123 TotBili-0.3 ___ 07:25PM BLOOD cTropnT-<0.01 ___ 04:52AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9 ___ 04:29AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.8 ___ 05:20AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8 ___ 05:24AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8 ___ 05:55AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.9 ___ 06:06AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9 ___ 04:11AM BLOOD Calcium-9.9 Phos-4.0 Mg-1.9 ___ 05:45PM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9 ___ 04:15AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9 ___ 05:29PM BLOOD Calcium-9.9 Phos-4.1 Mg-2.1 ___ 05:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0 ___ 05:30AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1 ___ 05:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.8 Mg-2.1 Iron-93 ___ 05:10AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.1 ___ 06:04AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0 ___ 04:52AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.0 ___ 07:25PM BLOOD Albumin-4.5 ___ 05:00AM BLOOD calTIBC-321 Ferritn-59 TRF-247 ___ 05:00AM BLOOD %HbA1c-8.4* eAG-194* ___ 05:45PM BLOOD Osmolal-286 ___ 03:44PM BLOOD Osmolal-285 ___ 05:20AM BLOOD TSH-1.8 ___ 05:00AM BLOOD 25VitD-37 ___ 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 08:02PM BLOOD Glucose-150* Creat-0.9 Na-139 K-4.0 Cl-99 calHCO3-29 ___ 08:35PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 08:35PM URINE Blood-NEG Nitrite-POS* Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 08:35PM URINE RBC-1 WBC-172* Bacteri-FEW* Yeast-NONE Epi-0 ___ 08:35PM URINE Mucous-RARE* ___ 06:07AM URINE Hours-RANDOM UreaN-736 Creat-78 Na-86 K-61 Cl-84 HCO3-2 ___ 07:09PM URINE Hours-RANDOM Na-91 ___ 03:44PM URINE Hours-RANDOM UreaN-563 Creat-47 Na-65 K-34 Cl-55 HCO3-2 ___ 06:07AM URINE Osmolal-557 ___ 07:09PM URINE Osmolal-654 ___ 03:44PM URINE Osmolal-441 ___ 08:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG ___ 12:50PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-29* Polys-7 ___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-12* Polys-0 ___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-156 LD(LDH)-40 ___ 06:10AM BLOOD WBC-4.8 RBC-3.79* Hgb-12.1* Hct-35.2* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.6 RDWSD-46.2 Plt ___ ___ 06:10AM BLOOD ___ PTT-25.1 ___ ___ 06:10AM BLOOD Glucose-194* UreaN-18 Creat-0.9 Na-134* K-4.7 Cl-94* HCO3-28 AnGap-12 ___ 06:10AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8 Brief Hospital Course: Mr. ___ is a ___ HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy ___ w/ rapid met recurrence s/p C3 TIP ___ who p/w RLE/RUE weakness and a fall, found to have new brain lesion, concerning for metastatic disease or second primary tumor. TRANSITIONAL ISSUES =================== [ ] Continue dexamethasone 4 mg BID until follow up with neuro-oncology. This was tapered from TID as of ___ evening. His insulin needs will fluctuate with this taper. His insulin is being decreased by 30% to accommodate this change, but will likely need further adjustment in insulin based on his sliding scale needs. [ ] Discharge diabetes regimen: - Continue Lantus 25 units QHS - Continue Humalog 12 units AC breakfast, Humalog 10 units AC lunch and Humalog 8 units AC supper - Continue sliding scale to start at 200 mg/dL 2 units+2 units/50mg/dl - Metformin 1000 mg daily [ ] Continue PPI and Bactrim for prophylaxis while on steroids. [ ] Recommend slow dexamethasone taper when indicated given prolonged course. Would recommend transition to hydrocortisone to complete taper before stopping completely. [ ] Continue Keppra for seizure prophylaxis. [ ] Recommend rechecking electrolytes in 1 week to assess hyponatremia. [ ] Continue outpatient follow up with primary oncologist, neuro oncologist and radiation oncology. #New left frontoparietal brain lesion His R hemiplegia is most likely from the new brain lesion. MRI demonstrated a 1 cm lesion with vasogenic edema. There is a question of whether this is a metastatic lesion vs new primary. Total spine MRI without additional lesions. S/p LP with CSF Cytology, CEA, immunofixation and Beta2 macroglobulin negative. More likely metastasis from penile Ca > new primary (e.g. GBM). Was seen by Neurosurgery, but patient denied surgery or biopsy. With the caveat that a GBM would do poorly with radiation, patient elected to start Cyber Knife treatments to lesion. Started Stereotactic XRT for brain lesion, and completed three fractions (___). Received dexamethasone before and during radiation for reduction of vasogenic edema with good response and significant return of strength to RUE and RLE. His dexamethasone was tapered from 4 mg QID to TID, then to BID on discharge. #T2DM #Increasing insulin requirements T2DM background, on home metformin, held as inpatient. Required large amounts of short acting insulin with metformin held and Dexamethasone treatment. Had been started on Glargine nightly and humolog with meals. The ___ has been consulted and followed along, insulin scales adjusted as needed, insulin teaching was provided prior to discharge. While on dexamethasone 4 mg TID he was stabilized on insulin regimen of glargine 35 U QHS, Humalog 17 U breakfast/14 U lunch/12 U dinner with sliding scale. His insulin was decreased by 30% on day of discharge given the plan to taper his dexamethasone. His metformin was held during the admission and restarted on discharge. #Hypointensity in the C4 and C5 vertebral bodies Dedicated C-spine MRI negative for spinal mets per Neuro Onc. T11 lesion identified by CT Torso and T-Spine MRI has been stable since ___ and unlikely represented new progression of disease. #RUE, RLE weakness Secondary to new brain lesion as above. As per neuro oncology, less likely that RLE will recover. Radiation planned. ___ consulted and are following, able to walk for short distances daily. Will be discharged to ___ rehab. #UTI / Asymptomatic Bacteuria ED UA reflexed to ___ and found to have bacteria in urine. Was started on Ceftriaxone for empiric care, final culture grew ENTEROBACTER CLOACAE COMPLEX, and so therapy was escalated to IV Cefepime and then changed to PO Bactrim. Assymptomatic and may be colonized, however chose to complete a course of seven days. #Hyponatremia Sodium trending low with nadir of 131 (baseline 141 on admission). Clinically euvolemic. Normal blood osmolality, urine Na=65 and urine osmolality=441 raise concern for SIADH in the presence of known brain lesion, which was communicated to care team. Hyponatremia asymptomatic. Stable at 131 with water restriction, but seems dry by kidney function. Sodium up to 133 after 500ml NS, but urine more concentrated (sodium 90, Osm ~600). Sodium stable at 133 with further hydration and resolution of renal function to baseline, supporting hypovolemia. TSH wnl. Sodium stable after gentle hydration. Electrolytes were trended as needed. #Met Penile Squamous Cell Ca Unfortunately his high risk localized disease has rapidly progressed to at least soft tissue and RP nodes. He is being treated with TIP with palliative intent ___ ___ ___ w/near CR. He completed TIP therapy ___ and has close f/u with oncology. Given negative LP and scans, planned for surveillance as outpatient with follow up imaging at 8 weeks with therapy reserved in case of progression of disease. #Asthma: quiescent - Continued advair/flonase, albuterol prn #HTN: - Held ACEI and remained normotensive so was not continued on discharge. Held aspirin indefinitely given brain lesion. #Dyslipidemia: - Continued statin #RA: - Continued prn oxy #CODE STATUS: FULL CODE (Confirmed ___ with patient) This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lisinopril 10 mg PO DAILY 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 7. Vitamin D 1000 UNIT PO DAILY 8. Dexamethasone 4 mg PO ASDIR 9. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. Atorvastatin 40 mg PO QPM 12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 13. diclofenac sodium ___ grams topical BID Discharge Medications: 1. Glargine 25 Units Bedtime Humalog 12 Units Breakfast Humalog 10 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. LevETIRAcetam 1000 mg PO Q12H 3. Omeprazole 20 mg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 8.6 mg PO DAILY:PRN Constipation - Second Line 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Dexamethasone 4 mg PO BID Continue BID dosing until follow up with his neuro-oncologist 8. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 9. Atorvastatin 40 mg PO QPM 10. Docusate Sodium 100 mg PO BID:PRN constipation 11. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Do Not Crush 14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 15. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 16. Vitamin D 1000 UNIT PO DAILY 17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until you follow you with the ___ ___ clinic 18. HELD- diclofenac sodium ___ grams topical BID This medication was held. Do not restart diclofenac sodium until you follow up with the ___ clinic 19. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until You follow up with your PCP and your blood pressure is evaluated. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Metastatic Penile Squamous Cell Carcinoma New Brain Lesion, most likely ___ metastasis Hyperglycemia Type II Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at ___ ___! Why was I here? - You came to the hospital because you noticed weakness in your right leg and right arm. What was done while I was here? - You had a scan of your head which showed a mass. - This mass was thought to be causing your symptoms and looked consistent with a cancer. - You had a spinal tap which did not show any cancer cells. - You were started on steroids which helped with your weakness. - You had radiation therapy to your brain. - You were seen by physical therapy who recommended discharge to an acute rehab facility to help you gain your strength back. What should I do when I get home? - Please take all of your medications as prescribed and go to all of your follow up appointments as listed below. We wish you the best! - Your ___ Team Followup Instructions: ___

10030579-DS-11

DS

2189-07-07 00:00:00

2189-07-07 14:56:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Hayfever / adhesive tape / Latex / Effexor XR Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: R hip TFN - ___ History of Present Illness: HPI: ___ male with history of hepatic steatosis presents s/p fall with R hip pain and deformity. States he was watching television this morning when he dozed off, rolled off the cough landing on his right side on a concrete floor with immediate onset of severe R hip pain. Also reports mild L anterior chest wall pain. Called EMS and was transported to ___ ED where he was noted to have shortening and external rotation of the R leg with intact neurovascular exam. No other complaints at this time. Imaging showed an intertrochanteric fracture of the R hip, for which we are consulted. Past Medical History: PMH/PSH: -Hepatic steatosis -Perforated duodenal ulcer, s/p repair -L shoulder labral repair -Bilateral meniscal repair -Ruptured appendix s/p appendectomy Social History: ___ Family History: N/C Physical Exam: Exam on Discharge 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 intertrochanteric fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hip TFN 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 rehab 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 WBAT in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram ___ mg PO DAILY 2. Gabapentin 600 mg PO TID 3. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis 4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 5. QUEtiapine Fumarate 50-100 mg PO QHS 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Citalopram ___ mg PO DAILY 2. Gabapentin 600 mg PO TID 3. Multivitamins 1 TAB PO DAILY 4. QUEtiapine Fumarate 50-100 mg PO QHS 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 6. Calcium Carbonate 1250 mg PO TID 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks Start: Today - ___, First Dose: Next Routine Administration Time 9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain Do not drink alcohol, drive, or operate heavy machinery while taking. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 hours Disp #*50 Tablet Refills:*0 10. Senna 8.6 mg PO DAILY 11. Vitamin D 800 UNIT PO DAILY 12. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right intertrochanteric femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Instructions After Orthopedic 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: - Weight bearing as tolerated right lower extremity with upper extremity assist as needed 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 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. - No dressing is needed if wound continues to be non-draining. - 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 Physical Therapy: ___ - WBAT RLE with upper extrmeity assist as needed Treatments Frequency: Dry sterile dressing changes daily, as needed PRN staining. Followup Instructions: ___

10030682-DS-13

DS

2118-01-31 00:00:00

2118-01-31 14:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Cervical stenosis with spinal cord compression Major Surgical or Invasive Procedure: ___ - C3-C7 laminectomies and posterior fusion History of Present Illness: ___ is a ___ year old female who presented to the Emergency Department on ___ as a transfer from an outside facility status post motor vehicle collision with complaints of generalized numbness and weakness. The patient was transferred to ___ for further evaluation and management. MRI of the cervical spine in the Emergency Department was concerning for cervical stenosis with spinal cord compression. The Neurosurgery Service was consulted for question of acute neurosurgical intervention. Past Medical History: - hyperlipidemia - hypertension Social History: ___ Family History: Noncontributory Physical Exam: On Admission: ------------- Vital Signs: T 98.1F, HR 66, BP 126/59, RR 17, O2Sat 96% on room air General: Well nourished. In cervical collar. Extremities: Warm and well perfused. Neurologic: Mental Status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: Deltoid Biceps Triceps Wrist Extension Wrist Flexion Grip Right4- 4- 4- 0 0 0 Left4- 4- 3 0 0 0 IP Quadriceps Hamstring AT ___ Gastrocnemius Right2 3 2 2 3 2 Left2 3 2 2 3 2 Sensation: Intact to light touch and pinprick, but complaining of diffuse numbness. Reflexes: Right biceps reflex 2+. Unable to elicit left biceps reflex. Patellar reflexes 2+ bilaterally. Toes mute. Proprioception intact. Rectal tone intact. No ___ sign bilaterally. No clonus bilaterally. On Discharge: ------------- Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trapezius Deltoid Biceps Triceps Grip WF WE Right5 4+ 5 5 5 4+ 5 Left5 4+ 4+ 4- 3 4+ 5 IP Quadriceps Hamstring AT ___ Gastrocnemius Right5 5 4+ 5 5 5 Left5 5 4+ 5 5 5 [x]Sensation intact to light touch Pertinent Results: Please see ___ Record for relevant laboratory and imaging results. Left Shoulder Xray Study Date of ___ 9:45 AM IMPRESSION: 1. Calcific tendinosis of the supraspinatus/infraspinatus. 2. Minimal degenerative changes in the left shoulder 3. No acute fracture or dislocation. Radiology Report ___ NON-TRAUMA ___ VIEWS Study Date of ___ 2:26 ___ IMPRESSION: There is posterior fusion hardware from C3 to C7. No hardware related complications are seen. There are degenerative changes with loss of intervertebral disc height at several levels and worse at C3-C4 and C4-C5. Lung apices are grossly clear. Radiology Report BILAT LOWER EXT VEINS Study Date of ___ 10:52 AM IMPRESSION: No evidence of venous thrombosis. UNILAT UP EXT VEINS US RIGHT Study Date of ___ 3:10 ___ IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 5:21 AM IMPRESSION: 1. Status post bilateral laminectomy and posterior fusion at C3-C7 with expected postsurgical changes. 2. New focal expansion and increased T2 signal within the cord at the C3-4 level. Some degree of underlying myelomalacia is suspected at the C4-5 level. 3. Overall improvement in the degree of spinal canal narrowing from C2-C7, with the worst level, at C2-3, displaying mild to moderate spinal canal narrowing. MR ___ W/O CONTRAST Study Date of ___ 3:12 ___ IMPRESSION: 1. Motion limited exam. 2. Prevertebral edema from the craniocervical junction through C5-C6. No clear evidence for anterior longitudinal ligament edema or disruption, but evaluation is limited by motion. No other evidence for ligamentous edema or bone marrow edema. 3. From C3-C4 through C5-C6, there are disc protrusions and endplate osteophytes severely narrowing the spinal canal and compressing the spinal cord. At C6-C7, right paracentral disc protrusion endplate osteophytes cause moderate spinal canal narrowing with ventral spinal cord remodeling. There is patchy T2 hyperintensity in the cord from C2-C3 through C6-C7 levels, which may represent contusion in the setting of trauma, versus chronic myelomalacia in the setting of spinal canal stenosis. 4. No evidence for acute traumatic injuries in the thoracic or lumbar spine. 5. Multilevel lumbar degenerative disease. Spinal canal stenosis is moderate to severe at L4-L5, and moderate at L3-L4 and L5-S1, with crowding of the intrathecal nerve roots. There is also mass effect on multiple traversing and exiting nerve roots, as detailed above. 6. Trace left pleural effusion and mild bilateral dependent atelectasis. 7. Highly distended bladder. Please correlate clinically whether the patient is able to void. Brief Hospital Course: ___ year old female with cervical stenosis s/p motor vehicle collision with central cord syndrome. #Cervical Stenosis With Spinal Cord Compression #Central cord syndrome The patient was taken emergently to the operating room for a C3-C7 laminectomy and posterior fusion. The procedure was uncomplicated. Please see separately dictated operative report by Dr. ___ further details. A surgical drain was left in place, which was subsequently removed on POD#5. The patient was extubated in the operating room and recovered in the PACU. She was transferred to the step down unit for close neurologic monitoring. Her neurologic exam slowly improved postoperatively. Postoperative x-rays of the cervical spine showed no evidence of retained surgical drain or hardware complications. On ___ overnight, the patient was noted to have worsened weakness on exam. A CT of the cervical spine was obtained, which was grossly negative, but there was significant artifact from the hardware. An MRI of the cervical spine was also obtained, which showed increased T2 signal in cord at C3-C4, but overall improvement in the degree of spinal canal narrowing from C2-C7. Her weakness subsequently improved and continued to improve with continued physical and occupational therapy. #Rib Fracture Acute Care Surgery was consulted for fracture of the first rib on the left. There was no surgical intervention or follow-up needed. #Hypoxia The patient required supplemental oxygen on ___. She was subsequently weaned off the supplemental oxygen, and her oxygen saturations remained stable on room air for the remainder of her hospitalization. #Right Shoulder and wrist Pain The patient complained of significant right shoulder pain. An x-ray of the right shoulder was obtained, which showed no definite fracture or dislocation, however there was a well corticated rounded density, which was thought to reflect sequela of remote injury or calcific tendinitis. She also c/o significant right wrist pain. An ultrasound of the right wrist was negative. Pain medications were adjusted. #Urinary Retention The patient experienced urinary retention postoperatively. Her Foley catheter was discontinued. She failed a voiding trial on ___, and catheter was replaced. Her Foley catheter was discontinued again on ___, and she was able to void but still required intermittent straight cath for retention. On discharge patient was voiding without difficulty. #Constipation / Ileus She was started on an aggressive bowel regimen for constipation. On ___, the patient was noted to have abdominal distension. KUB showed postop ileus. No nausea/vomiting. She was made NPO, limited narcotics, and continued on aggressive bowel regimen. Repeat abdominal XR ___ showed interval improvement. On ___, the patient was passing her bowels and her diet was advanced to regular. A repeat KUB showed interval improvement of the ileus. On discharge patient was moving her bowels without difficulty. #Fever #UTI The patient became febrile postoperatively. Urinalysis was positive. Urine culture showed PROTEUS MIRABILIS UTI. She was started on Ceftriaxone ___. Blood cultures were negative. Chest x-ray was negative. On discharged there is no evidence of UTI or ongoing infection, patient is afebrile. #Hyponatremia The patient was hyponatremic and was started on sodium chloride tablets on ___ with improvement. On ___, the patient's serum Na level remained low and the salt tablets were increased. The serum Na level normalized on ___ and the sodium was monitored closely. On ___, the salt tablets were titrated down to 1g three times daily. The serum sodium continued to be monitored, and was stable on ___. Her sodium tablets were weaned off and her serum sodium levels remained stable. #Elevated BUN The patient's BUN was elevated. She received a 500mL normal saline bolus on ___ with improvement. The BUN returned to normal range on ___. Her BUN was elevated on ___ and returned to normal limits the next day. #Left shoulder pain Patient developed severe left shoulder pain ___. Ibuprofen was started with some relief. XR on ___ showed no fracture or dislocation, but did show mild calcific tendinitis. Ibuprofen was increased and continued ___ was recommended. #Disposition Physical Therapy and Occupational Therapy were consulted and recommended discharge to rehabilitation. However, the patient's health insurance does not provide any rehabilitation benefits. Family training was done inpatient to work towards a safe discharge. Social Work was consulted given her limited health insurance. A family meeting was organized that resulted in the patient's family working to get the patient insurance so benefits can be obtained. The goal was to obtain benefits for acute rehab at the recommendation of physical therapy, either through the ___ or ___. A second family meeting was held ___ where her son, ___, was given power of attorney and health care proxy status as the family worked on insurance. Patient was approved for health insurance on ___. She was discharged on ___ to ___ for further care. Medications on Admission: - hydrochlorothiazide 12.5mg by mouth once daily - lisinopril 40mg by mouth once daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line 3. Docusate Sodium 100 mg PO BID 4. Fleet Enema (Mineral Oil) ___AILY:PRN constipation 5. Gabapentin 300 mg PO TID 6. Heparin 5000 UNIT SC BID 7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 8. Lidocaine 5% Patch 2 PTCH TD QAM 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 10. Polyethylene Glycol 17 g PO DAILY 11. Senna 8.6 mg PO BID 12. Simethicone 40-80 mg PO QID:PRN gas pain 13. Hydrochlorothiazide 12.5 mg PO DAILY 14. Lisinopril 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Cervical stenosis with spinal cord compression Urinary tract infection ileus post operative pain electrolyte abnormalities Rib 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 Cervical Spinal Fusion Surgery •Do not apply any lotions or creams to the site. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •Please do NOT take any blood thinning medication (Plavix, Coumadin) until cleared by the neurosurgeon. You are cleared to take Aspirin and Ibuprofen if indicated. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •New weakness or changes in sensation in your arms or legs. Followup Instructions: ___

10030746-DS-19

DS

2169-07-12 00:00:00

2169-07-12 13:06:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: ___ Cardiac catheterization ___: Coronary artery bypass grafts x3 (LIMA-LAD, SVG-AntRV, SVG-OM1); Endovascular saphenous vein harvest History of Present Illness: Mr. ___ is a ___ year old male with a past medical history of diabetes mellitus type 2, hyperlipidemia, and hypertension. He initially presented to his PCP with epigastric pain and nausea. An EKG reportedly showed accelerated junctional rhythm with HR ___. He was then sent to ___ and EKG showed sinus bradycardia. He ruled in NSTEMI and was then transferred to ___ for coronary angiogram which revealed three-vessel disease. Cardiac surgery consulted for revascularization. Past Medical History: Diabetes mellitus type 2 Gastritis c/b duodenal stricture Hyperlipidemia Hypertension Social History: ___ Family History: Father w/ MI and passed in his ___ Mother CVA and passed at ___ Physical Exam: BP: 120/72 HR: 56 RR: 18 O2 sat: 97% RA Height: 68 in Weight: 74.9 kg Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ ___ Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: none Discharge examination 24 HR Data (last updated ___ @ 727) Temp: 98.1 (Tm 99.1), BP: 114/65 (112-133/65-79), HR: 64 (60-71), RR: 16 (___), O2 sat: 96% (95-98), O2 delivery: Ra, Wt: 167.33 lb/75.9 kg Fluid Balance (last updated ___ @ 859) Last 8 hours Total cumulative -230ml IN: Total 420ml, PO Amt 420ml OUT: Total 650ml, Urine Amt 650ml Last 24 hours Total cumulative -1270ml IN: Total 880ml, PO Amt 880ml OUT: Total 2150ml, Urine Amt 2150ml Physical Examination: General: NAD Neurological: A/O x3 non focal Cardiovascular: RRR no murmur or rub Respiratory: CTA No resp distress GI/Abdomen: Bowel sounds present Soft ND NT multipleBM andpassing flatus Extremities: Right Upper extremity Warm Edema tr Left Upper extremity Warm Edema tr Right Lower extremity Warm Edema tr Left Lower extremity Warm Edema tr Pulses: DP Right:p Left:p ___ Right:p Left:p Radial Right:p Left:p Sternal: CDI no erythema or drainage Sternum stable Lower extremity: Left CDI Pertinent Results: Cardiac Catheterization ___ at ___ LM: 70% stenosis in the distal segments, eccentric, calcified LAD: medium caliber vessel. Cx: large caliber vessel; 70-80% stenosis in the ostium that extends into the ___ Obtuse Marginal RCA: 80% stenosis in the ostium; 100% stenosis in the mid and distal segments. Collaterals from the mid segment of the AM connect to the distal segment. Transthoracic Echocardiogram ___ There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. Overall left ventricular systolic function is mildly depressed secondary to hypokinesis of the inferior and posterior walls. The visually estimated left ventricular ejection fraction is 45%. Tricuspid annular plane systolic excursion (TAPSE) is normal. There is no evidence for an aortic arch coarctation. There is mild [1+] mitral regurgitation. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. IMPRESSION: inferior posterior hypokinesis; mild mitral regurgitation Transesophageal Echocardiogram ___ PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Left Atrium ___ Veins: Dilated ___. No spontaneous echo contrast or thrombus in the ___. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Dilated RA. No spontaneous echo contrast or thrombus is seen in the RA/RA appendage. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Mild symmetric hypertrophy. Normal cavity size. Mild-moderate global hypokinesis. Mildly depressed ejection fraction. Right Ventricle (RV): Mild global hypokinesis. Aorta: Normal ascending diameter. No dissection. Simple atheroma of ascending aorta. Simple arch atheroma. Simple descending atheroma. Aortic Valve: Moderately thickened (3) leaflets. Moderate leaflet calcification. Minimal stenosis. No regurgitation. Mitral Valve: Moderately thickened leaflets. Moderate leaflet calcification. No systolic prolapse. No stenosis. Mild annular calcification. Mild [1+] regurgitation. Central jet. Pulmonic Valve: Thickened leaflets. Trivial regurgitation. Tricuspid Valve: Mildly thickened leaflets. Mild annular calcification. Mild [1+] regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 14:16:00. Atrial paced rhythm. Support: Vasopressor(s): none. Left Ventricle: Systolic function is improved. Global ejection fraction is normal. Right Ventricle: Improved systolic function. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. No change in aortic regurgitation. Mitral Valve: No change in mitral valve morphology from preoperative state. No change in valvular regurgitation from preoperative state. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. ___ 06:10AM BLOOD WBC-7.5 RBC-3.67* Hgb-11.2* Hct-34.2* MCV-93 MCH-30.5 MCHC-32.7 RDW-11.9 RDWSD-40.5 Plt ___ ___ 06:10AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-140 K-3.6 Cl-99 HCO3-31 AnGap-10 ___ 11:34PM BLOOD WBC-8.2 RBC-4.46* Hgb-13.8 Hct-41.0 MCV-92 MCH-30.9 MCHC-33.7 RDW-12.0 RDWSD-40.6 Plt ___ ___ 06:51AM BLOOD ___ PTT-41.3* ___ ___ 11:34PM BLOOD Glucose-270* UreaN-13 Creat-1.2 Na-141 K-3.9 Cl-102 HCO3-27 AnGap-12 ___ 07:06PM BLOOD ALT-23 AST-36 LD(LDH)-312* AlkPhos-46 Amylase-30 TotBili-0.4 ___ 05:35PM BLOOD CK(CPK)-719* ___ 06:51AM BLOOD CK-MB-30* cTropnT-1.26* ___ 07:06PM BLOOD Lipase-22 ___ 05:35PM BLOOD CK-MB-70* MB Indx-9.7* ___ 05:35PM BLOOD cTropnT-0.53* ___ 06:10AM BLOOD Mg-2.0 ___ 02:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.5 ___ 06:10AM BLOOD ALT-9 AST-11 LD(LDH)-203 AlkPhos-41 Amylase-13 TotBili-0.4 Brief Hospital Course: Presented to OSH with epigastric pain and ruled in for NSTEMI and was transferred for cardiac workup including cardiac catheterization that revealed significant coronary artery disease. He was managed under cardiology and cardiac surgery was consulted for surgical evaluation. He underwent routine preoperative testing and evaluation. He remained hemodynamically stable and was taken to the operating room on ___. He underwent coronary artery bypass grafting x 3. Please see operative note for full details. Post operatively he was taken to the intensive care unit for management on Propofol and nitroglycerin. Within a few hours he was weaned of sedation, awoke neurologically intact and was extubated without complications. He was transitioned to nicardipine for blood pressure control. He continued to progress and was transitioned to betablocker and diuretic on post operative day one allowing nicardipine to be weaned off. He continued to progress and was transitioned to the floor. Chest tubes and epicardial wires were removed per protocol. He developed nausea and medications were adjusted including pain medications and bowel medications. It resolved after bowel movement and scopolamine patch. He was then able to tolerate oral intake. He worked with physical therapy on strength and mobility with recommendation for home with services. He was clinically stable, tolerating diet and pain controlled with acetaminophen at time of discharge home on post operative day four. Plan to have labs checked in few days due to recent addition of Ace inhibitor due to recent NSTEMI. Medications on Admission: 1. Rosuvastatin Calcium 20 mg PO QPM 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. GlipiZIDE 5 mg PO BID 4. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 5. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 6. Metoprolol Tartrate 50 mg PO BID RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 8. Scopolamine Patch 1 PTCH TD ONCE nausea Duration: 72 Hours remove ___. Senna 17.2 mg PO DAILY change to as needed if loose stool RX *sennosides 8.6 mg 2 tablets by mouth once a day Disp #*60 Tablet Refills:*0 10. Omeprazole 40 mg PO DAILY 40 mg for 1 month daily then decrease back to 20 mg daily as prior to admission RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 11. Rosuvastatin Calcium 40 mg PO QPM RX *rosuvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 12. GlipiZIDE 5 mg PO BID 13. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Coronary Artery Disease s/p coronary revascularization Non-ST Elevation Myocardial Infarction Secondary Diagnosis: Diabetes Mellitus Type II Gastritis Hyperlipidemia Hypertension Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with acetaminophen Sternal Incision - healing well, no erythema or drainage Left Leg EVH - healing well, no erythema or drainage Edema trace Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___

10030753-DS-28

DS

2194-04-25 00:00:00

2194-04-26 10:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Chest pain, presyncopal episode, hyperglycemia. Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo woman with extensive PMH including poorly controlled DM1, CAD (s/p MI, s/p PTCA w/ angioplasty to OM1 no stent ___, CREST syndrome, APLA, PE in ___ on coumadin, GERD, and hypothyroidism who is admitted for chest pain, hyperglycemia and presuncopal event. . Last night she felt lousy as if her blood pressure was dropping. She stood up to answer the door and felt unsteady. She denied lightheadedness or dizziness. She hit her head when she fell but denies headache, neck pain, or LOC. . She reports right arm and chest pain starting at approximately 8:00 last night. She feels as if her right arm pain is her anginal equivalent, and was relieved by nitro when given in the ED. She felt ___ right sided chest pressure is around her breast and is worse when moving around and with deep breathing. . She reports an increasing blood sugar over the past 24 hours. It was 200 then 400 after not eating. She gave herself 20U of humalog at home. . She reports a UTI which has been treated "since ___". She could not remember the antibiotic she was using, but nitrofurantoin was listed in OMR. It appears that she has been switching antibiotics since then. She was instructed to straight cath daily but has been only spot cathing when she feels as if she needs to since ___. . She called EMS after her presyncopal event and complained of right arm pain. EMS reported no deformity of the right arm and a critically high BS. . In the ED, initial vitals were Pain ___ 99/46 14 98% on RA. Labs revealed trop neg X1 (2AM), WBC 10.6 w/ 90% PMN, Cr:BUN 1.3 (recent baseline Cr 0.9-1.1), Glu = 522, Lactate = 3.8, INR = 2.1, UA: Glu +++, Ketone +. EKG: (ED read) sinus tachycardia 100, indeterminate axis (isoelectric in all limb leads), small Q wave at III, IRBBB, NI, ? minimal < 0.5mm STE II, III, V2-V6 (STE and axis are changed from prior tracing of ___. CXR: (ED read) AP film, no infiltrate, edema, effusions; unchanged from prior. Her arm/chest pain resolved with NTGX2. She got Aspirin 81mg and got 14u humalog per patient's home sliding scale for a FSBS of ___ NS given. and she had an #18 RFA #20 LFA from the field. Most Recent Vitals prior to transfer were afeb 94 116/57 19 97% RA. . Currently, she reports her right arm pain has completely resolved. She reports persistent right sided chest pain. . ROS: +per HPI, fever, night sweats, nausea, constipation, food getting stuck/not going down as easily -chills, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder treated - ESRD ___ diabetes s/p L side living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - CAD s/p MI in ___, s/p PTCA ___: one vessel disease with LAD 60% apical lesion and 90% ___ diagonal lesion. ___ diagonal branch was treated with ballon angioplasty w/o stenting. Final angiography demonstrated ___ residual stenosis and improved flow down the diagonal branch - LVH - Gastroparesis - GERD/Hiatal hernia - Hypothyroidism - Gout - Herniated disk - OSA not on CPAP - Multiple UTI's Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Physical Exam: VS - 98.2 124/76 59 18 100% on RA GENERAL - NAD, uncomfortable with movement, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, ___ systolic murmur heard best over USB, nl S1-S2, markedly tender at right parasternal border and around right breast ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding, no graft tenderness EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, decreased sensation in lower extremities bilaterally, cerebellar exam intact Pertinent Results: Labs: ___ 02:00AM BLOOD WBC-10.6 RBC-3.84* Hgb-12.3 Hct-35.8* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.0 Plt ___ ___ 02:00AM BLOOD Neuts-91.2* Lymphs-5.4* Monos-3.3 Eos-0.1 Baso-0.1 ___ 02:14AM BLOOD ___ PTT-43.6* ___ ___ 02:00AM BLOOD Plt ___ ___ 11:15AM BLOOD Glucose-148* UreaN-22* Creat-1.0 Na-139 K-3.6 Cl-107 HCO3-25 AnGap-11 ___ 06:55PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:15AM BLOOD tacroFK-8.8 ___ 02:14PM BLOOD D-Dimer-<150 ___ 02:22AM BLOOD Glucose-478* Lactate-3.8* Na-135 K-3.9 Cl-98 calHCO3-24 ___ 02:22AM BLOOD Hgb-12.8 calcHCT-38 ___ 04:50AM BLOOD Hct-32.8* ___ 04:50AM BLOOD UreaN-19 Creat-1.1 Micro: ___ URINE CULTURE-PENDING ___ Blood Culture, Routine-PENDING Imaging: ___ EKG: ST at 100, NA, NI, RSR' in V2, no ST-T wave changes compared to prior of ___ ___ EKG: NSR at 90, NA, NI, no ST-T wave changes ___ CXR: Lung volumes are low. No focal opacity to suggest pneumonia is seen. No pleural effusion, pulmonary edema or pneumothorax is present. The heart size is top normal. IMPRESSION: No evidence of acute cardiopulmonary process. ___ rib films: No displaced fracture is present. No sclerotic or lytic lesions are Preliminary Reportidentified. On the frontal chest radiograph, the heart size is normal, and Preliminary Reportthe hilar and mediastinal contours are within normal limits. There is no Preliminary Reportfocal consolidation, pleural effusion, or pneumothorax. The patient is Preliminary Reportpost-cholecystectomy. Preliminary ReportIMPRESSION: No rib fractures detected. Brief Hospital Course: ___ yo female with extensive PMH including poorly controlled DM1, CAD (s/p MI, s/p PTCA w/angioplasty to OM1 no stent ___, CREST syndrome, APLA, PE in ___ on coumadin, GERD, and hypothyroidism who is admitted for right arm and chest pain, hyperglycemia and presyncopal event. # Right arm and chest pain: The patient reported her right arm pain was similar to her anginal equivalent and resolved quickly with nitro in the ED. Her right sided chest pain persisted and given concern for a cardiac cause, we obtained an EKG, troponins, telemetry, and a cardiology consult. Multiple EKGs, troponins x3 and the telemetry were negative for ischemic changes. Cardiology agreed that this was not cardiac in origin. Her chest pain was felt to be musculoskeletal given its reproducibility on exam and its improvement with Tylenol. Rib fractures were ruled out with xrays. She was placed on standing Tylenol for one week and will follow up with her primary care physician ___ ___. # Presyncopal episode: Likely related to hypovolemia given elevated urine specific gravity and prerenal ___ in the setting of marked glucouria. She was given IVF during her stay, ate regularly and was not orthostatic prior to discharge. # Uncontrolled Type 1 Diabetes with Complications: Elevated BS at baseline, with hyperglycemia to 400 on a weekly basis. She was treated with her home dose insulin lantus twice daily and a sliding scale. Nutrition was consulted to review consistent carbohydrate, diabetic diets with her. # ESRD s/p left kidney transplant: She was followed by the nephrology team in house and will follow up as an outpatient. Tacro doses were within normal limits during her stay. TRANSITIONAL ISSUES: # Code: Full # Contact: Sister ___ ___ on Admission: ALLOPURINOL ___ mg Tablet - 2 Tablet(s) by mouth once a day ATORVASTATIN 80 mg Tablet by mouth qpm CALCITRIOL 0.25 mcg Capsule by mouth once a day CILOSTAZOL 100 mg Tablet- ___ Tabletby mouth bid 1 qam and ___ qpm DESIPRAMINE 50 mg Tablet by mouth once a day DULOXETINE 30 mg Capsule - 3 Capsule(s) by mouth once a day ESOMEPRAZOLE MAGNESIUM - 40 mg Capsule EC bid GABAPENTIN 600 mg Tablet by mouth twice a day INSULIN GLARGINE 100 unit/mL Solution - 40 units qam, 30 units QPM INSULIN LISPRO 100 unit/mL Cartridge - sliding scale LEVOTHYROXINE 137 mcg Tablet by mouth once a day METOPROLOL SUCCINATE 25 mg Tablet ER 24 hr 0.5 qhs MYCOPHENOLATE MOFETIL 500 mg Tablet by mouth bid NIFEDIPINE 30 mg Tablet ER 24 hr daily NITROGLYCERIN [NITROSTAT] 0.4 mg Tablet, Sublingual - ___ prn CP PREDNISONE 5 mg Tablet ___ Tablet(s) by mouth once a day PROMETHAZINE 25 mg Suppository rectally twice a day prn vomiting PROMETHAZINE 25 mg Tablet by mouth twice a day prn nausea TACROLIMUS 1 mg Capsule by mouth twice a day TRAZODONE 50 mg Tablet by mouth once a day VALSARTAN 40 mg Tablet by mouth once a day WARFARIN 4mg MWF, 3mg STTS ZOLPIDEM 10 mg Tablet by mouth once a day ASPIRIN 81 mg Tablet EC daily CALCIUM CARBONATE-VITAMIN D3 600 mg calcium (1,500 mg)-400 unit bid LOPERAMIDE 2 mg Tablet - ___ Tablet(s) by mouth bid prn OMEGA 3-DHA-EPA-FISH OIL 900 mg (253 mg-647 mg)-1,400 mg Capsule bid Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO qAM (). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 7. prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO HS (at bedtime). 10. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. insulin glargine 100 unit/mL Solution Sig: One (1) 40 Subcutaneous qam. 14. insulin glargine 100 unit/mL Solution Sig: One (1) 30 Subcutaneous qpm. 15. insulin lispro 100 unit/mL Cartridge Sig: One (1) Sliding Scale Subcutaneous every six (6) hours as needed for Hyperglycemia. 16. allopurinol ___ mg Tablet Sig: Two (2) Tablet PO once a day. 17. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for pain: Use one to three tabs as needed for right arm or chest pain. Please call your doctor when this occurs. 18. promethazine 25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 19. promethazine 25 mg Suppository Sig: One (1) Rectal twice a day as needed for nausea. 20. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 21. loperamide 2 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 22. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 23. cilostazol 100 mg Tablet Sig: 0.5 Tablet PO at bedtime. 24. desipramine 50 mg Tablet Sig: One (1) Tablet PO once a day. 25. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 26. gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day. 27. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day: ___. 28. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: ___. 29. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 30. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a day. 31. omega-3 fatty acids Oral 32. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 1 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Chest Pain, Presyncope, Uncontrolled Type 1 Diabetes with complications, Prerenal acute renal failure Secondary Diagnosis: ESRD s/p left kidney transplant, CREST syndrome with scleroderma, GERD 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 ___ during your hospitalization. You were seen here in the hospital when you developed chest pain and fell. You were given nitroglycerin in the emergency department which temporarily relieved your right arm pain. However, your right sided chest pain was persistent. We ruled out all potentially serious etiologies of your chest pain, including heart involvement. You were seen by the cardiologists who do not feel this episode of chest pain is related to your heart. In addition, xrays did not show any evidence of rib fracture. This is most likely musculoskeletal chest pain. Please continue to take up to three grams of Tylenol throughout the day for this discomfort. The following changes were made to your medication regimen: START tylenol ___ three times daily for one week Followup Instructions: ___

10030753-DS-29

DS

2194-10-23 00:00:00

2194-10-24 11:16:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Nausea/vomiting, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ F with a complicated past medical history, including Type I DM c/b ESRD s/p renal transplant ___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote h/o PE on coumadin, and scleroderma, who presents with two days of nausea, vomiting, confusion, and lethargy. The patient developed nausea during a scheduled dobutamine stress test on the evening of ___. Her nausea worsened and she began vomiting on ___, unable to take any POs. She had many episodes of NBNB emesis. She did not check her blood glucose during this time but continued to take her standing insulin (glargine 30U QAM, 40U QHS). On ___, the patient's nausea and vomiting continued and she became weak and lethargic, unable to even 'lift her head up'. She had some moderate substernal burning pain associated with vomiting, which has since resolved. She urinated normally on ___ but did not urinate at all on ___ (she catheterizes herself occasionally for neurogenic bladder. She states her urine looked dark but denies dysuria or hematuria. She also described some mild night sweats and subjective fever. She denies any cough, rhinorrhea, congestion, abdominal pain, diarrhea, or shortness of breath. She presented to ___, where labs were notable for Glucose >600, AG 30, WBC 17.6, Cr 2.0 (baseline 1.0), troponin 0.02. She was started on an insulin gtt, given 3L of NS, and transferred to ___ for further treatment. In the ___ ED her anion gap had decreased to 14. She was quickly converted to SQ insulin with one hour of gtt overlap. By that time her WBC had decreased to 13.5, BUN/Cr 38/1.8. A UA revealed 5 WBC, few bacteria and trace leukocyte esterase, also glucose 1000 and ketones 40. Renal transplant was consulted and recommended treating bacteriuria with Vancomycin and ciprofloxacin. She was also restarted on her home tacrolimus and Cellcept On the floor, the patient feels much better, denies nausea, vomiting, confusion, or abdominal pain. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catherization) - most recent HgbA1c 12.4 in ___ - End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel disease with LAD 60% apical lesion and 90% ___ diagonal lesion. ___ diagonal branch was treated with ballon angioplasty w/o stenting. Final angiography demonstrated ___ residual stenosis and improved flow down the diagonal branch. - LVH - Gastroparesis/GERD/Hiatal hernia - Hypothyroidism - Gout diagnosed ___ years ago - Herniated disk - OSA - Carpal tunnel s/p release - H/o multiple UTIs (Enterococcus vanc & amp sensitive, Klebsiella, E. Coli) Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Physical Exam: Physical exam on admission: VITALS: T 98.3 BP 127/63 HR 97 RR 18 SpO2 97% RA GENERAL: NAD, appears comfortable HEENT: dry mucous membranes NECK: JVP flat LUNGS: CTAB, no wheezes, rales or rhonchi, transmitted upper airway sounds HEART: RRR, normal S1 S2, II/VI systolic murmur at ___ ABDOMEN: quiet bowel sounds, soft, non-distended, no TTP in LLQ (over donor kidney) EXTREMITIES: warm and well-perfused, no c/c/e NEUROLOGIC: A+OX3 Physical exam on discharge: VS T 97.8 Tm 98.3 145/65 (138-188/65-97) HR ___ RR16 100% RA I/O: ___ 24hrs ___/4900 FSBG: 9:30am 221->40L 14H -> 12pm 55 - 6pm 221 ->6H->8:30pm 255 ->16H->163 Gen: NAD, asleep, comfortable Cardio: RRR, nl S1 S2, II/VI murmur at ___, unchanged from previous exam Pulm: CTAB Abd: +BS, soft, NT, ND Ext: wwp, no edema, 2+ DP pulses Pertinent Results: Labs on admission: ___ 10:15PM BLOOD Neuts-88.7* Lymphs-5.8* Monos-5.1 Eos-0.2 Baso-0.2 ___ 10:15PM BLOOD Glucose-297* UreaN-38* Creat-1.8* Na-137 K-4.5 Cl-104 HCO3-19* AnGap-19 ___ 10:15PM BLOOD Calcium-9.0 Phos-3.0 Mg-2.2 ___ 10:53PM BLOOD tacroFK-5.3 ___ 11:02PM BLOOD Lactate-1.8 ___ 10:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 10:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 10:15PM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1 ___ 10:15PM URINE CastHy-4* ___ 08:39AM URINE Hours-RANDOM Creat-56 Na-75 K-23 Cl-81 ___ 08:39AM URINE Osmolal-537 Pertinent results: ___ 07:05AM BLOOD ___ PTT-65.5* ___ ___ 07:05AM BLOOD ___ PTT-55.6* ___ ___ 05:20AM BLOOD ___ PTT-38.8* ___ ___ 07:30AM BLOOD ___ PTT-31.8 ___ ___ 10:15PM BLOOD cTropnT-0.02* ___ 07:05AM BLOOD CK-MB-5 cTropnT-0.07* ___ 04:10PM BLOOD cTropnT-0.05* ___ 10:53PM BLOOD tacroFK-5.3 ___ 07:05AM BLOOD tacroFK-4.1* ___ 07:05AM BLOOD tacroFK-7.8 ___ 05:20AM BLOOD tacroFK-5.8 ___ 07:30AM BLOOD tacroFK-7.1 ___ 11:18PM BLOOD Vanco-25.6* Labs on discharge: ___ 07:30AM BLOOD WBC-4.4 RBC-3.83* Hgb-11.6* Hct-34.7* MCV-91 MCH-30.4 MCHC-33.5 RDW-13.5 Plt ___ ___ 07:30AM BLOOD ___ PTT-31.8 ___ ___ 07:30AM BLOOD Glucose-188* UreaN-19 Creat-1.1 Na-144 K-3.9 Cl-107 HCO3-34* AnGap-7* ___ 07:30AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.8 ___ 07:30AM BLOOD tacroFK-7.1 Microbiology: ___ 10:33 pm URINE Site: NOT SPECIFIED ADDED TO ___. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S ___ 10:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date ___ 11:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date Imaging: -CXR ___ - No evidence of acute cardiopulmonary process. -Renal Transplant Ultrasound ___ - The transplant kidney is imaged in the left hemipelvis and measures 12.7 cm in length. Echogenicity and renal architecture is normal, and there are no signs of ___ fluid collection or hydronephrosis. Color flow and pulsed Doppler assessment demonstrate normal arterial waveforms in the main renal artery with no delay in acceleration time and normal peak velocities of 72 cm/sec. Venous outflow is also normal. Arterial flow is symmetrically seen throughout the transplant, but the resistive indices are elevated ranging from 0.79-0.85. The bladder is not evaluated due to drainage by Foley catheter. Brief Hospital Course: This is a ___ F with complex past medical history, most notable for poorly controlled Type I DM c/b ESRD s/p renal transplant ___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote h/o PE on coumadin, and scleroderma, who presented with DKA, ___, and enterococcal UTI. Active issues: #DIABETIC KETOACIDOSIS: The patient initially presented to ___ ___ with glucose >600, Anion gap 30. This rapidly improved with administration of IV fluids and insulin gtt. On transfer to ___ ED, her glucose was 297, and anion gap had almost closed at 14. She was transition to subcutaneous insulin with one hour overlap with gtt and maintained on IV fluids until ___, at which point her creatinine returned to baseline and she was taking adequate PO fluids. Her nausea and vomiting had resolved prior to admission to the floor. She was restarted on her home insulin regimen and her FSBGs remained mostly stable in the ___. The trigger for this episode of DKA was most likely the patient's UTI, treatment for this was begun immediately upon admission as below. #ENTEROCOCCAL URINARY TRACT INFECTION: UA on admission showed trace leukocytes, 5WBC, few bacteria. The patient has a history of frequent UTI (likely ___ self-catheterization), although the patient denied dysuria. She was begun immediately on antibiotic treatment with vancomycin and ciprofloxacin. Urine culture grew out >100,000 Enterococcus sensitive to vancomycin, after which the ciprofloxacin was discontinued and the patient was maintained on vancomycin until blood cultures from ___ showed no growth by ___. Prior to discharge, the patient was transitioned from vancomycin to PO nitrofurantoin, on which she is discharged and will finish the remainder of a 10-day course at home. The patient remained afebrile and asymptomatic throughout her admission. #ACUTE RENAL INSUFFICIENCY: The patient presented with Crt 2.0 (baseline 1.0), most likely secondary to dehydration, with possible contribution from post-renal obstruction (patient had no urine output the day prior to admission). Acute rejection in the setting of missing 3 doses of immunosuppressants is possible, but unlikely in this case with rapid response to intravenous fluid repletion. The patient was maintained on intravenous fluids until her creatinine returned to near baseline (1.2) and remained stable, and she was taking adequate PO fluids. Her creatinine remained at baseline throughout the remainder of her admission. #ESRD S/P RENAL TRANSPLANT: The patient missed 3 doses of her home tacrolimus and Cellcept due to nausea and vomiting. She was restarted on her immunosuppresant medications upon admission to the hospital and her tacrolimus levels were trended and followed by the renal transplant team. Her renal function quickly returned to baseline with IV fluid repletion. Acute rejection in the setting of missed immunosuppressants was thought unlikely. A renal transplant ultrasound on ___ showed no evidence of obstruction in the graft kidney. The patient's home vitamin D and calcitriol were continued throughout her admission. She will need to have her tacrolimus level checked one week after discharge (___). #SUPRATHERAPEUTIC INR: On coumadin for antiphospholipid syndrome. She had an elevated INR of 6.5 (goal 2.5-3.5) on admission likely due to drug-drug interaction between warfarin and ciprofloxacin. Her warfarin was held and INR was trended until it returned to her goal range. It was restarted at 3mg daily on ___ following an INR of 3.5 the previous day. Her INR was 1.1 on discharge, and she was instructed to measure her INR at home daily for the next several days and to communicate the results to her ___ clinic for further titration of coumadin. Lovenox bridge was considered, but the patient reports having been subtherapeutic in the past without any need for bridge. #TYPE I DIABETES MELLITUS: The patient was maintained on her home dose of insulin Glargine (40U QAM and 30U QHS) as well as her home Humalog sliding scale, with stable daytime FSBGs. Chronic issues: #ANTIPHOSPHOLIPID AB SYNDROME with H/O PE: The patient's warfarin was held due to a supratherapeutic INR as above and restarted on ___. She will check her INR at home and communicate results with her ___ clinic as she has been doing. #CAD s/p MI: Due to an episode of chest pain during vomiting before admission, she was ruled out for MI, with EKG only significant for right axis deviation that was resolving on follow-up EKG. Her troponin was mildly elevated, peaking at 0.07 in the setting of demand ischemia due to tachycardia on admission. She remained asymptomatic and was continued on her home regimen of atorvastatin, metoprolol, and aspirin. #SCLERODERMA: The patient was maintained on her home dose of 7.5mg prednisone daily with good symptom control. #HYPERTENSION: The patient remained normotensive to slightly hypertensive during admission, with systolic blood pressures ranging 120s - 160, with a one-time asymptomatic SBP of 188,. She was continued on her home regimen of amlodidpine and metoprolol. Her home valsartan was held until her Creatinine returned near baseline and was restarted on ___. # GOUT: The patient was continued on her home allopurinol. # PAD: The patient was continued on her home cilostazol 100 mg every other day. # DEPRESSION/ANXIETY: The patient was continued on her home duloxetine and despiramine for depression and Ativan for anxiety. She was continued on her home trazodone and zolpidem QHS for sleep. # HYPOTHYROIDISM: The patient was continued on her home levothyroxine dose. # GERD: The patient was continued on her home ranitidine and Nexium. Transitional issues: # FOLLOW-UP: -Primary care: the patient will be contacted by Dr. ___ office to schedule a follow-up appointment -Nephrology: the patient will be contacted by Dr. ___ office to schedule a follow-up renal appointment within the next two weeks -Endocrinology/diabetes: the patient will follow up with Dr. ___ at the ___ on ___ at 3:30pm -___: the patient was scheduled to have an appointment with Dr. ___ the ___ on ___ to plan for a breast biopsy. The patient's admission was communicated to Dr. ___ the ___ will contact the patient within a few days of discharge to schedule a new appointment. -Blood cultures from admission were pending on discharge Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Tacrolimus 1.5 mg PO QAM 2. Tacrolimus 1 mg PO QPM 3. PredniSONE 7.5 mg PO DAILY 4. Mycophenolate Mofetil 500 mg PO BID 5. Atorvastatin 40 mg PO HS 6. Amlodipine 2.5 mg PO DAILY please hold for sbp<100 7. Allopurinol ___ mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. cilostazol *NF* 100 mg Oral qod 10. Duloxetine 90 mg PO DAILY 11. Glargine 40 Units Breakfast Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Levothyroxine Sodium 137 mcg PO DAILY 13. Metoprolol Succinate XL 12.5 mg PO DAILY please hold for sbp<100 please hold for hr<60 14. Lorazepam 0.5 mg PO Q8H:PRN anxiety 15. Nitroglycerin SL 0.3 mg SL PRN chest pain 16. Promethazine 25 mg PR Q6H:PRN nausea 17. Promethazine 25 mg PO BID:PRN nausea 18. Ranitidine 150 mg PO HS 19. esomeprazole magnesium *NF* 40 mg Oral bid 20. Gabapentin 800 mg PO BID 21. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain please hold for rr<12 or increased somnolence 22. Desipramine 50 mg PO DAILY 23. traZODONE 50 mg PO HS:PRN insomnia 24. Valsartan 20 mg PO DAILY 25. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 26. Acetaminophen 1000 mg PO BID:PRN pain 27. Aspirin 81 mg PO DAILY 28. Calcium Carbonate 500 mg PO BID 29. Vitamin D 800 UNIT PO DAILY 30. Warfarin 2.5 mg PO DAILY16 Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Amlodipine 2.5 mg PO DAILY please hold for sbp<100 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO HS 5. Calcitriol 0.25 mcg PO DAILY 6. Calcium Carbonate 500 mg PO BID 7. cilostazol *NF* 100 mg Oral qod 8. Desipramine 50 mg PO DAILY 9. Duloxetine 90 mg PO DAILY 10. Gabapentin 800 mg PO BID 11. Levothyroxine Sodium 137 mcg PO DAILY 12. Lorazepam 0.5 mg PO Q8H:PRN anxiety 13. Metoprolol Succinate XL 12.5 mg PO DAILY please hold for sbp<100 please hold for hr<60 14. Mycophenolate Mofetil 500 mg PO BID 15. PredniSONE 7.5 mg PO DAILY 16. Promethazine 25 mg PR Q6H:PRN nausea 17. Promethazine 25 mg PO BID:PRN nausea 18. Ranitidine 150 mg PO HS 19. Tacrolimus 1.5 mg PO QAM 20. Tacrolimus 1 mg PO QPM 21. traZODONE 50 mg PO HS:PRN insomnia 22. Valsartan 20 mg PO DAILY 23. Vitamin D 800 UNIT PO DAILY 24. Warfarin 3 mg PO DAILY16 25. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 26. esomeprazole magnesium *NF* 40 mg ORAL BID 27. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain please hold for rr<12 or increased somnolence 28. Acetaminophen 1000 mg PO BID:PRN pain 29. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *Macrobid ___ mg 1 capsule(s) by mouth every 12 hours Disp #*12 Tablet Refills:*0 30. Nystatin Oral Suspension 5 mL PO QID:PRN thrush, throat pain RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp #*200 Milliliter Refills:*1 31. Outpatient Lab Work You should have your tacrolimus level checked one week after discharge from the hospital; on ___. 32. Nitroglycerin SL 0.3 mg SL PRN chest pain 33. Glargine 40 Units Breakfast Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: -Diabetic ketoacidosis -Urinary tract infection -Acute renal insufficiency Secondary diagnoses: -Type I diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ on ___ for nausea, vomiting, and weakness. You were found to have a very high blood sugar and acidic blood due to a condition called 'diabetic ketoacidosis'. Your kidney function was also temporarily decreased, most likely due to dehydration. Your blood sugars and your kidney function improved with continuous insulin and intravenous fluids. This episode of 'diabetic ketoacidosis' was likely triggered by a urinary tract infection, for which you were treated with the antibiotic medicine Vancomycin, and were switched to the oral medicine nitrofurantoin (Macrobid) before discharge, which you will take every 12 hours until the evening of ___. Finally, your INR was found to be higher than normal, so several doses of your home warfarin were held until the INR came back down to a normal level, at which time your warfarin was restarted. Please note that your INR subsequently decreased to 1.1 which is below the desired level, so please continue checking your INR at home and call your ___ clinic with the results so that they can adjust your dose. You should also have your tacrolimus level checked at the outpatient laboratory in one week, on ___. You should continue to administer your long-acting insulin every morning and every evening. You should also administer short-acting insulin before each meal based on your blood sugar levels and carbohydrate counting, as you have been in the past. When it is necessary to catheterize yourself for urination, you should make sure to use good sterile technique. Please not the following change in your medication: -ADDITION of nitrofurantion (to treat urinary tract infection) Followup Instructions: ___

10030753-DS-35

DS

2198-07-12 00:00:00

2198-07-13 21:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan Attending: ___ Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a medically complex ___ with PMH significant for poorly controlled T1DM c/b retinopathy, ESRD s/p living kidney xplant in ___, neuropathy with neurogenic bladder and gastroparesis, CAD s/p MI in ___ and with 3 DES placed in ___, hypothyroidism and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and antiphospholipid antibody syndrome with h/o PE in ___ who presents to the ED with intractable N/V and mechanical fall with head strike. Patient was in her usual state of health until one week prior to admission when she developed nausea and vomiting. This nausea and vomiting seemed to occur after she took an oral antibiotic while on vacation in ___ (unclear why this was prescribed - clinic paperwork said for inguinal ___. She became concerned that she was not able to tolerate PO intake and specifically that she was not keeping down her anti-rejection meds so she went to ___ urgent care. Vitals at urgent care were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and IV Zofran 4mg x1. Labs were checked which showed an INR of 4.9. Urgent care recommended that she be seen at the ___ ED for further evaluation. Patient decided to drive herself to ___ but unfortunately fell while exiting a restaurant (she felt better after the Zofran and stopped for food on the way to ___. She fell down some stairs and struck her head but did not lose conciousness. At this point in time, EMS was called and brought her to ___. Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA Exam was notable for: laceration to right forehead and right wrist swelling. Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8 but decline is recent in last 4 months), INR 4.8, plts 292, BNP 1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly positive. Blood and urine cultures were sent. Imaging showed: No acute fractures or intracranial pathology but with right supraorbital soft tissue hematoma. C-spine intact. No fracture of the right wrist. Patient was given: IV ciprofloxacin 400mg x1 Consults: transplant nephrology who recommended medicine admission. Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA On the floor, patient reports that she feels better and only complains of right wrist pain. She denies nausea since she received Zofran at the urgent care clinic. ROS: per HPI, denies fever, 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: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catherization) - most recent HgbA1c 12.4 in ___ - End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel disease with LAD 60% apical lesion and 90% ___ diagonal lesion. ___ diagonal branch was treated with ballon angioplasty w/o stenting. Final angiography demonstrated ___ residual stenosis and improved flow down the diagonal branch. - LVH - Gastroparesis/GERD/Hiatal hernia - Hypothyroidism - Gout diagnosed ___ years ago - Herniated disk - OSA - Carpal tunnel s/p release - H/o multiple UTIs (Enterococcus vanc & amp sensitive, Klebsiella, E. Coli) - Hx of TIA? Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Physical Exam: ADMISSION EXAM VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg. General: well appearing Caucasian female in NAD HEENT: NC, sclerae anicteric. Significant bruising and soft tissue swelling of the right periorbital area. PERRL, EOMI. OP clear without lesion or exudate. Neck: Supple, no ___, no thyromegaly CV: Tachycardic but regular. Normal s1/s2, no m/r/g Lungs: CTAB posteriorly, no w/r/r Abdomen: Distended but soft and nontender. Normal bowel sounds, no rebound or guarding. Unable to appreciate organomegaly. GU: no foley Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or edema Neuro: CN ___ grossly intact, moving all 4 extremities with purpose. Gait deferred. Skin: Ecchymoses around right eye, right wrist, above right breast and scattered throughout lower extremities. DISCHARGE EXAM Vitals 98.3 ___ 18 100RA General: obese, NAD HEENT: swollen erythematous R eye that has overall improved but has some crusting; now L eye has some ecchymoses Heart: borderline tachycardic, normal rhythm, no murmurs Lungs: CTAB Abdomen: Obese, NT, NABS, several well-healed scars Extremities: 1+ pitting edema bilaterally Skin: bruising on stomach, R breast, R eye Pertinent Results: ADMISSION LABS ___ 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1* MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt ___ ___ 04:10PM BLOOD ___ PTT-60.1* ___ ___ 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136 K-3.7 Cl-101 HCO3-24 AnGap-15 ___ 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85 TotBili-0.2 ___ 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6 ___ 06:41AM BLOOD tacroFK-7.4 DISCHARGE LABS ___ 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1* MCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt ___ ___ 04:42AM BLOOD ___ PTT-35.9 ___ ___ 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140 K-4.0 Cl-105 HCO3-27 AnGap-12 ___ 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8 ___ 04:42AM BLOOD tacroFK-5.6 MICRO ___ 4:57 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. >100,000 ORGANISMS/ML.. ___ 8:02 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:37 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING WRIST XRAY ___ Dorsal soft tissue swelling along the wrist without underlying fracture. Extensive vascular calcification. CT HEAD ___. No acute intracranial hemorrhage. 2. Right frontal supraorbital superficial soft tissue hematoma. No underlying fracture seen. CT C-SPINE ___ No fracture or malalignment in the C-spine. RENAL TRANSPLANT US ___ Mildly elevated intrarenal resistive indices which are slightly higher than ___. CT ABD/PELVIS ___. No intra or retroperitoneal or intramuscular hematoma noted in the abdomen or pelvis. 2. Transplant kidney in the left lower quadrant demonstrates no hydronephrosis. 3. Moderate amount of stool throughout the colon without bowel obstruction. CT HEAD ___. No acute intracranial hemorrhage. 2. Small, residual, supraorbital, right frontal scalp hematoma. CXR ___ IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE CHANGE AND NO ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION, PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA. CT HEAD ___. No evidence of fracture, infarction or intracranial hemorrhage. 2. Minimal residual right frontal/supraorbital scalp swelling. Brief Hospital Course: ___ yo F with history of T1DM and ESRD s/p living kidney transplant ___ on MMF, tacro, prednisone, also with history of CAD s/p multiple MI's and recent ___ 3 ___, and h/o multiple UTI's (mostly enterococcus, Klebsiella, coag neg staph) who presents for elevated INR and a mechanical fall down some stairs at ___. Suffered trauma but no head bleed. Nausea/vomiting resolved on admission. Experienced labile blood pressures and orthostatic hypotension a/w anemia, improved after transfusion of 1 unit of blood. INR drifted to <2 with improved nutrition and warfarin resumed prior to d/c. Investigations/Interventions 1. Elevated INR: patient is on coumadin for history of PE, and she presented with INR 4.8 in setting of 1 week of nausea and vomiting. Elevated INR likely due to poor nutrition. INR was trended and coumadin restarted ___ when INR was 1.8. INR 1.5 on day of discharge. 2. Fall: patient fell down some stairs at restaurant and had no preceding symptoms. EKG on admission was at baseline. We felt fall to be mechanical in nature due to poor vision related to diabetic nephropathy. 3. Hypotension: patient initially presented with hypertension sbp in 190s, then became hypotensive when working with ___ sbp in ___. She was orthostatic. Home anti-hypertensives discontinued. In setting of fall with elevated INR there was concern for internal bleeding so CT abd/pelvis, CT head, and CXR (PA & lateral) were obtained which were negative for evidence of bleeding. She refused IVF so we encouraged po intake which resulted in stabilization of blood pressures. Discharging home on blood pressure medication regimen of metoprolol succinate 12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued in favor of increasing losartan. 4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in house. As this was associated with hypotension, bleeding was ruled out with imaging described above. She was transfused 1 unit PRBC's with return of her hgb to baseline. No evidence of GI bleeding during hospitalization. 5. Vitreous, retinal hemorrhage: patient reported blurry vision during hospitalization. Ophthalmology consulted who diagnosed vitreous and retinal hemorrhage. Recommended to keep HOB elevated, avoid bending over or straining. Instructed to follow up with ___ clinic. 6. Diabetes mellitus: patient followed at ___. Home regimen continued in house initially but patient experienced hypoglycemia into the 70's in the morning. ___ consulted and patient agreed to change pm Lantus from 20 units to 16 units. She will also change her correction factor to 14. 7. History of UTI's: patient has history of many UTI's. UA on admission c/w UTI so patient placed on ciprofloxacin. UCx grew yeast which we did not treat. Due to her history of infection we decided to discharge her on ciprofloxacin for 14 days, last day being ___. 8. CKD, ESRD s/p kidney transplant: patient is s/p living donor kidney transplant in ___. Maintained on tacro, MMF, prednisone as outpt. Her graft has CKD, likely related to diabetic nephropathy. Serial tacro levels were within goal range and she was maintained on her home regimen of 1mg q12h. Home prednisone dose changed from 6mg qd to 5mg qd. Patient also is on Bactrim DS tab qd which was changed to SS tab qd for PCP ___. 9. CAD: patient with recent ___ 3 placed. Continued on Asa, Plavix, statin in house. Transitional Issues: []Medication changes: Prednisone to 5mg qd, Bactrim to SS tab qd, losartan to 50 mg daily, qhs Glargine to 16 units daily. Amlodipine discontinued. []Patient should take ciprofloxacin through ___ []Patient instructed by ___ attending to change her carbohydrate correction factor to 14 []Patient is on several drugs which may not be needed, please consider decreasing number of medications on an outpatient basis []Patient instructed to keep HOB elevated, avoid bending over or straining due to retinal hemorrhage []Please follow up pending BCx []Patient has follow up with PCP ___ patient also instructed to call Dr. ___ for nephrology and diabetes appointments #CODE: Full #CONTACT: Patient, HCP sister ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Amlodipine 2.5 mg PO DAILY 3. Aspirin EC 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcitriol 0.25 mcg PO DAILY 6. Cilostazol 50 mg PO TID 7. DULoxetine 60 mg PO DAILY 8. Gabapentin 100 mg PO QHS 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Losartan Potassium 25 mg PO DAILY 11. Metoprolol Succinate XL 12.5 mg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Pramipexole 0.5 mg PO QHS 15. PredniSONE 6 mg PO DAILY 16. Promethazine 25 mg PO Q6H:PRN nausea or vomiting 17. Ranitidine 300 mg PO QHS 18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 19. Tacrolimus 1 mg PO Q12H 20. TraZODone 50 mg PO QHS 21. Vitamin D 400 UNIT PO DAILY 22. Warfarin 3 mg PO DAILY16 23. Clopidogrel 75 mg PO DAILY 24. alpha lipoic acid ___ mg oral DAILY 25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN 26. Esomeprazole Magnesium 40 mg ORAL BID 27. Lidocaine 5% Patch 1 PTCH TD QPM 28. Promethazine 25 mg PR Q6H:PRN nausea or vomiting 29. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain 30. Glargine 36 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 31. melatonin 5 mg po Q24H Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 50 mg PO TID 6. Clopidogrel 75 mg PO DAILY 7. DULoxetine 60 mg PO DAILY 8. Gabapentin 100 mg PO QHS 9. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QPM 12. Mycophenolate Mofetil 500 mg PO BID 13. Pramipexole 0.5 mg PO QHS 14. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 15. Promethazine 25 mg PO Q6H:PRN nausea or vomiting 16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting 17. Ranitidine 300 mg PO QHS 18. Tacrolimus 1 mg PO Q12H 19. TraZODone 50 mg PO QHS 20. Vitamin D 400 UNIT PO DAILY 21. Warfarin 3 mg PO DAILY16 22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 24. Esomeprazole Magnesium 40 mg ORAL BID 25. melatonin 5 mg po Q24H 26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN 27. alpha lipoic acid ___ mg oral DAILY 28. Ciprofloxacin HCl 500 mg PO Q12H Duration: 19 Doses RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*19 Tablet Refills:*0 29. Glargine 26 Units Breakfast Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 30. Losartan Potassium 50 mg PO DAILY RX *losartan 25 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 31. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Elevated INR Mechanical fall Anemia Secondary: CAD Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were hospitalized after a fall. You experienced extensive bruising since you are on blood thinners. You required 1 unit of blood to be transfused since your blood levels were low, likely related to all of the bruising. We obtained extensive imaging of your body to ensure no internal bleeding, and this was all negative. You also developed some right eye floaters and blurry vision. You were evaluated by Ophthalmology who felt that you had a mild vitreous hemorrhage. You should make sure to sleep with the head of the bed elevated and to avoid any activities requiring bending over or straining. We continued your immunosuppressive drugs and insulin. Please make sure to follow up with your PCP and kidney doctor, ___. ___. in addition, the diabetes doctors talked with ___ and we changed your nightly insulin to 16 units of Glargine instead of 20. You should also change your correction factor to 14. It was a pleasure taking care of you! Your ___ team Followup Instructions: ___

10030753-DS-40

DS

2199-05-16 00:00:00

2199-05-22 16:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan Attending: ___ Chief Complaint: Dizziness and Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMhx of ___ s/p living kidney transplant ___ on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p ___ and OM ___ who presents for hypotension and prescyncope in the setting of recent up-titration of her home blood pressure medications. Of note, she was recently discharged from the ET service for an admission related to a new ___ for which she underwent renal bx. Initial concern was for possible acute rejection of her transplant, but bx was reassuring in this regard, showing advanced changes associated with diabetic nephropathy. Additionally during her stay, she was noted to have volume overload in the setting of her ___, and she was started on a number of different medications for hypertension management, volume control and diuretics, as well as an aggressive insulin regimen recommended by the ___. Since her discharge, she has felt overall well until in the middle of the night she awoke and felt dizzy. She notes this was prior to taking her AM medications. She went back to bed following this incident, and when she awoke she was notably lightheaded and dizzy. She went to her PCP office for routine follow-up, and was noted to have blood pressures ranging from 60-80 systolic, and thus was sent to the ED for further evaluation. She denies any fevers, chills, CP, SOB, cough, diarrhea, abd pain, or dysuria. In the ED, initial vitals were: 97.1 71 110/56 19 93% RA - Labs notable for: SCr 2.0, stable from recent admission - Imaging was notable for: Absent diastolic flow in transplanted kidney The patient was given 1L NS and her home nifedipine and Lasix were held. SBPs improved to 150s overnight and patient is hypertensive to 180s this morning. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___, DES to LAD and Cx/OM ___ - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed ___ years ago - OSA NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - this diagnosis viewed unlikely per ___ hematology/oncology note Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITAL SIGNS: Afeb, 120-180/60, 80-90, ___, 94% RA GENERAL: Comfortable, NAD HEENT: PERRL, OP clear without lesions or thrush NECK: supple, no JVD CARDIAC: RRR, no MRG LUNGS: CTAB without wheezing or rhonchi ABDOMEN: soft, nt, nd EXTREMITIES: wwp, no peripheral edema or cyanosis SKIN: no suspicious rashes or lesions DISCHARGE PHYSICAL EXAM: ======================== VS: 98.1, 158/71, 80, 18, 99% RA GENERAL: Comfortable, NAD HEENT: PERRL, OP clear without lesions or thrush NECK: supple, no JVD CARDIAC: RRR, no MRG LUNGS: CTAB without wheezing or rhonchi ABDOMEN: soft, nt, nd EXTREMITIES: wwp, no peripheral edema or cyanosis SKIN: no suspicious rashes or lesions Pertinent Results: ADMISSION LABS: =============== ___ 06:10AM PLT COUNT-323 ___ 06:10AM WBC-7.3 RBC-2.76* HGB-8.3* HCT-25.9* MCV-94 MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5* ___ 06:10AM CYCLSPRN-168 ___ 06:10AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9 ___ 06:10AM GLUCOSE-85 UREA N-49* CREAT-2.0* SODIUM-138 POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17 ___ 05:45PM PLT COUNT-272 ___ 05:45PM NEUTS-92.0* LYMPHS-3.0* MONOS-4.2* EOS-0.2* BASOS-0.1 IM ___ AbsNeut-7.47* AbsLymp-0.24* AbsMono-0.34 AbsEos-0.02* AbsBaso-0.01 ___ 05:45PM WBC-8.1 RBC-2.74* HGB-8.2* HCT-26.1* MCV-95 MCH-29.9 MCHC-31.4* RDW-13.8 RDWSD-48.3* ___ 05:45PM ALBUMIN-3.2* CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.0 ___ 05:45PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-81 TOT BILI-0.3 ___ 05:45PM GLUCOSE-231* UREA N-48* CREAT-2.0* SODIUM-134 POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18 ___ 05:52PM LACTATE-1.3 DISCHARGE LABS: =============== ___ 05:24AM BLOOD WBC-6.1 RBC-2.43* Hgb-7.5* Hct-23.2* MCV-96 MCH-30.9 MCHC-32.3 RDW-13.4 RDWSD-46.5* Plt ___ ___ 05:24AM BLOOD Glucose-166* UreaN-42* Creat-1.8* Na-140 K-4.2 Cl-104 HCO3-26 AnGap-14 ___ 07:44AM BLOOD ALT-17 AST-12 LD(LDH)-257* AlkPhos-75 TotBili-0.2 ___ 05:24AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 ___ 05:24AM BLOOD Cyclspr-204 MICROBIOLOGY: ============= None IMAGING: ======== ___ (PA & LAT) Stable mild cardiomegaly, decreased right pleural effusion, now tiny. ___ TRANSPLANT U.S. The left lower quadrant transplant renal morphology is normal measuring 13.2 cm in length. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. Doppler: There is absent diastolic flow main renal artery as well as the intralobar branches, which is more convincing on todays exam compared with prior. The main renal vein is patent. Brief Hospital Course: Ms. ___ is a ___ with PMhx of ___ s/p living kidney transplant ___ on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p ___ and OM ___ who presents for hypotension and prescyncope in the setting of up-titrating her anti-hypertensives. On admission, the patient was given 1L NS and her nifedipine and Lasix were held. Her symptoms resolved. She remained significantly orthostatic, likely ___ longstanding diabetes and autonomic dysfunction. Patient was discharged home on Carvedilol 12.5mg PO QAM, 25mg PO QPM and Lasix 20mg PO daily with plans to continue to adjust her blood pressure medications as an out-patient and possible outpatient ABPM. #Presyncope/hypotension: Patient presented with hypotension i/s/o starting multiple antihypertensives and a new diuretic regimen. Held antihypertensives and diuretics for ___ and gave IVF with improvement of blood pressure. Likely d/t medication effect, as no evidence of infection. See "Hypertension" for discharge regimen. #Hypertension/Orthostasis: Essential hypertension in the setting of tacrolimus therapy with very poorly controlled blood pressures and difficult medication titration given orthostasis and hypotension. Patient initially hypotensive on admission but quickly became hypertensive to SBPs of 200s with IVF and holding antihypertensives. However patient was very orthostatic with drop to SBPS of 120s from 200s with standing, despite being asymptomatic. Concern for diabetes induced dysautonomia. Patient was maintained on carvedilol 12.5mg qAM, 25mg qPM and lasix 20mg PO daily on discharge with SBPs in the 160s-170s. Plan is forcontinued titration of BP meds and monitoring of orthostatics as an out-patient with ABPM. # CKD # S/p living unrelated donor kidney transplant ___: Recent admission with renal bx showing diabetic changes without signs of rejection. Her immunosuppressive regimen was increased and she was discharged with a more aggressive antidiabetic regimen and antihypertensive regimen. - Decreased cyclosporine to 50mg BID given levels - Continued home prednisone 5mg PO daily - Continued home MMF 500mg BID - Continued home diabetes regimen as below # DM1, hyperglycemia: A1C 7.5% (___), had issues with hypoglycemia d/t poor intake. - Continued prior discharge regimen: * Lantus 22 units qAM and 17 units qhs * Humalog 8 units TID with meals * Humalog sliding scale TID with meals * ___ c/s CHRONIC ISSUES =============== # Hypothyroidism: recent TSH 0.69 - Continued home levothyroxine 125 mcg QD # PE. Hx of provoked PE in 1990s, on warfarin until last admission ___ at ___. Warfarin was stopped given hx of GIB on warfarin and negative anti-cardiolipin AB on repeat check. # CAD. S/p ___ and OM ___. Completed 6 months on Plavix - Continued home ASA 81 mg QD - Continued home Ranexa ER 500 mg BID # Nausea - Continued home Zofran 8 mg QD:PRN, reglan 10 mg TID # Gout - Continued home allopurinol ___ mg QD # HLD - Continued home atorvastatin 20 mg QD # CREST: - Held home esomeprazole 40 mg capsule BID - Pantoprazole 40 mg BID while inpatient # PVD - Continued home cilostazol 100 mg QAM, 50 mg QPM TRANSITIONAL ISSUES: ==================== NEW MEDICATIONS: - None ADJUSTED MEDICATIONS: - Cyclosporin 50mg PO Q12H - Lasix 20mg daily - Carvedilol 12.5mg PO QAM, 25mg PO QPM STOPPED MEDICATIONS: - Nifedipine CR 30mg daily TO-DOs: [ ] Monitor blood pressure and adjust anti-hypertensives accordingly [ ] Monitor weight and adjust Lasix accordingly - Dry weight 61.5 Kg [ ] Set-up patient for ABPM within ___ weeks of discharge with Dr. ___ appointment above) [ ] Recheck CMP and CsA levels on ___ [ ] Recheck CMP and CsA levels on ___ # CODE: Full # Contact: ___ (sister/HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 100 mg PO QAM 6. Cilostazol 50 mg PO QHS 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Mycophenolate Mofetil 500 mg PO BID 9. PredniSONE 5 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Carvedilol 25 mg PO BID 12. NIFEdipine CR 30 mg PO DAILY 13. Ascorbic Acid ___ mg PO DAILY 14. Calcium Carbonate 500 mg PO BID 15. Esomeprazole Magnesium 40 mg oral BID 16. Ferrous Sulfate 325 mg PO DAILY 17. Ranolazine ER 500 mg PO BID 18. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 19. Furosemide 20 mg PO BID 20. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Carvedilol 25 mg PO QHS RX *carvedilol 25 mg 1 tablet(s) by mouth Daily at bedtime Disp #*30 Tablet Refills:*0 2. Carvedilol 12.5 mg PO QAM RX *carvedilol 12.5 mg 1 tablet(s) by mouth Daily in the morning Disp #*30 Tablet Refills:*0 3. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H RX *cyclosporine modified 25 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*0 4. Furosemide 20 mg PO DAILY RX *furosemide 40 mg 0.5 (One half) tablet(s) by mouth Daily Disp #*15 Tablet Refills:*0 5. Glargine 22 Units Breakfast Glargine 17 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Allopurinol ___ mg PO DAILY 7. Ascorbic Acid ___ mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Calcitriol 0.25 mcg PO DAILY 11. Calcium Carbonate 500 mg PO BID 12. Cilostazol 100 mg PO QAM 13. Cilostazol 50 mg PO QHS 14. Esomeprazole Magnesium 40 mg oral BID 15. Ferrous Sulfate 325 mg PO DAILY 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Mycophenolate Mofetil 500 mg PO BID 18. PredniSONE 5 mg PO DAILY 19. Ranolazine ER 500 mg PO BID 20. Vitamin D ___ UNIT PO DAILY 21.Outpatient Lab Work Z94.0 ___: CHEM10, Cyclosporin level Please fax to Dr. ___ at ___. 22.Outpatient Lab Work Z94.0 ___: CHEM10, Cyclosporin level Please fax to Dr. ___ at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: ======== Hypotension Supine hypertension Orthostatic hypotension Secondary: ========== Status-post kidney transplant, uncontrolled DMI, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted for lightheadedness and low pressure. This was likely due to your new blood pressure medications and the water pills. Some of these symptoms are also related to the longstanding diabetes that causes nerve damage that prevents you blood vessels from maintaining a stable blood pressure. You were give intravenous fluid and your blood pressure improved. We have stopped your nifedipine and decreased the dose of the carvedilol you were on. We restarted you on a small dose of the water pills to keep you from accumulating fluid. You should follow-up with your primary care physician ___ 2 days of discharge. This appointment has been scheduled for you. We wish you all the best! Your ___ Team Followup Instructions: ___

10030753-DS-41

DS

2199-06-02 00:00:00

2199-06-02 17:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan Attending: ___. Chief Complaint: Lightheadedness/Nausea/Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman, with ___ s/p living kidney transplant ___ on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p ___ and OM ___, labile blood pressures who presents with hypotension. She notes that he has long-standing issues with orthostatic hypotension. She checks her BP at home multiple times per day in lying and standing positions, and will range from 180-200 while lying, to 110-120 while standing, and she is sometimes symptomatic with lightheadedness. Although was feeling well on the morning of admission, for the ___ days prior to that she had been having multiple episodes of vomiting. She had no fevers, abdominal pain, diarrhea. She states that it is typical for her to have several-day bouts of vomiting, which tend to resolve without treatment, possibly due to gastroparesis. The patient was at her cardiologist's office on the day of admission, where she was getting fitted for outpatient monitoring of her blood pressure, when she became lightheaded, was found to be hypotensive. Initial BP was 113 systolic, which fell to 72. She then had vomiting, and felt like she was going to lose consciousness. She then had improvement of her symptoms after being placed in the supine position her systolic BP increased to 98 mmHg. Patient currently denies any symptoms. She was admitted ___ to ___ after presenting with similar symptoms of hypotension and dizziness after up-titration of her home blood pressure medications. She was given IV fluids, and nifedipine and Lasix were held, and her symptoms resolved, although she was consistently orthostatic despite resting SBP in the 200s, attributed to longstanding diabetes and autonomic dysfunction. She was discharged on carvedilol, Lasix 20mg PO daily. Her past medical history is significant for poorly controlled type 1 diabetes with onset around age ___, a left sided kidney transplant in ___, coronary artery disease with prior MI. Her most recent drug-eluting stent was placed in the LAD and circumflex in ___. She also has a history of scleroderma with CREST syndrome and has a questionable diagnosis of antiphospholipid antibodies with pulmonary embolism. She has chronic gastroparesis and vomits frequently. There is a history of gout and obstructive sleep apnea. She has multiple urinary tract infections. In the ED initial vitals were: 96.8 HR 86 BP 139/70 RR16 98RA EKG: Sinus rhythm, 86, normal axis, normal intervals, ST depression with T wave inversions in lead one, aVL. ST segment depression in lateral leads Imaging: CXR with No acute cardiopulmonary process. Labs/studies notable for: Hgb 9.8, Troponin 0.14 w/ CKMB 2, Creatinine 1.9 (at baseline). Repeat troponin 0.11. Patient was given: ASA 243 mg, PO Zofran 4mg Vitals on transfer: 98.8 95 139/55 14 99% RA On the floor she feels at her baseline. Overnight she received Carvedilol 12.5mg x2 (home dose 25mg). Home Lasix was held. Past Medical History: 1. CARDIAC RISK FACTORS - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___, DES to LAD and Cx/OM ___ 3. OTHER PAST MEDICAL HISTORY End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed ___ years ago - OSA -NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - this diagnosis viewed unlikely per ___ hematology/oncology note; warfarin discontinued ___ Social History: ___ Family History: Former smoker: ___ years, ___ ppd. Quit ___ years ago. Denies etoh/drugs. Lives at home with daughter. Currently on disabilities. FAMILY HISTORY: Per OMR Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAMINATION: ============================== VS: T 98.3, bp 158/67, hr 92, rr 20, spo2 95% on RA GENERAL: Well developed, well nourished woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 6-7 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. III/VI systolic murmur at upper sternal borders LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-distended. Mild tenderness over renal transplant in LLQ 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 EXAMINATION: =============================== Vitals: T=98.2 HR=100 BP=133/65 RR=18 O2= 94% on RA Lying 164/73 sitting 123/68 standing 112/66 I/O= ___ Weight: 60.1 Weight on admission: 60.2 Telemetry: No events GENERAL: Well developed, well nourished woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 6-7 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. III/VI systolic murmur at upper sternal borders LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-distended. Mild tenderness over renal transplant in LLQ 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: =============== ___ 03:12PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.8* Hct-30.2* MCV-95 MCH-30.8 MCHC-32.5 RDW-13.7 RDWSD-47.5* Plt ___ ___ 03:12PM BLOOD Neuts-85.7* Lymphs-5.2* Monos-7.4 Eos-1.1 Baso-0.2 Im ___ AbsNeut-7.81* AbsLymp-0.47* AbsMono-0.67 AbsEos-0.10 AbsBaso-0.02 ___ 03:12PM BLOOD Plt ___ ___ 04:48AM BLOOD ___ PTT-28.2 ___ ___ 03:12PM BLOOD Glucose-83 UreaN-41* Creat-1.9* Na-143 K-4.0 Cl-106 HCO3-26 AnGap-15 ___ 03:12PM BLOOD CK(CPK)-34 ___ 03:12PM BLOOD CK-MB-2 cTropnT-0.14* ___ 09:40PM BLOOD cTropnT-0.11* ___ 04:48AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 ___ 09:00AM BLOOD Cyclspr-196 DISCHARGE LABS: ================ ___ 06:05AM BLOOD WBC-8.4 RBC-2.95* Hgb-9.1* Hct-28.1* MCV-95 MCH-30.8 MCHC-32.4 RDW-13.6 RDWSD-47.1* Plt ___ ___ 06:05AM BLOOD Glucose-64* UreaN-48* Creat-2.0* Na-142 K-4.4 Cl-108 HCO3-22 AnGap-16 ___ 06:05AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9 ___ 08:45AM BLOOD Cyclspr-181 MICRO: ======= ___ 11:44 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. STUDIES/IMAGING: ================ CXR ___: No acute cardiopulmonary process. RENAL TRANSPLANT US ___: 1. Patent renal transplant vasculature. No hydronephrosis and no peritransplant fluid collection identified. 2. Small amount of movable debris noted within the urinary bladder which could represent sludge, infectious material or blood. Correlation with urinalysis is suggested. Brief Hospital Course: ___ with PMhx of ___ s/p living kidney transplant ___ on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p ___ and OM ___ who presents for orthostatic hypotension and prescyncope. #Orthostatic Hypotension/Syncope: Patient became hypotensive to ___ with standing with associated emesis at cardiology office and was referred to ___. Patient with multiple admissions for symptomatic orthostatic hypotension thought to be secondary to autonomic dysregulation likely with component of vasovagal syncope. On presentation patient with lying 160/70 and standing SBP 86/50. Carvedilol and Lasix with discontinued and patient was started on Nifedipine 30mg CR with improvement in orthostatics of 164/73 lying to 112/66 standing. Patient was instructed to take Lasix 20mg if she gained more than 3lbs in one day and if she has significant lower extremity edema. #Troponin elevation: Patient with ST depression in I, TWI in AVL, slightly elevated troponin to 0.14 (higher than prior checks) with flat MB and baseline creatinine. Troponin trending down on recheck to 0.11. She does have known CAD, with PI in LAD in ___, had 80% stenosis with diagonal with stenosis as well. She denies chest pain, likely demand ischemia in setting of labile pressures and hypovolemia from emesis. #Nausea/emesis: Patient with emesis occurring with standing. Chronic issue for patient thought to be secondary to gastroparesis. Also may have component of vasovagal response to standing. She also had improvement in nausea and emesis prior to discharge with change in anti-hypertensive regimen. # ___ on CKD # S/p living unrelated donor kidney transplant ___: Prior admission for ___ with renal bx showing diabetic changes without signs of rejection. Her immunosuppressive regimen was increased and she was discharged with a more aggressive antidiabetic regimen and antihypertensive regimen. Had Cr elevation to 2.6 thought to be due to hypovolemia. Improved to 2.0 (baseline 1.9) with small fluid bolus. Cyclosporine 12 hour trough was 181 on ___, goal 45-100. Dose was reduced to Cyclosporine (Neoral)25mg BID. Patient needs to have 12 hour Cyclosporine trough drawn in one week (___). She was continued on home prednisone 5mg PO daily, MMF 500mg BID. UA initially with bacteria and WBCs, urine culture negative. Per renal may need ace inhibitor, will determine if blood pressure can tolerate. # DM1: Patient with A1C 7.5% (___). Decreased ___ Lantus to 15 given low AM blood sugars. Updated insulin regimen below. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin CHRONIC ISSUES =============== # Hypothyroidism: recent TSH 0.69, Continue home levothyroxine 125 mcg QD. # PE: Hx of provoked PE in 1990s, on warfarin until last admission ___ at ___. Warfarin was stopped given hx of GIB on warfarin and negative anti-cardiolipin AB on repeat check. # Gout: States she is no longer taking allopurinol ___ mg QD. # HLD: Continue home atorvastatin 20 mg QD # CREST: Omeprazole 40 mg BID while inpatient, discharged on home PPI. # PVD: Continue home cilostazol 100 mg QAM, 50 mg QPM Proxy name: ___ ___: SISTER Phone: ___ #Code status: Full TRANSITIONAL ISSUES: ==================== -New Medications: Nifedipine CR 30mg daily, Lasix 20mg PRN if she gains more than 3lbs or has significant lower extremity edema. -Stopped Medicaitons: Carvedilol, Lasix daily -Changed Medications: Cyclosporine 25mg BID. Decreased ___ Lantus to 15 given low AM blood sugars. Updated insulin regimen below. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin -Discharge Cr: 2.0 - Please monitor orthostatic blood pressures. If patient continues to have low pressures with standing can reduce dose of Nifedipine. - Recommend avoiding Carvedilol as this medication seemed to exacerbate patient's orthostasis. - Recommend follow up with autonomic neurology for evaluation of patient's autonomic dysregulation. --Consider outpatient stress testing given the demand troponin seen in the setting of hypotension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Cilostazol 100 mg PO QAM 7. Cilostazol 50 mg PO QHS 8. Ferrous Sulfate 325 mg PO DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Ranolazine ER 500 mg PO BID 13. Vitamin D ___ UNIT PO DAILY 14. Esomeprazole Magnesium 40 mg oral BID 15. Carvedilol 25 mg PO QHS 16. Carvedilol 12.5 mg PO QAM 17. Furosemide 20 mg PO DAILY 18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 19. Glargine 22 Units Breakfast Glargine 17 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Furosemide 20 mg PO DAILY:PRN leg swelling Please take this medication if your weight goes up by more than 3lbs in one day. RX *furosemide 20 mg 1 tablet(s) by mouth Daily as needed Disp #*30 Tablet Refills:*0 2. NIFEdipine CR 30 mg PO DAILY RX *nifedipine [Afeditab CR] 30 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H RX *cyclosporine modified [Neoral] 25 mg 1 capsule(s) by mouth Twice daily Disp #*60 Capsule Refills:*0 4. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Ascorbic Acid ___ mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 500 mg PO BID 10. Cilostazol 100 mg PO QAM 11. Cilostazol 50 mg PO QHS 12. Esomeprazole Magnesium 40 mg oral BID 13. Ferrous Sulfate 325 mg PO DAILY 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Mycophenolate Mofetil 500 mg PO BID 16. PredniSONE 5 mg PO DAILY 17. Ranolazine ER 500 mg PO BID 18. Vitamin D ___ UNIT PO DAILY 19.Outpatient Lab Work ICD 10: Z94.0 Please draw 12 hour cyclosporine trough on ___. Fax to: Renal ___ fax ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Orthostatic hypotension Secondary: Kidney transplant, acute kidney failure, troponin elevation secondary to demand ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ because had low blood pressures and felt lightheaded. We think this is due to dysregulation of your nervous system. It may have also been related to dehydration from vomiting. We stopped your Carvedilol and started you on a medication called Nifedipine. You should stop taking your Lasix everyday. Weigh yourself every morning and take your Lasix 20mg if weight goes up more than 3 lbs or you notice significant leg swelling. If you have to take your Lasix please call your primary care physican. You should also wear compression stockings to prevent blood from accumulating in your legs. Your Cyclosporin level was high so your dose was reduced. You should take Cyclosporine (Neoral) 25mg twice daily. You will need to have your Cyclosporine level checked in one week (___) and the results should be sent to the Kidney ___. Should you experience a recurrence or worsening of the symptoms that originally brought you to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern you, please seek medical attention. It was a pleasure taking care of you! Your ___ Care Team Followup Instructions: ___

10030753-DS-42

DS

2199-07-23 00:00:00

2199-07-23 17:57:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan Attending: ___. Chief Complaint: Right facial swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a history of ESRD s/p living renal transplant in ___ on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI presenting with pre-septal cellulitis, course complicated by DKA requiring MICU transfer, now with resolved DKA. The patient notes that when she woke on ___, her eye felt swollen and had significant redness on skin around her eyelid. She notes that it worsened since that time, and was associated with clear, teary discharge and crusting. She does note antecedent rhinorrhea without sore, throat, cough or shortness of breath. She developed a fever at home up to 101.9 which prompted her to come in on ___. She states that her vision may be slightly more blurry, but does not feel significantly difference from her baseline blurry vision, given her diabetic retinopathy and prior laser surgeries. In the ED, her initial vitals were temp 99.4, HR 114, BP 127-64, RR 18, 98% on room air. Her labs were notable for WBC 1.8, Hg 10.3, platelets 227. Chem-7 Na 131, Cl 93, bicarb 18, BUN 36, Cr 2.2, and Lactate 1.7. She had a chest x ray notable for no acute cardiopulmonary process. She was given IV Cefepime, IV Vancomycin. She was seen by renal transplant who recommended isotonic bicarbonate 500cc/hour for two hours, given her slight elevation in Creatinine, as well as: -agree with optho consult -CXR, blood cx, urine cx, CMV VL -would cover broadly with IV vanc/ceftazidime -hold MMF tonight and in the AM, continue cyclosporine 50mg BID Optho consulted: Concern for pre-septal cellulitis. Low suspicion of orbital involvement given no pain with eye movements or proptosis. -Dilated fundus examination shows extensive PRP scarring with vitreous hemorrhage in the right eye that appears unchanged from her last examination. -recommended CT of the orbit -antibiotics - artificial tears as needed - No heavy lifting, bending, straining or activities with rapid head movement. - Follow-up with ___ Ophthalmology as scheduled - Vitals prior to transfer: Temp. 98.7, HR 102, BP 134/68, RR 16, 100% RA ROS negative for SOB, chest pain, nausea, or diarrhea. Patient denies headache. She does endorse chronic nausea and vomiting on multiple PRN's for this. Notes this is stable. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___ 3. OTHER PAST MEDICAL HISTORY End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed ___ years ago - OSA -NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin ___ - this diagnosis viewed unlikely per ___ hematology/oncology note; warfarin discontinued ___ Social History: ___ Family History: Per OMR: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VS: 99.6 PO 114 / 61 102 16 98 Ra GENERAL: Right eye erythematous with swelling. HEENT: EOMI, pain with eye movement CARDIAC: RRR PULMONARY: clear bilaterally, no wheezes or rubs ABDOMEN: soft, non-tender to palpation GENITOURINARY: no foley EXTREMITIES: no edema SKIN: no rash NEUROLOGIC: CN grossly intact ======================== DISCHARGE PHYSICAL EXAM ======================== Vitals: T 98.0, BP 180/77 (lying), HR 89, RR 18, ___ 94 on room air General: Pleasant, well-appearing, lying in bed. HEENT: Atraumatic with improving erythema around right eyelid, now limited to ~1.5cm around upper/lower lids. Oropharynx clear. Neck: Supple with no lymphadenopathy or jugular venous distention Lungs: Clear to auscultation bilaterally CV: Regular rate/rhythm, with systolic ejection murmur heard best at lower sternal border. No rubs or gallops. Abdomen: Soft, nontender, nondistended Ext: Warm, well-perfused with 1+ pitting edema bilaterally. Neuro: Alert, oriented to self, place, time. Moving all extremities spontaneously and purposefully. Pertinent Results: =============== ADMISSION LABS =============== ___ 11:38PM ___ PO2-135* PCO2-29* PH-7.29* TOTAL CO2-15* BASE XS--10 COMMENTS-GREEN TOP ___ 11:13PM GLUCOSE-601* UREA N-49* CREAT-2.5* SODIUM-125* POTASSIUM-5.2* CHLORIDE-88* TOTAL CO2-12* ANION GAP-30* ___ 11:13PM CALCIUM-8.2* PHOSPHATE-5.2* MAGNESIUM-1.7 ___ 04:31PM LACTATE-1.7 ___ 04:30PM GLUCOSE-365* UREA N-36* CREAT-2.2* SODIUM-131* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-18* ANION GAP-25* ___ 04:30PM estGFR-Using this ___ 04:30PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-1.7 ___ 04:30PM WBC-1.8*# RBC-3.36* HGB-10.3* HCT-31.6* MCV-94 MCH-30.7 MCHC-32.6 RDW-13.0 RDWSD-44.5 ___ 04:30PM NEUTS-3* BANDS-0 ___ MONOS-65* EOS-0 BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-0.05* AbsLymp-0.56* AbsMono-1.17* AbsEos-0.00* AbsBaso-0.00* ___ 04:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL ___ 04:30PM PLT SMR-NORMAL PLT COUNT-227 =============== DISCHARGE LABS =============== ___ 06:09AM BLOOD WBC-3.8* RBC-3.36* Hgb-10.1* Hct-30.1* MCV-90 MCH-30.1 MCHC-33.6 RDW-13.9 RDWSD-45.4 Plt ___ ___ 06:09AM BLOOD Neuts-64 Bands-0 Lymphs-18* Monos-16* Eos-1 Baso-0 ___ Myelos-1* NRBC-2* AbsNeut-2.43 AbsLymp-0.68* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.00* ___ 06:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 06:09AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06:09AM BLOOD Glucose-149* UreaN-46* Creat-2.3* Na-138 K-4.5 Cl-101 HCO3-28 AnGap-14 ___ 06:09AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8 ___ 06:09AM BLOOD Cyclspr-PND ============= MICROBIOLOGY ============== ___ 5:08 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ========= IMAGING ========= ___ CHEST (PA & LAT) FINDINGS: There is minor right middle lobe atelectasis. No focal consolidation is seen. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. Right upper quadrant surgical clips are seen, presumed prior cholecystectomy. IMPRESSION: No acute cardiopulmonary process. ___ CT ORBIT, SELLA & IAC W IMPRESSION: 1. Pre-septal and periorbital soft tissue cellulitis without drainable fluid collection or post-septal cellulitis. ___ CHEST (PORTABLE AP) FINDINGS: Compared to prior, there is a new right pleural effusion. There is also increased vascular congestion with mild pulmonary edema. There is no pneumothorax. Heart size is mildly enlarged. IMPRESSION: Mild pulmonary edema with a small right pleural effusion. Brief Hospital Course: ___ with a history of ESRD s/p living renal transplant in ___ on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI presenting with pre-septal cellulitis, course complicated by DKA requiring MICU transfer, now with resolved DKA. # DKA The patient has a history of poorly controlled type 1 diabetes with prior admissions for DKA. While on treatment for preseptal cellulitis, she was found to have elevated blood sugars that were non-responsive to subcutaneous insulin. She was transferred to the MICU. Chem7 at 2300 on ___ showed glucose of 600, K of 5.2, HCO3 of 12, Gap of 25. She received an insulin bolus and was started on a drip. She was also given bicarbonate. Her glucose and gap improved on her insulin drip, so it was discontinued. She was subsequently found to be hyperglycemic again, so she was started on an insulin drip again, before ultimately being transferred to subcutaneous insulin before her transfer to the floor. Glucose was 103 and gap was 13 on transfer to floor (___). She was followed by ___ while inpatient, with adjustments made to her insulin regimen. Given an episode of hypoglycemia one day prior to discharge, the patient's insulin regimen was adjusted. She will follow up with ___ at her scheduled appointment within one week of discharge. # Pre-septal Cellulitis Patient presented with right periorbital erythema without vision changes from baseline and without pain on lateral gaze. She had a CT scan which showed no orbital cellulitis. Ophthalmology was consulted, who agreed that her presentation was consistent with preseptal cellulitis. She was started on vancomycin and cefepime on ___, given penicillin allergy. She did not have a reaction to cefepime. She was later transitioned to vancomycin/ceftriaxone/flagyl on ___, with improving periorbital erythema and edema. MRSA screen was negative on ___, and vancomycin discontinued. On ___ she was transitioned to cefpodoxime/flagyl in preparation for discharge with plan to continue until her ID follow up appointment on ___. # Leukopenia On initial presentation, she was found to be leukopenic, in the setting of a pre-septal cellulitis and immunosuppression. She was treated with antibiotics as above, and her leukopenia resolved. Her immunosuppressive medications were adjusted per renal transplant recommendations. Her CBC with diff was trended. Her leukopenia resolved prior to discharge. She will need her CBC with diff checked within 1 week after discharge. # ESRD s/p renal transplant w/metabolic acidosis (baseline Cr 1.8-2) ___ on CKD. Patient presented with Cr of 2.2, which peaked at 2.9 in the setting of DKA and infection. Her home mycophenylate was stopped per renal transplant consult, and she was given IV fluids and her DKA was treated as above. Her mycophenylate was restarted at 250mg (half home dose) upon improvement of her DKA. Her home cyclosporinge and prednisone were adjusted. Her home calcitriol, bicarbonate, and calcium carbonate were continued. CR lowered and stabilized at 2.3 on the floor. Her home dose of MMF and prednisone were eventually resumed prior to discharge. She was discharged on a lower dose of cyclosporine compared to her home dose that she had previously been taking. She will need her cyclosporine level to be checked within 1 week following discharge with adjustments as indicated. # Supine Hypertension with orthostasis # Dysautonomia The patient reported that this has been occurring for months, likely secondary to her dysautonomia and potentially worsening cardiac function. She was continued on home metoprolol. She was started on QHS metoprolol tartrate to help with her supine hypertension. She was also given support stockings as she wears at home. # Coronary Artery Disease s/p MI X2 and DES ___ She was continued on her home metoprolol, aspirin, atorvastatin, cilostazol, ranolazine. # Hyperlipidemia She was continued on home atorvastatin. # CREST She was continued on home esomeprazole, metroclopramide, and prochlorperazine # Hypthyroidism She was continued on home levothyroxine. # History of Pulmonary Embolism Patient had a history of provoked PE in 1990s, and was on warfarin until last admission ___ at ___. Warfarin was stopped given history of GI bleed on warfarin and negative anti-cardiolipin AB on repeat check. TRANSITIONAL ISSUES: -treated preseptal cellulitis, discharged on cefpodoxime 200mg q12h, flagyl 500mg q8h, with plan to continue PO abx until scheduled ID follow-up on ___ at 10AM -admitted to MICU for treatment of DKA in the setting of her pre-septal cellulitis -the patient's insulin regimen was adjusted per ___ recs. She was discharged on a lower lantus dose compared to her home dose, 20U QAM with 8U at bedtime. Please adjust standing insulin accordingly at ___ follow up appointment -patient will need follow up labs drawn by ___ next week, including CBC with diff, Chem 10, and cyclosporine level. -the patient's cyclosporine dose was adjusted during her hospitalization. She was discharged on 25mg q12h with plan to recheck cyclosporine level on repeat labs next week. Please follow up cyclosporine level and adjust accordingly. -she was started on additional metoprolol QHS to help with her supine hypertension. Please trend BP checks at outpatient follow up visits Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 20 mg PO QPM 2. Calcitriol 0.25 mcg PO DAILY 3. CycloSPORINE (Sandimmune) 50 mg PO Q12H 4. Esomeprazole 40 mg Other BID 5. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain 6. Glargine 22 Units Breakfast Glargine 11 Units Bedtime 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Metoclopramide 10 mg PO QIDACHS 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Promethazine 25 mg PO DAILY PRN nausea 13. Ranolazine ER 500 mg PO BID 14. Ascorbic Acid ___ mg PO DAILY 15. Aspirin 81 mg PO DAILY 16. Calcium Carbonate 500 mg PO BID 17. Ferrous Sulfate 325 mg PO DAILY 18. Vitamin D ___ UNIT PO DAILY 19. Cilostazol 100 mg PO QAM 20. Cilostazol 50 mg PO QPM Discharge Medications: 1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes RX *dextran 70-hypromellose (PF) [Tears Naturale Free (PF)] 0.1 %-0.3 % ___ drops to eyes prn Disp #*1 Bottle Refills:*2 2. Cefpodoxime Proxetil 200 mg PO Q12H please continue until follow up appointment with ID on ___ RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 3. Metoprolol Tartrate 12.5 mg PO QHS RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H please take until follow up appointment with ID on ___ RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 5. Ondansetron 4 mg PO Q8H RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H please call your transplant doctor for medication adjustment RX *cyclosporine modified 25 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*60 Capsule Refills:*0 7. Glargine 20 Units Breakfast Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 20 Units before BKFT; 8 Units before BED; Disp #*30 Syringe Refills:*0 8. Ascorbic Acid ___ mg PO DAILY RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*0 11. Calcitriol 0.25 mcg PO DAILY RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 12. Calcium Carbonate 500 mg PO BID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Cilostazol 100 mg PO QAM RX *cilostazol 100 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet Refills:*0 14. Cilostazol 50 mg PO QPM RX *cilostazol 50 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 15. Esomeprazole 40 mg Other BID RX *esomeprazole magnesium 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 16. 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 17. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain RX *furosemide 20 mg 1 tablet(s) by mouth daily prn Disp #*30 Tablet Refills:*0 18. Levothyroxine Sodium 125 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 19. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 20. Mycophenolate Mofetil 500 mg PO BID RX *mycophenolate mofetil 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 21. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 22. Promethazine 25 mg PO DAILY PRN nausea RX *promethazine 25 mg 1 tablet by mouth daily prn Disp #*30 Tablet Refills:*0 23. Ranolazine ER 500 mg PO BID RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 24. Vitamin D ___ UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 25.Outpatient Lab Work ICD 10: Z94.0 : Kidney transplant status Chem 10, CBC with differential, Cyclosporine level Date: please draw with ___ visit on ___ or ___ Please fax results to ___ at ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Preseptal Cellulitis Diabetic Ketoacidosis (resolved) End-stage renal disease with left-sided living kidney transplant Diabetes Mellitus Type 1 complicated by neuropathy, retinopathy, neurogenic bladder Hypertension Autonomic Dysfunction/Dysautonomia Secondary Diagnoses: Dyslipidemia Coronary Artery Disease Scleroderma w/ CREST syndrome Gastroparesis/GERD/Hiatal hernia Gout Obstructive Sleep Apnea 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. You were admitted because of an infection in the skin around your eye, a condition called pre-septal cellulitis. You were given antibiotics for this and developed DKA during your treatment. You went to the MICU for treatment of your DKA. You were given insulin and fluids and your DKA eventually resolved. The swelling and redness around your eye improved with IV antibiotic treatment. You were discharged home with oral antibiotics to clear the infection. Please continue to take all medications as prescribed, including the oral antibiotics until your outpatient appointment with Infectious Disease on ___. Please weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. Please be sure to get your labs checked within one week of hospital discharge. A prescription has been written for ___ to draw your labs next week, with instructions to fax results to Dr. ___. We wish you the best in your health. Sincerely, Your ___ Team Followup Instructions: ___

10030753-DS-45

DS

2199-11-29 00:00:00

2199-11-30 08:14:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan / carvedilol Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with ESRD s/p LRRT ___, (bl Cr 1.5-2.0; bx w diabetic nephropathy and grade 2 IFTA ___, CAD s/p DES ___, ___, HTN, CREST syndrome, T1DM, who presents with shortness of breath found to have volume overload, hyperglycemia, and sepsis in the ED. Of note, patient was recently admitted ___ on the kidney transplant service due to shortness of breath. This is attributed to acute decompensated systolic heart failure in the setting of dietary noncompliance. ACS was ruled out. She had a repeat that admission that showed a newly depressed EF of 40%. Cardiology was consulted and her meds were altered. Specifically, she was discontinued on metoprolol, furosemide, carvedilol; nitro patch, and hydralazine were added, and home cyclosporine was increased. She subsequently followed up with cardiology since that visit and Lasix 40 mg twice daily was added. In ED initial VS: T ___ 26 96% Nasal Cannula Exam: none Labs significant for: Patient was given: IV Ondansetron 4 mg IV Vancomycin IV DRIPNitroglycerin (0.35-3.5 mcg/kg/min ordered)Started 0.4 IV Piperacillin-Tazobactam PO Acetaminophen 1000 mg IV Vancomycin 1000 mg IV Levofloxacin 750 mg(chosen given pcn allergy) IV insulin regular 10 Imaging notable for: CXR 1. Compared to ___, persistent moderate cardiomegaly and increased vascular congestion, now with moderate bilateral pulmonary edema. 2. Small bilateral pleural effusions. Consults: VS prior to transfer: T 102.1 122 177/78 26 96% Nasal Cannula On arrival to the MICU, patient reports her breathing is mildly improved Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___ 3. OTHER PAST MEDICAL HISTORY. End-stage renal disease ___ diabetes s/p L-sided living kidney transplant in ___ - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed ___ years ago - OSA Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: Admission exam: VITALS: T 98.2 108 156/24 26 96% Nasal Cannula GENERAL: Alert, oriented, moderately uncomfortable appearing HEENT: Sclera anicteric, dry MM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: bilateral rales in bases bilaterally; no rhonchi or wheeze CV: tachycardic, regular rhythm, no rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rash NEURO: no tremor, no asterixis, CNII-XII intact, no neck stiffness, neg Kernig's Discharge exam: VS: 109 / 69 Standing 113 98 GENERAL: NAD HEENT: AT/NC, MMM, no JVD HEART: RRR, S1/S2, II/VI systolic murmur heard best at USB and apex LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: grossly intact PSYCH: Alert, responsive, appropriate responses SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission labs: ___ 05:06AM BLOOD WBC-11.9* RBC-3.09* Hgb-9.5* Hct-28.4* MCV-92 MCH-30.7 MCHC-33.5 RDW-12.8 RDWSD-42.5 Plt ___ ___ 05:06AM BLOOD Neuts-86.7* Lymphs-4.5* Monos-7.1 Eos-0.9* Baso-0.3 Im ___ AbsNeut-10.28* AbsLymp-0.53* AbsMono-0.84* AbsEos-0.11 AbsBaso-0.04 ___ 05:06AM BLOOD ___ PTT-28.4 ___ ___ 05:06AM BLOOD Glucose-738* UreaN-48* Creat-2.3* Na-135 K-3.9 Cl-93* HCO3-25 AnGap-17* ___ 05:06AM BLOOD ALT-9 AST-8 AlkPhos-116* TotBili-0.4 ___ 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84 TotBili-0.5 ___ 05:06AM BLOOD ___ ___ 05:06AM BLOOD cTropnT-0.16* ___ 05:06AM BLOOD Lipase-10 ___ 05:06AM BLOOD Albumin-3.4* Calcium-9.8 Phos-3.4 Mg-1.7 ___ 05:25AM BLOOD Cyclspr-129 ___ 05:53AM BLOOD Cyclspr-181 ___ 02:50PM BLOOD freeCa-1.04* ___ 05:17AM BLOOD ___ pO2-47* pCO2-41 pH-7.43 calTCO2-28 Base XS-2 ___ 06:45AM URINE RBC-4* WBC-19* Bacteri-FEW* Yeast-NONE Epi-0 ___ 06:45AM URINE Color-Straw Appear-Clear Sp ___ Notable labs: ___ 10:21AM BLOOD WBC-10.4* RBC-2.74* Hgb-8.7* Hct-25.5* MCV-93 MCH-31.8 MCHC-34.1 RDW-13.1 RDWSD-44.2 Plt ___ ___ 05:25AM BLOOD WBC-7.0 RBC-2.91* Hgb-9.0* Hct-27.5* MCV-95 MCH-30.9 MCHC-32.7 RDW-13.3 RDWSD-45.5 Plt ___ ___ 05:12AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.4* Hct-29.6* MCV-97 MCH-30.7 MCHC-31.8* RDW-13.2 RDWSD-46.5* Plt ___ ___ 12:22AM BLOOD ___ PTT-30.7 ___ ___ 05:00AM BLOOD ___ PTT-29.9 ___ ___ 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84 TotBili-0.5 ___ 10:21AM BLOOD Glucose-431* UreaN-47* Creat-2.5* Na-138 K-3.6 Cl-97 HCO3-22 AnGap-19___ 05:25AM BLOOD Glucose-158* UreaN-51* Creat-2.8* Na-143 K-3.6 Cl-101 HCO3-29 AnGap-13 ___ 05:00AM BLOOD Glucose-188* UreaN-46* Creat-2.3* Na-144 K-3.6 Cl-103 HCO3-31 AnGap-10 ___ 05:12AM BLOOD Glucose-65* UreaN-43* Creat-2.3* Na-144 K-4.3 Cl-102 HCO3-33* AnGap-9 ___ 05:42AM BLOOD Cyclspr-198 ___ 05:50AM BLOOD Cyclspr-73* ___ 09:52AM BLOOD Cyclspr-70* ___ 09:04AM BLOOD Cyclspr-228 Discharge labs: ___ 06:00AM BLOOD WBC-7.6 RBC-3.00* Hgb-9.4* Hct-28.7* MCV-96 MCH-31.3 MCHC-32.8 RDW-13.0 RDWSD-44.7 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-196* UreaN-38* Creat-2.4* Na-141 K-4.4 Cl-97 HCO3-34* AnGap-10 ___ 06:00AM BLOOD Calcium-10.1 Phos-3.5 Mg-1.8 ___ 09:00AM BLOOD Cyclspr-79* MICROBIOLOGY: ___ 6:45 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. REPORTS: CXR ___ FINDINGS: The size of the cardiac silhouette is enlarged. There is a small left pleural effusion with subjacent atelectasis/pneumonia. The right lung is grossly clear. There is no pneumothorax or right pleural effusion. IMPRESSION: New opacities at the left lung base are reflective of a pleural effusion with subjacent atelectasis/pneumonia. CXR ___ FINDINGS: Compared to ___, the cardiac silhouette remains moderately enlarged. There is increased vascular congestion with moderate bilateral pulmonary edema. Small bilateral pleural effusions are again seen. No focal infiltrates or pneumothorax. IMPRESSION: 1. Compared to ___, persistent moderate cardiomegaly and increased vascular congestion, now with moderate bilateral pulmonary edema. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms. ___ is a ___ year old woman with a PMHx of ESRD s/p living renal transplant in ___, DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and chart history antiphospholipid antibody syndrome with h/o remote PE in ___, CAD s/p MI x 2 and DES ___ who presents to the hospital with dyspnea and hypertensive emergency as well as fever. Acute issues: # Hypertensive emergency: Patient presented with progressive dyspnea since recent discharge, weight gain, and orthopnea, and she was found to have hypertensive emergency, acute cardiogenic pulmonary edema, causing hypoxemic respiratory distress. Her respiratory status improved with control of blood pressure. Ineffective control of blood pressure and hypervolemia were the driving factors for her presentation. Her BP is very elevated while supine but difficult to control due to worsening of orthostasis when on antihypertensives. Her diuretic and blood pressure regimen was titrated while in-house and she was discharged with SBPs in 170s-180s while supine, 80s-100s while standing. She occasionally still got dizzy with these low blood pressures. Physical therapy worked with her and felt that other than her symptomatic hypotension, her strength and mobility was stable but did recommend home physical therapy. #Fever: Patient was febrile to 102.5 on the day of admission but was otherwise asymptomatic without signs of infection. Antibiotics were discontinued in light of cultures without complications. She did not have any further fevers. # ESRD s/p renal transplant ___, Cr baseline of 1.5-2.0, indicating allograft CKD. Creatinine was slightly elevated at 2.5 compared to baseline ~2.0. Her ___ is likely related to hypertensive urgency and improved with BP control. Her discharge creatinine was 2.4. Chronic issues: #Immunosuppression: Patient was maintained on her home dosages of prednisone and MMF. Her cyclosporine regimen was titrated so that her blood cyclosporine level was within goal. She was discharged on 25mg qAM and 50mg qPM. # Type 1 Diabetes: Maintained on insulin regimen which was titrated while in-house in setting of hypoglycemia. ___ followed her as an inpatient. She was discharged on 15U Toujeo in the AM and ___ (twice daily) as well as 6U Humalog with meals and sliding scale, per ___ recommendations, with follow-up within a week. # Hypothyroidism: Maintained on home synthroid # CAD s/p DES: Maintained on home aspirin, atorvastatin, and ranolazine # Peripheral arterial disease: Maintained on home cilostazol # Gout: Maintained on home allopurinol # Health Maintenance: Maintained on home calcium carbonate and vitamin D Transitional issues: STOPPED MEDICATIONS: - Amlodipine - Carvedilol- patient reported fatigue with this medication and would like to avoid beta blockers in the future - Losartan (holding) CHANGED MEDICATIONS: - Hydralazine - Cyclosporine - Furosemide - Insulin [ ] Discharge weight 130.5 lbs. Weigh patient and assess for adequacy of diuretic regimen at next appointment. [ ] Patient has been instructed that she can take one additional dosage of 20mg Lasix PO if needed for significant weight gain, shortness of breath, or swelling in her legs. However, she should call her doctor immediately. [ ] Losartan was held due to symptomatic hypotension as well as elevated creatinine. Consider restarting at discharge at next PCP or cardiology appointment if additional antihypertensive is needed. [ ] Patient was discharged with home ___ and ___ [ ] Measure BP and assess for continued autonomic lability. Of note, patient continues to be symptomatic (dizzy, lightheaded) with sitting/standing. # Communication: - ___ (HCP/sister): h ___ c ___ # Code: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Ranolazine ER 500 mg PO BID 13. Vitamin D ___ UNIT PO DAILY 14. Cilostazol 100 mg PO QAM 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Promethazine 25 mg PO DAILY PRN nausea 17. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 18. Esomeprazole 40 mg Other BID 19. Carvedilol 3.125 mg PO BID 20. HydrALAZINE 25 mg PO QHS 21. Furosemide 40 mg PO BID 22. Losartan Potassium 25 mg PO DAILY Discharge Medications: 1. Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Toujeo 15 Units Breakfast Toujeo 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM RX *cyclosporine modified 25 mg 1 capsule(s) by mouth Twice a day Disp #*90 Capsule Refills:*0 3. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 4. Furosemide 20 mg PO BID RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. HydrALAZINE 50 mg PO QHS RX *hydralazine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 6. Allopurinol ___ mg PO DAILY 7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 8. Ascorbic Acid ___ mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Calcitriol 0.25 mcg PO DAILY 12. Calcium Carbonate 500 mg PO BID 13. Cilostazol 100 mg PO QAM 14. Cilostazol 50 mg PO QPM 15. Esomeprazole 40 mg Other BID 16. Ferrous Sulfate 325 mg PO DAILY 17. Levothyroxine Sodium 125 mcg PO DAILY 18. Mycophenolate Mofetil 500 mg PO BID 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. PredniSONE 5 mg PO DAILY 21. Promethazine 25 mg PO DAILY PRN nausea 22. Ranolazine ER 500 mg PO BID 23. Vitamin D ___ UNIT PO DAILY 24. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until your doctor tells you to Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: - Hypertensive emergency - Autonomic lability Secondary diagnosis: - Type 1 Diabetes Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. ___, Why were you admitted? - You were admitted for elevated blood pressures that were causing you to have trouble breathing What happened in the hospital? - We adjusted your medications to better control your blood pressures - We also adjusted your water pill regimen (diuretics) so that your weight was back to normal at discharge What should you do when you leave the hospital? - Please remember to take precautions when standing- stand slowly and be careful about falling! - Please wear compression stockings whenever sitting or standing to increase your blood pressure - Weigh yourself every morning, call MD if weight goes up more than 3 lbs in 1 day. If needed (you notice trouble breathing, increased swelling, or weight gain) you can take an extra dose of your Lasix 20mg once, but please call your doctor too. It was a pleasure taking care of you! We wish you the best. - Your ___ Team Followup Instructions: ___

10030753-DS-48

DS

2200-05-29 00:00:00

2200-05-30 06:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ___ Allergies: Penicillins / Ativan / carvedilol / amlodipine Attending: ___. Chief Complaint: Traumatic Fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old woman with multiple medical comorbidities, including CAD s/p multiple ___ recently ___ on ticragelor and aspirin, DM1 c/b ESRD s/p renal transplant on immunosuppressing agents, who presented after unwitnessed fall and was found to have left subarachnoid hemorrhage. History provided by patient and family (niece who is a ___ ___). Per patient, she ___ been getting progressively weaker over the past few months, noting that she never recovered to her baseline following her coronary angioplasty on ___, which included PCI of Cx and OM with DES. Of note, she ___ a complicated cardiac history which includes DES to LAD (___) and Cx/OM ___ DES to LAD ___. Patient reports not being able to mobilize around the house as well as she used to due to her decreased sensation, which ___ been at baseline in the setting of dysautonomia. She reports frequently having her knees buckle under her. She also ___ been having episodes of orthostasis after taking furosemide for her CHFrEF (EF41% ___. In the days prior to her fall, the patient notes that her continuous glucose monitor was malfunctioning, reading blood glucose levels of ___ with corresponding finger sticks in the 200s. For this reason, she discontinued her continuous glucose monitor. She says that she got up in the middle of the night to walk to the bathroom and fell to the floor on her right side. She does not recall how she felt prior to her fall. She does not remember feeling dizzy or hot and she did not wake up sweating. She had no incontinence or tongue lacerations. She did endorse right-sided pain and pulled herself up to standing. The next day she still felt sick with nausea, diarrhea, right-sided rib pain and was worried about having a rib fracture. She called her niece (a nurse) who recommended that she call EMS due to the snow storm. She was initially brought to ___ where she was found to have glucose 400s with NCHCT demonstrated right SAH. She was transferred to ___ for further management. She was initially admitted to the ICU for monitoring of her subarachnoid hemorrhage and correction of nonketotic hyperosmolar hyperglycemia. Repeat non con head CT was stable and her neurological exam remained stable. Her hyperglycemia resolved s/p transient control with IV insulin. She was deemed clinically stable to transfer to the general floor after one day in the ICU for medical management and support of her labile blood glucose levels. Cardiac workup notable for troponin 0.18, downtrending to 0.17, with normal CK and without signs of ischemic changes on EKG. On admission to ICU: - insulin gtt transitioned off, blood glucose labile (40s, then stable on humalog and lantus); ___ consulted. - repeat non-con head CT unchanged with stable neuro exam - received 1U Platelets, 1U PRBC for Hgb 6.7, PLT 260s while on anti-platelet with appropriate correction Past Medical History: Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) Hypertension Dyslipidemia CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___. Then DES to LAD in ___ and ___ PCI of Cx and OM with ___ ___ w/ CREST syndrome Gastroparesis GERD Hiatal hernia Gout OSA End-stage renal disease due diabetes s/p L-sided living kidney transplant in ___ anemia Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: Admission exam: T:98.2 BP:164/75 HR:97 RR:16 O2Sats:99% Gen: HEENT: Pupils:4mm bilaterally EOMs Full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and ___. 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 sluggishly,4mm to 3 mm bilaterally, hx of Laser eye surgery. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Unable to assess pronator drift r/t right rib pain. Motor: Patient with generalized weakness TrapDeltoidBicepTricepGrip Right 4 4 4 4 4 Left 4 4 4 4 4 IPQuadHamATEHLGast Right4 4 4 4 2 4 Left4 4 4 4+ 2 4 *Exam limited r/t pain Sensation: peripheral neuropathy to bil hands and bilateral lower extremity from knees down DISCHARGE EXAM: VITALS: 98.5F 128/65 83 18 94% FSBG 223 General: alert, oriented, no acute distress, flattened affect Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, holosystolic murmur heard best in the left upper sternal border, no rubs and gallops Abdomen: Diffusely distended and tympanitic, tender in RUQ near ribs, no rebound tenderness or guarding, organomegaly not assessed due to distention GU: Foley in place for "straight cath" Ext: warm, several scabbed lesions appreciated on feet, no edema Neuro: GCS 15, ___ strength in lower extremities bilaterally Pertinent Results: ___ 09:01AM BLOOD WBC-4.7 RBC-2.77* Hgb-8.4* Hct-25.4* MCV-92 MCH-30.3 MCHC-33.1 RDW-15.1 RDWSD-49.7* Plt ___ ___ 08:13PM BLOOD Neuts-96.2* Lymphs-1.9* Monos-1.1* Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.58 AbsLymp-0.09* AbsMono-0.05* AbsEos-0.01* AbsBaso-0.01 ___ 09:01AM BLOOD Plt ___ ___ 09:01AM BLOOD Glucose-59* UreaN-56* Creat-2.3* Na-145 K-3.7 Cl-117* HCO3-13* AnGap-15 ___ 01:50AM BLOOD Glucose-174* UreaN-57* Creat-2.3* Na-143 K-3.8 Cl-115* HCO3-12* AnGap-16 ___ 09:01AM BLOOD CK(CPK)-145 ___ 09:01AM BLOOD CK-MB-4 cTropnT-0.17* ___ 01:50AM BLOOD CK-MB-3 cTropnT-0.18* ___ 09:01AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.5 ___ 01:50AM BLOOD Calcium-6.9* Phos-2.5* Mg-1.8 ___ 08:13PM BLOOD Calcium-7.2* Phos-2.5* Mg-0.7* NCHCT: FINDINGS: Re-demonstrated is right sided subarachnoid hemorrhage, centered in the sylvian fissure. No extension or new hemorrhage is identified. Basal ganglia calcifications are unchanged. No new large territorial infarct or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: -Essentially unchanged examination from 11 hours prior. ___ MRA: IMPRESSION: 1. Study is moderately degraded by motion. 2. New left SCA focal occlusion versus high-grade stenosis compared to ___ prior exam. 3. New nonocclusive irregularity of right M1 segment compared to ___ prior exam, likely artifactual as described. 4. Otherwise grossly patent circle of ___ as described. ___ CT Torso 1. Nonspecific small volume ascites along the left paracolic gutter and spleen. Splenic or colonic injury cannot be excluded on this unenhanced exam. Recommend contrast-enhanced CT or MRI if possible to further evaluate. 2. 2.1 x 1.4 cm hypodensity in the region of the pancreatic head is probably a pancreatic lesion rather than duodenal diverticulum. 1 cm exophytic hypodensity off anterior aspect of the pancreatic body. No main pancreatic ductal dilation. Lesions are incompletely characterized without intravenous contrast and a contrast enhanced CT or MRI if possible is recommended to further evaluate and exclude malignancy. 3. Nonspecific mesenteric fat stranding and multiple scattered prominent lymph nodes throughout the abdomen and pelvis, AP and not enlarged by size criteria. 4. Mild soft tissue fat stranding along the right flank. No evidence of rib fracture. 5. Anemia. 6. Prominent main pulmonary artery suggests sequelae of chronic pulmonary hypertension. 7. Status post left lower quadrant renal transplant, stable in appearance. Markedly atrophic native kidneys. 8. Markedly distended urinary bladder. Discharge labs: ___ 06:35AM BLOOD WBC-7.1 RBC-2.84* Hgb-8.6* Hct-25.7* MCV-91 MCH-30.3 MCHC-33.5 RDW-15.7* RDWSD-51.2* Plt ___ ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD Glucose-214* UreaN-70* Creat-2.6* Na-140 K-4.2 Cl-105 HCO3-19* AnGap-16 ___ 06:35AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.7 ___ 06:35AM BLOOD Cyclspr-75* Brief Hospital Course: ___ year old woman with multiple medical comorbidities, including CAD s/p multiple ___ recently ___ on ticragelor and aspirin, DM1 c/b ESRD s/p living donor renal transplant on immunosuppressing agents, who presented after unwitnessed fall and was found to have left subarachnoid hemorrhage. Etiology of her SAH thought to be traumatic in the setting of her fall. Fall was most likely related to hyperglycemia with component of orthostatic hypotension/dysautonomia. #Left ___ Patient presented after traumatic fall, and was admitted to the Neuro ICU for monitoring of a subarachnoid hemorrhage and correction of nonketotic hyperosmolar hyperglycemia. Fall was likely secondary to labile blood sugars with components of dysautonomia and orthostatic hypotension. EKG was reassuring for arrhythmia as cause of syncope. No incontinence or tongue lacerations or report of post-ictal state so seizure unlikely. Repeat non con head CT showed stability of her bleed, and her neurological exam remained stable. She was deemed clinically stable to transfer to the general floor after one day in the ICU for medical management. On the floor, a repeat MRA brain w/o contrast that showed grossly patent circle of ___ without concern for aneurysm. Patient complained of some left sided lower extremity weakness, however trended Neuro exams were found to be stable and not significant for new weakness. Neurosurgery was consulted for management of ___ and trending of Neuro exam. Blood pressures were closely monitored for a goal of systolic <160. Fall was believed likely traumatic. Low suspicion for aneurysmal rupture. Etiology of fall thought to be related to labile blood glucose levels with exacerbation from underlying dysautonomia. Unlikely to be syncopal event from cardiac etiology based on normal EKG, and normal cardiac enzymes. Fall could be related to unwitnessed seizures, possibly triggered by labile glucose levels, although no incontinence or tongue lacerations and no documentation or report of postictal state. Patient was given lidocaine patches and analgesics for pain ___ contusions from fall. ___ consulted for weakness, recommendation for rehab. #Supine Hypertension/Orthostatic Hypotension/Dysautonomia Patient had very labile blood pressures while in-house ranging from 110-202 systolic. Per Neuro-surgery, patient was not at risk for SAH re-bleed, however, goal to keep systolic <160 to prevent increased intracranial pressures. In consultation with Renal Transplant, long-acting anti-hypertensives were favored for better monitoring of pressures throughout the day. Home Metoprolol succinate was transitioned to Metoprolol XL 100 mg, and home Hydralazine 50 mg qHS was maintained throughout admission, however pressures continued to be significant for supine hypertensive urgency. Orthostatic vitals were done over the course of 2 days, and patient was found to be orthostatic intermittently. CCB were considered as additional agents, however patient reports significant orthostatic hypotension with these agents. Captopril was deemed to be too short-acting. A trial of Losartan was considered, however, given patient's intermittent orthostatic vitals, high risk of falls, and pressures in target range of 130-150's systolic when sitting/standing, an additional agent was not started but may be considered in the outpatient setting. She was treated with 50mg PO hydralazine as needed. #Type 1 Diabetes Mellitus Patient presented with hyperglycemia to the 600's. She was brought to the Neuro ICU for her SAH, where an insulin drip rapidly corrected her blood sugars to the 40-200's. On the floor, Lantus was restarted in consultation with ___ ___, and insulin regimen was dosed daily to good effect. She maintained normal to low normal blood sugars with Lantus 10U qAM +/- 5UqPM, ___ fixed dose Humalog at meals +/- ISS. Prior to discharge she was receiving 8U AM, her Humalog dose was 2U with meals. #Incidental Pancreatic Mass A non-con CT Torso at ___ was significant for 2.1 x 1.4 cm hypodensity in the region of the pancreatic head and a 1 cm exophytic hypodensity off anterior aspect of the pancreatic body, cannot r/o malignancy. Masses were poorly characterized without contrast, however patient's ESRD and transplanted kidney limited imaging modalities to fully characterize the findings. GI was consulted for an esophageal ultrasound, however, it was recommended waiting ___ weeks for outpatient EUS to prevent SAH re-bleed in the setting of increased intracranial pressure ___ anesthesia for the procedure. #Anemia Admission H/H of 7.2/21.8 which downtrended to 6.2/19.4. Patient was given a unit of pRBCs to good effect. Outpatient notes significant for chronic anemia. Iron/anemia labs significant for low-normal iron with low iron/TIBC ratio (19%), normal B12, a low-normal folate, and elevated ferritin. Patient started on multivitamins and folate supplements. A stool guaiac was ordered but could not be performed due to lack of specimen while in house. Recommend hematology work-up as outpatient. #Gastroparesis #Nausea/Vomiting/Diarrhea Patient reported weeks of nausea, vomiting, and diarrhea prior to admission, though patient did not experience these symptoms on the medical floor. An infectious work-up was negative. Prior nausea/vomiting likely secondary to diabetic gastroparesis and elevated blood glucose at home. N/V likely not related to SAH given chronic time course. #Neurogenic Bladder Patient ___ neurogenic bladder secondary to Diabetes complications, for which she straight caths at home. Patient was bladder scanned regularly and straight-cathed appropriately. #CAD/HFREF Hx of CAD, no s/p multiple Percutaneous coronary interventions. Resumed home ASA/Brillinta after repeat imaging showed stability of SAH. Continued home furosemide 20mg PRN volume exam, however patient remained euvolemic in-house. # ESRD s/p LDRT ___ Continued home immunosuppression, cyclosporine, MMF, and prednisone. Serum cyclosporine and creatinine were monitored daily. Low bicarb- likely secondary to GI and renal losses- was treated with sodium bicarbonate. Renal transplant following throughout admission. ============================= Transitional Issues ============================= [] Pancreatic mass: CT Torso at ___ with incompletely characterized pancreatic lesions not noted on prior CT torso. GI to schedule esophageal US as outpatient and pt ___ appointment with Dr. ___ GI on ___. []f/u ___ clinic with Dr. ___. Please call ___ for appointment. []f/u with Hematology for chronic anemia, appointment ___ been scheduled []Patient will need to call number on back of CGM to order new CGM from Dexicom []Consider DCing Cilostazol, as may be contra-indicated in ___ patients []Consider starting Losartan for elevated pressures if not orthostatic as outpatient. []Pt will need to call ___ to schedule an appointment with Dr. ___ in ___ clinic. [] Foley was placed for urinary retention of 1000cc iso patient preference for foley over straight catherization; please perform void trial at rehab [] continue to monitor cyclosporine level, Goal 75-125. [] Pt intermittently required extra doses of hydralazine 50mg PO to control blood pressures in the 180s-200s systolic [] check weekly chemistry levels and assess if sodium bicarbonate dose is adequate [] consider IV iron if patient still iron deficient since PO iron can be very constipating I have seen and examined Ms. ___, reviewed the findings, data, and plan of care documented by Dr. ___ ___, MD dated ___ and agree, except for any additional comments below. Ms. ___ is clinically stable for discharge today, ___. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. ___, MD ___ of ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Cilostazol 50 mg PO QPM 9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 10. Esomeprazole 40 mg Other BID 11. Ferrous Sulfate 325 mg PO DAILY 12. HydrALAZINE 50 mg PO QHS 13. Levothyroxine Sodium 125 mcg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Mycophenolate Mofetil 500 mg PO BID 16. PredniSONE 6 mg PO DAILY 17. Promethazine 25 mg PO DAILY PRN nausea 18. Ranolazine ER 500 mg PO BID 19. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 20. Vitamin D ___ UNIT PO DAILY 21. Cilostazol 100 mg PO QAM 22. Furosemide 20 mg PO DAILY 23. melatonin 10 mg oral QHS 24. Metoprolol Succinate XL 25 mg PO DAILY 25. naftifine 2 % topical BID To soles of feet and between toe webs 26. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 27. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q Breakfast 28. Captopril 12.5 mg PO BID PRN SBP > 160 29. trimethobenzamide 300 mg oral BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. FoLIC Acid 1 mg PO DAILY 4. Glargine 8 Units Breakfast Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Multivitamins 1 TAB PO DAILY 6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Sodium Bicarbonate 1300 mg PO TID 9. Furosemide 20 mg PO DAILY 10. Metoprolol Succinate XL 100 mg PO DAILY 11. Allopurinol ___ mg PO DAILY 12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 13. Ascorbic Acid ___ mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Calcitriol 0.25 mcg PO DAILY 17. Calcium Carbonate 500 mg PO BID 18. Cilostazol 50 mg PO QPM 19. Cilostazol 100 mg PO QAM 20. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 21. Esomeprazole 40 mg Other BID 22. Ferrous Sulfate 325 mg PO DAILY 23. HydrALAZINE 50 mg PO QHS 24. Levothyroxine Sodium 125 mcg PO DAILY 25. Lidocaine 5% Patch 1 PTCH TD QAM 26. melatonin 10 mg oral QHS 27. Mycophenolate Mofetil 500 mg PO BID 28. naftifine 2 % topical BID To soles of feet and between toe webs 29. PredniSONE 6 mg PO DAILY 30. Promethazine 25 mg PO DAILY PRN nausea 31. Ranolazine ER 500 mg PO BID 32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 34. Trimethobenzamide 300 mg oral BID 35. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses: Subarachnoid Hemorrhage Nonketotic hyperosmolar hyperglycemic state Type 1 Diabetes Mellitus Hypertension Orthostatic Hypotension Neurogenic Bladder ESRD status post living donor transplant Anemia Secondary diagnoses: Gastroparesis Pancreatic mass CAD s/p ___ Failure with reduced ejection fraction 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 ___, ___ were admitted to the hospital after ___ suffered from a head injury when ___ fell. ___ were initially admitted to the neurosurgery ICU because ___ suffered from a small amount of blood in your brain (subarachnoid hemorrhage), which occurred when ___ hit your head. On admission to the hospital, we found that your blood sugar levels were high. We think that changes in your blood sugar levels may have contributed to your fall. We adjusted your insulin and were able to keep your blood sugars in a normal range. We initially held your aspirin and brilanta but restarted it on ___. We imaged your brain arteries to obtain a more comprehensive picture of the blood in your head. Your MRA showed that the bleeding had stopped and that your brain arteries were not clogged. We recommend that ___ try to keep your blood pressure below 160 to protect your brain from having another bleed. While ___ were at ___ ___ had a picture taken of your belly which showed a pancreatic mass. We cannot tell what this mass is because the quality of the picture was limited. Unfortunately, we cannot improve the quality of the picture because it may cause damage to your kidney transplant. Therefore, we have scheduled ___ for an outpatient esophageal ultrasound- another type of picture that will not hurt your kidneys- to try to get a better look at your pancreas. We were not able to do this in the hospital because we were worried that if ___ vomited while getting the anesthesia needed for the ultrasound, it might make your brain bleed worse. It will be safer to get this ultrasound done in a week or so when ___ have healed more. What ___ should do when ___ get home: -Work on getting stronger at rehab. -Continue to monitor your blood pressure and take your blood pressure medications. Try to keep your blood pressure in the 120-150's to protect your brain from re-bleeding. -Continue to monitor your blood glucose closely, and take your insulin. ___ will need a new continuous glucose monitor. Please call the phone number on the back of your current CGM to order a new one. -Follow up in the dysautonomia, hematology, GI, traumatic brain injury clinics to make sure that ___ are healing well. -Take great care when ___ get up from lying down or sitting to prevent yourself from falling again. Medication changes on this admission: -We changed your metoprolol succinate to 100 mg Metoprolol XL. XL is the longer acting form of the medication and will help control your blood pressure. -We changed your insulin to 8U Lantus in the morning and 2U Humalog before meals Thank ___ for allowing us to participate in your care. Take Care, Your SIRS General ___ ___ Team Followup Instructions: ___

10030753-DS-49

DS

2200-06-19 00:00:00

2200-06-19 18:35:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan / carvedilol / amlodipine Attending: ___. Chief Complaint: Weight gain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with DM1, CAD and dysautonomia presents from rehab with sudden onset of lower extremity swelling and pain. Yesterday evening, the patient noticed the sudden onset ___ pain and swelling that is described as throbbing. She does not note any exacerbating factors but does not alleviation with movement. This morning, she noticed progression of the pain to her lower back. She ___ no fevers or chills. She notes no chest pain, palpitations or dyspnea. She ___ no cough, wheezing or orthopnea. +n/v for over ___ year. She ___ had large, loose, watery bowel movements ___ times per day for the last week. She stats her blood glucose ___ been under good control. Of note, the patient was hospitalized at ___ from ___ after suffering a SAH after a mechanical fall. The etiology of the fall was attributed to labile blood sugars and blood pressures due to dysautonomia. Her hospital course was complicated by HHS and labile blood pressures. She was seen by ___ and ___ blood sugars were controlled with an insulin gtt and eventually transitioned to Lantus 8u qAM and 2U Humalog at meals with sliding scale. . Regarding her labile blood pressures, this was thought to be from dysautonomia due to her poorly controlled DM1. She was started on metoprolol succinate and hydralazine In the ED, initial VS were: T 97.5 HR 83 BP 147/63 R 16 SpO2 99% RA Exam notable for: 2+ pitting edema to mid calf, swelling diffuse up legs with scattered petechiae, no CVA tenderness, no midline tenderness ECG: NSR Rate 83. L-axis Normal Intervals, QTc 450. No significant change from prior Labs showed: 145|106|53 -----------<84 4.2|24|2.1 Ca: 7.8 Mg: 1.0 P: 3.3 ALT: 17 AP: 86 Tbili: 0.3 Alb: 2.7 AST: 20 Lip: 9 Lactate:1.6 Trop-T: 0.14 CK: 130 MB: 3 ___: ___ 7.3 8.2>----<382 23.4 Imaging showed: ___ Liver Or Gallbladder Us No evidence of biliary obstruction or portal vein thrombosis ___ Chest (Pa & Lat) IMPRESSION: No acute cardiopulmonary abnormality. Consults: Per Renal Transplant: cyclosporine(neoral) 25 mg bid. Goal 75-125. Cyclosporine AM trough level daily MMF 500 mg bid. Prednisone 6 mg daily. Patient received: ___ 17:25 IV Magnesium Sulfate ___ 17:51 IV Furosemide 20 mg ___ 18:30 IV Magnesium Sulfate 2 gm ___ 20:00 SC Insulin Not Given per Sliding Scale ___ 20:17 PO/NG Ondansetron 4 mg On arrival to the floor, patient reports no dyspnea and improvement of her leg pain. Past Medical History: Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) Hypertension Dyslipidemia CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___. Then DES to LAD in ___ and ___ PCI of Cx and OM with ___ ___ w/ CREST syndrome Gastroparesis GERD Hiatal hernia Gout OSA End-stage renal disease due diabetes s/p L-sided living kidney transplant in ___ anemia Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION EXAM VS: T 97.9 BP 137/59 HR 87 R 16 SpO2 97 Ra GEN: NAD, speaking comfortably lying flat in bed HEENT: Clear OP, moist mucous membranes ___: Regular, II/VI SEM, JVP at mid-neck at 45 degrees +Hepatojugular reflex RESP: RRR, no wheezing, crackles or rhonchi. No increased WOB ABD: NTND, no HSM EXT: Warm, Pitting edema to mid thigh bilaterally. NEURO: CN IV-XII intact. Pupils dilated and minimally-reactive to light (baseline). SKIN: Fine, scattered erythematous erosions L medial thigh, R lateral thigh with overlying crusting. No excoriations. No lesions in web spaces. Small 1cm linear abrasion over L small toe and 1cm, circular, erythematous macule with overlying scab over L great toe. DISCHARGE EXAM Pertinent Results: ADMISSION LABS ================= ___ 04:00PM BLOOD WBC-8.2 RBC-2.52* Hgb-7.3* Hct-23.4* MCV-93 MCH-29.0 MCHC-31.2* RDW-21.2* RDWSD-70.5* Plt ___ ___ 04:00PM BLOOD Glucose-84 UreaN-53* Creat-2.1* Na-145 K-4.2 Cl-106 HCO3-24 AnGap-15 ___ 04:00PM BLOOD CK-MB-3 cTropnT-0.15* ___ ___ 04:00PM BLOOD Albumin-2.7* Calcium-7.8* Phos-3.3 Mg-1.0* ___ 04:00PM BLOOD Cortsol-3.1 ___ 04:22PM BLOOD Lactate-1.6 ___ 09:16AM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 09:16AM URINE Hours-RANDOM Creat-39 Na-85 Mg-<1.4 Albumin-242.0 Alb/Cre-6205.1* ___ 09:16AM URINE Osmolal-395 INTERVAL LABS ================= DISCHARGE LABS ================= MICROBIOLOGY ================= CMV IgG ANTIBODY (Final ___: NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Greatly elevated serum protein with IgG levels ___ mg/dl may cause interference with CMV IgM results. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. 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 O157:H7 found. URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING ================= RUQUS ___: No evidence of biliary obstruction or portal vein thrombosis. CXR ___ No acute cardiopulmonary abnormality. Rib Series ___ 1. Right lower lobe atelectasis versus early infiltrate, slightly worse. Follow up to resolution is recommended to exclude pneumonia. 2. No displaced rib fracture. Renal US ___ 1. Elevated resistive indices similar to the prior study with differential which may include acute tubular necrosis and rejection. 2. Patent vasculature, no hydronephrosis. TTE ___ The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. IMPRESSION: Moderate left ventricular hypertrophy with low normal global systolic function. Small pericardial effusion without echo evidence of tamponade. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of ___ global left ventricular systolic function is improved. Moderate pulmonary hypertension is seen. As before amyloid cardiomyopathy should be considered). CXR ___ Cardiomegaly is severe, minimally improved since previous examination. Right pleural effusion ___ increased. There is no overt pulmonary edema, mild vascular congestion is better than on ___. No pneumothorax. Brief Hospital Course: Ms. ___ is a ___ female with history of HFrEF (EF 41%) ESRD s/p LURT ___ longstanding DMI on CellCept, Neoral, and prednisone, CAD s/p multiple ___ recently on ___ on aspirin and ticagrelor, CREST, remote PE, dysautonomia with orthostatic hypotension, recent fall with right sided SAH, recently seen new pancreatic head mass on CT A/P, who presented with a 1 week history of lower extremity swelling and weight gain admitted for acute on chronic HFrEF exacerbation requiring IV diureses subsequently transitioned to PO lasix 20 with a contingency for an extram 20mg for lower extremity edema, with plan for GI follow-up for ongoing work-up of incidental pancreatic mass. Of note patient requested to be discharged despite remaining volume overloaded with ___ on CKD with plan for outpatient ongoing diuresis and renal monitoring. On the day of discharge the patient was very insistent on being discharged so that she could be able to attend to very special family ___. We discussed this with the renal transplant team as well. Together we both felt that was ongoing medical management and optimization that should be done but in an attempt to meet her wishes and give her some quality life time we were willing to make a compromise on a plan to discharge her with full disclosure to her that she was not quite as optimized as possible. We also created a plan to treat her UTI in the outpatient setting for a total 14 days of treatment end of treatment would be ___. She will also need to eat a very low sodium diet of 2gram max per day and have her renal function assessed and have her results faxed to the BI renal team. We will also gave her a rx for Lasix 20mg daily with extra 20mg for leg swelling. ACUTE ISSUES =================== #Acute on chronic HFrEF - Patient ___ a history of HFrEF EF 41% who initially presented with a one week history of worsening lower extremity swelling and weight gain found to be volume overloaded on exam with BNP 22,235 on admission. The trigger for her acute on chronic HFrEF exacerbation was unclear. Her EKG showed no ischemic changes, troponins were at baseline with flat CK-MB. She was initially diuresed with intermittent IV lasix 80 boluses, however subsequently had worsening renal function. Diureses was subsequently held however renal functioned continued to worsen, thought to be attributed to cardiorenal syndrome and concomitant UTI per below. CXR showed worsening right sided pleural effusion. In consultation with transplant nephrology, she was subsequently diuresed with 80mg IV Lasix X2 which did not show a large improvement in the Cr. and she was transitioned to PO 20mg lasix daily with contingency for extra dose of 20mg for ___ edema. Discharge weight was 60.4kg and discharge creatinine was 3.4. Plan for ongoing outpatient diuresis with PO regimen and continued renal monitoring. ___ on CKD #ESRD s/p renal transplant: With history of ESRD in the setting of long standing DMI, s/p LURT ___ maintained on cellcept, cyclosporine and prednisone. Baseline Cr over the last 6 months ranged between 2.0-2.5. Renal US showed elevated resistive indices, stable from prior with no evidence of hydronephrosis. Per above, she had worsening renal function despite periods of aggressive diuresis as well as rising Cr when holding diuretics. Upon discharge, it seemed as though her ___ was most likely due to over diuresis as she was nearly back to her baseline weight w/very little ___ edema. This being the case in her fluid status was incongruent with her worsening creatinine to 3.4 on day of discharge. Ultimately we felt that a large component of her increasing creatinine was not solely based on a pre-renal picture or CRS but likely a component of chronic renal graft rejection. There was no evidence of ATN on urinalysis. She was continued on MMF 500mg BID, neoral 25mg BID with goal cyclosporin level 40-100, and continued on prednisone 6mg daily. #Incidental Pancreatic Mass: Recent Non-con CT Torso at ___ ___ was significant for a 2.1 x 1.4 cm hypodense mass in the region of the pancreatic head and a 1 cm exophytic hypodensity off anterior aspect of the pancreatic body, suspicious for malignancy. She was initially planned for an outpatient EUS on ___. GI was consulted for possible inpatient EUS, however after multi-disciplinary meeting involving radiology, per GI mass appeared more consistent with IPMN. Plan for interval MRCP in 4 weeks from now (6 weeks from original CT to evaluate for interval change. Of note, any additional advanced imaging will be limited by current renal function given inability to use contrast, and if biopsy is pursued, will have to consider holding ticagrelor given she is on DAPT for recent ___ in ___. Follow-up will be arranged with Dr. ___ in ___ weeks. #UTI - Urine culture ___ growing E. Coli. She was initially started on ceftriaxone and subsequently transitioned to p.o. cefpodoxime, with plan for 14 day total course given her history of renal transplant end of treatment for ___. #Anemia - History of chronic anemia with baseline Hb 7.0-8.0. Initial Hb on admission was 6.8 and she recieved 1U PRBC with post-transfusion Hb 9.5. There was no evidence of hemolysis. Anemia was thought to be inflammatory also in the setting of her CKD. She was started on IV ferric gluconate x 4 doses given her transferrin saturation of 19%. Plan to follow-up with GI per above. #Subarachnoid hemorrhage #Intracranial stenosis - Patient had a recent admission for mechanical fall and subsequent SAH. No neurosurgical intervention was performed and goal SBP remains <160. She ___ had very difficult to control blood pressure given her history of chronic orthostatic hypotension and dysautonomia. She was continued on aspirin 81 mg daily, atorvastatin 20 mg daily, home hydralazine was uptitrated from 50mg PO QHS to 75mg TID given frequent SBP ranging 160-200, and continued on home metoprolol succinate 125 mg daily. #Orthostatic Hypotension #Dysautonomia - Patient ___ a well-documented history of severe orthostatic hypotension and dysautonomia. On previous discharge in consultation with renal transplant, she was maintained on a regimen of hydralazine 50 mg daily, and metoprolol succinate 125 mg daily. Her blood pressure was better controlled on longer acting agents, and she previously ___ not tolerated CCB, captopril due to her severe orthostatic hypotension. Her antihypertensives were uptitrated to hydralazine 75 mg TID and continued metoprolol succinate 125 mg daily per above. We were unable to start an ___ given her ___ on CKD per above. #Skin findings - Patient was found to have multiple skin findings including an erythematous erosions on L medial thigh and R lateral thigh with overlying crusting. RUQUS was initially obtained on admission in the setting of her petechial appearing rash, ___ swelling to evaluate for PVT which was negative. She also had a left MTP erythematous macule which was non-cellulitic appearing and unlikely to be an abscess. She initially came in on levofloxacin for this possibly infected diabetic ulcer per her rehab, antibiotics were not continued given low suspicion for underlying infection. # Diarrhea - Patient initially endorsed a one week history of diarrhea approximately ___ episodes daily, last episode 2 days prior to admission. She had received a 2 day history of levaquin for possible diabetic foot ulcer per above. Stool cultures and CMV were negative. CHRONIC ISSUES ========================== #CAD - History of CAD s/p multiple ___ recently ___. Prior data reveal EF 41% and s/p Cath on ___ showed normal LM, 40% proximal LAD, 80% distal lesion beyond previous stent. She also had a 80% mid LCx lesion with planned staged cath. She underwent successful PTCA and DES x1 to distal LAD lesion in ___. She was continued on aspirin 81 mg daily, ticagrelor 90mg BID, ranolazine 500mg ER BID, atorvastatin 20mg daily. Home cilostazol was resumed on discharge. #DM1: Long-standing history of diabetes mellitus type 1, complicated by dysautonomia, neurogenic bladder and gastroparesis. She was maintained on home glargine 24 units QAM. Home Humalog 2 units TID with meals was discontinued given hypoglycemia during hospitalization. Was also placed on insulin sliding scale. #Neurogenic Bladder - Patient ___ neurogenic bladder secondary to DM Type 1, and intermittently straight caths at home. She had a Foley placed for a brief period of time during hospitalization given subjective urinary hesitancy and inability to obtain accurate I/O's, which was later pulled. #Hypothyroidism: She was continued on home levothyroxine 125mcg daily. TRANSITIONAL ISSUES =========================== [ ] New/Changed Medications - Hydralazine increased from 50 QHS to 75 mg TID given hypertension - Started on cefpodoxime for UTI to continue for 14 day total course (end date ___ - Sodium bicarbonate 1300mg PO TID discontinued metabolic alkalosis [ ] Repeat BMP, Cr in 3 days to monitor creatinine trend and fax results to outpatient renal team at ___ [ ] discharged to complete a 14 day course of PO abx last day of treatment for UTI in a renal transplant patient will be ___ of cefpodoxime [ ] Consider ongoing up titration of PO diuretic as indicated given remains volume overloaded [ ] MRCP in 4 weeks to further evaluate pancreatic mass, possible IPMN, and follow-up with Dr. ___ in ___ weeks [ ] If pursuing pancreatic biopsy, will need to consider holding ticagrelor in consultation with cardiology given recent DES in ___ [ ] Goal SBP <160 given recent SAH, consider outpatient up titration of antihypertensives as indicated [ ] Consider re-starting sodium bicarbonate at transplant nephrology follow-up if indicated [ ] Discharge diuretic 20mg Lasix po daily plus additional PRN dose 20mg for lower extremity edema [ ] Discharge weight 60.4 kg [ ] Discharge creatinine 3.4 #CONTACT: Name of health care proxy: ___: SISTER Phone number: ___ Cell phone: ___ #CODE: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Cilostazol 50 mg PO QPM 4. Cilostazol 100 mg PO QAM 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 6. HydrALAZINE 50 mg PO QHS 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Metoprolol Succinate XL 125 mg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 6 mg PO DAILY 12. Promethazine 25 mg PO DAILY PRN nausea 13. Ranolazine ER 500 mg PO BID 14. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 15. Acetaminophen 1000 mg PO Q6H 16. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 17. FoLIC Acid 1 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Sodium Bicarbonate 1300 mg PO TID 22. Trimethobenzamide 300 mg oral BID 23. Vitamin D ___ UNIT PO DAILY 24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 25. Atorvastatin 20 mg PO QPM 26. Ferrous Sulfate 325 mg PO DAILY 27. Furosemide 20 mg PO DAILY 28. melatonin 10 mg oral QHS 29. naftifine 2 % topical BID To soles of feet and between toe webs 30. Calcium Carbonate 500 mg PO BID 31. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 32. Allopurinol ___ mg PO DAILY 33. Glargine 24 Units Breakfast aspart 2 Units Breakfast aspart 2 Units Lunch aspart 2 Units Dinner Insulin SC Sliding Scale using aspart Insulin 34. Omeprazole 40 mg PO BID 35. Ondansetron 4 mg PO Q8H:PRN nausea 36. Toujeo SoloStar U-300 Insulin (insulin glargine) 300 unit/mL (1.5 mL) subcutaneous QAM Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q24H urinary tract infection Duration: 10 Days RX *cefpodoxime 200 mg 2 tablet(s) by mouth once daily Disp #*10 Tablet Refills:*0 2. Furosemide 20 mg PO DAILY take an additional pill of 20mg in addition to your daily dose if your legs become swollen RX *furosemide 20 mg 1 tablet(s) by mouth one tablet daily Disp #*60 Tablet Refills:*1 3. HydrALAZINE 75 mg PO TID RX *hydralazine 25 mg 3 tablet(s) by mouth three times a day Disp #*126 Tablet Refills:*0 4. Glargine 24 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Acetaminophen 1000 mg PO Q6H 6. Allopurinol ___ mg PO DAILY 7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 11. Calcitriol 0.25 mcg PO DAILY 12. Calcium Carbonate 500 mg PO BID 13. Cilostazol 50 mg PO QPM 14. Cilostazol 100 mg PO QAM 15. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 16. Ferrous Sulfate 325 mg PO DAILY 17. FoLIC Acid 1 mg PO DAILY 18. Levothyroxine Sodium 125 mcg PO DAILY 19. Lidocaine 5% Patch 1 PTCH TD QAM 20. melatonin 10 mg oral QHS 21. Metoprolol Succinate XL 125 mg PO DAILY 22. Multivitamins 1 TAB PO DAILY 23. Mycophenolate Mofetil 500 mg PO BID 24. naftifine 2 % topical BID To soles of feet and between toe webs 25. Omeprazole 40 mg PO BID 26. Ondansetron 4 mg PO Q8H:PRN nausea 27. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe 28. Polyethylene Glycol 17 g PO DAILY:PRN constipation 29. PredniSONE 6 mg PO DAILY 30. Promethazine 25 mg PO DAILY PRN nausea 31. Ranolazine ER 500 mg PO BID 32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 34. Toujeo SoloStar U-300 Insulin (insulin glargine) 300 unit/mL (1.5 mL) subcutaneous QAM 35. Trimethobenzamide 300 mg oral BID 36. Vitamin D ___ UNIT PO DAILY 37. HELD- Sodium Bicarbonate 1300 mg PO TID This medication was held. Do not restart Sodium Bicarbonate until you follow-up with your transplant nephrologist 38.Outpatient Lab Work Please check a BMP (Na, K, Cl, HC03, BUN and Creatinine) for this patient on ___ and fax these results to ___. Thank you. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on chronic HFrEF - ___ on CKD - UTI - Incidental Pancreatic Mass SECONDARY DIAGNOSIS - ESRD s/p LURT - SAH - DM1 - Orthostatic hypotension - Dysautonomia - Anemia - CAD - Neurogenic Bladder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Was a pleasure taking care of your ___ ___. Why did you come to the hospital? -You initially came to the hospital because of worsening lower extremity swelling and weight gain What happened during your hospitalization? -You were given medications through your IV in order to help remove extra fluid because of your heart failure exacerbation -You were given antibiotics for a UTI -You were evaluated by the gastroenterology team to further workup your possible pancreatic mass, you will obtain a MRI in 4 weeks and follow-up with Dr. ___ in ___ weeks What should you do when you leave the hospital? -Continue to take all your medications as prescribed - It is very important that you stick to a very strict low sodium diet. - This is of utmost importance, you should try to eat less than 2 grams of sodium per day. 1 piece of toast ___ about 500mg of sodium or a quarter of the total daily salt that you should eat in your diet. - please avoid canned foods, processed foods or meats and restaurant foods. - Get blood work checked in 3 days and have your labs sent to you kidney doctors at ___ at ___ -Weigh yourself daily, if your weight goes up by more than 2 pounds in 1 day or 5 pounds in 1 week, call your PCP -___ with your primary care physician ___ 1 week -Keep all your other scheduled healthcare appointments listed below Sincerely, Your ___ Care Team Followup Instructions: ___

10030753-DS-51

DS

2200-08-21 00:00:00

2200-08-21 19:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan / carvedilol / amlodipine Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ Female with ESRD (s/p LURT ___ on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p ___ 4 (most recently ___, HFrEF (55% EF ___, HTN, T1DM (A1c 9.9% ___, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and chart history antiphospholipid antibody syndrome (but on evaluation by hematology does not appear to meet diagnostic criteria) with h/o remote PE in ___, presenting with 3 witnessed pre-syncopal episodes. Reports was sitting on the couch - feeling nauseated, and tired, and lightheaded. Reports most of the afternoon wasn't feeling well. Report tried to get up to go to the bathroom but couldn't make it bc was getting really disoriented and dizzy and felt like she was going to pass out. Reports around 5 pm daughter was trying to help her. Tried on rollator and kept slumping over, feeling transiently out of it, not responding. She denies losing consciousness during these episodes. Reports 3 episodes of slumping over. Denies chest pain, palpitations. Reports feels similar to when had orthostatic episodes in the past. Reports was feeling SOB when was trying to get into bed. She did not feel chest tightness or pain. She was not diaphoretic. Reports when woke up this morning took BP and was 130/65 which is low for her. Reports skipped metoprolol this morning from the low bp and all day every time stood up was so lightheaded. Denies cough. Reports has issue with vomiting but this has been at her baseline; she has not seen blood in her vomitus. Denies BRBPR or melena. Reports saw cardiology on ___ and was put back on 20 mg lasix daily. Denies SOB now, chest pain. Of note, the pt reports she is also being worked up for a 4 cm pancreatic mass with plans for biopsy in ___ once she can stop taking DAPT (6 mos after her DES). She also reports that she has been increasingly pruritic and that family members have noted that she appears to have a more yellow complexion. She has also had a 20 pound unintentional weight loss. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___ DES to LAD ___ PCI of Cx and OM with ___ -___ renal disease ___ diabetes s/p L-sided living kidney transplant in ___ -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed ___ years ago -OSA Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION EXAM: ============== GENERAL: Yellow complexion, NAD HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink conjunctiva, MMM, no sublingual icterus noted NECK: supple, no LAD, no JVD HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP in supraumbilical and suprapubic regions, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Jaundiced, warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM; ============= Temp: 98.9 (Tm 98.9), BP: 160/75 (96-175/60-107), HR: 94 (80-96), RR: 20 (___), O2 sat: 97% (96-100) GENERAL: Lying comfortably in bed HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink conjunctiva, MMM, no sublingual icterus noted NECK: supple, no LAD, no JVD HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP in supraumbilical and suprapubic regions, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS: ------------------- ___ 07:05PM BLOOD WBC-8.1 RBC-1.91* Hgb-5.8* Hct-17.9* MCV-94 MCH-30.4 MCHC-32.4 RDW-18.6* RDWSD-61.7* Plt ___ ___ 07:05PM BLOOD Glucose-288* UreaN-68* Creat-2.3* Na-138 K-3.6 Cl-109* HCO3-16* AnGap-13 ___ 07:05PM BLOOD CK-MB-4 ___ ___ 07:05PM BLOOD Calcium-7.7* Phos-3.6 Mg-1.5* RADIOLOGY: Transplant US ___: The left iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. No diastolic flow is detected within the intrarenal arteries with a resistive index of 1.0. The main renal artery shows an abnormal waveform, with prompt systolic upstroke but without continuous diastolic flow. Peak systolic velocity of 51.8 centimeters/second is seen in the main renal artery. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. No diastolic flow within the intrarenal arteries with resistive index of 1, new since ___ with lack of continuous diastolic flow within the main renal artery. 2. Patent main renal vein. 3. No hydronephrosis or perinephric fluid collection. MICRO: Urine culture: No growth DISCHARGE LABS: ___ 05:00AM BLOOD WBC-6.4 RBC-2.86* Hgb-8.8* Hct-26.2* MCV-92 MCH-30.8 MCHC-33.6 RDW-18.1* RDWSD-59.3* Plt ___ ___ 05:00AM BLOOD ___ PTT-28.6 ___ ___ 05:00AM BLOOD Glucose-433* UreaN-71* Creat-2.5* Na-138 K-4.8 Cl-109* HCO3-18* AnGap-11 ___ 05:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7 ___ 09:35AM BLOOD Cyclspr-68* Brief Hospital Course: ___ woman with transfusion-dependent anemia on epo, CAD s/p DESx4 (most recent ___, HFrEF (EF now 55%), ESRD ___ T1DM s/p LURT PMH HFrEF (EF 41%), ESRD ___ T1DM s/p LURT ___ (on cellcept, prednisone, and cyclosporine), CREST/systemic sclerosis and dysautonomia with orthostatic hypotension who presented with presyncope, found to be profoundly anemic. She was transfused and volume resuscitated with normalization of her orthostatic vital signs and was discharged home with close heme/onc follow up. ACUTE ISSUES: =============== #Syncope: The patient's symptoms and presentation all seemed most consistent with orthostasis, particularly given orthostatic VS on check ___. However, given her extensive cardiac history including a recent MI, she was a monitored on telemetry for evidence of arrhythmia. Her telemetry remained without any events. She was volume resuscitated gently given her history of heart failure. Her orthostatic vital signs were trended and ultimately normalized after IVF and PRBCs. # Type II NSTEMI: The patient had a troponin of 0.2 on admission which downtrended to 0.___K-MB. She did not complain of any chest pain or anginal symptoms on admission. In the setting of her acute anemia (discussed below) she did have some EKG changes including ST segment depressions in her lateral precordial leads. However, with the resolution of her underlying anemia her EKG changes resolved. Her home regimen consisting of ASA 81mg daily, Ticagrelor 90mg BID, Ranolazine 500mg ER BID, cilostazole 100mg qAM, 50mg qPM was continued on discharge. No statin due to interaction with immunosuppression. #Anemia: The patient's baseline Hgb is ___. Iron studies conducted on previous admission suggest anemia of chronic inflammation; reduced renal function and low epo also likely cause. She is being followed closely as an outpatient by heme/onc, and is currently getting weekly transfusions of one unit of packed red blood cells and epo. She had no signs of active bleeding during her hospitalization, and her Hgb remained stable following the transfusion of two units of pRBCs. #Pancreatic mass The patient has a known pancreatic mass detected on abd CT ___ s/p fall. Pt awaiting biopsy in ___ mos s/p ___ ___ when she can stop DAPT. Very concerning for malignancy given pt reporting full body pruritus, unintentional weight loss, malaise, early satiety, and gnawing abdominal pain. LFTs not concerning right now for any obstructive process. #HFrEF: LVEF 55% on admission in ___, recovered from 40%. At that time discharged on Lasix 40mg PO BID, Metoprolol succinate 50mg PO daily, Hydralazine 50mg PO BID. Her weight on discharge was 56.97, which is her current admit weight. On this admission, she displayed no signs/sx of volume overload. Her lasix was held on admission given her recent syncopal episodes. Ultimately, her discharge heart failure regimen was as follows: #Pyuria The patient has a history of MDR UTIs. Her urine culture was negative on admission and she was not treated with antibiotics. CHRONIC ISSUES: =============== #ESRD s/p Transplant: Ongoing CKD likely related to poorly controlled T1DM. Discharge creatinine was 2.5. # DM1: Poorly controlled, most recent A1c 9.9% at ___ on ___, with multiple sequelae. Patient was hyperglycemic during her hospital stay while off her home ___, however on the day prior to discharge was transitioned to 25u of glargine with better control of her sugars. At discharge her home insulin regimen was continued. # Hypothyroidism: Continued on home levothyroxine # Gout: Continued on home allopurinol TRANSITIONAL ISSUES: ================== [ ] follow up CBC and transfusion per heme/onc, next scheduled for ___ [ ] Lasix was held in setting of hypovolemia on presentation [ ] renal transplant showed no diastolic flow within the intrarenal arteries with resistive index of 1, new since ___ with lack of continuous diastolic flow within the main renal artery. This was discussed with radiology who reported the artery remained patent. [ ] consider uptitration of home ___ given hyperglycemia while in the hospital # CODE: Presumed FULL # CONTACT: ___ (SISTER) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. melatonin 10 mg oral QHS 2. naftifine 2 % topical BID To soles of feet and between toe webs 3. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Allopurinol ___ mg PO DAILY 6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 7. Aspirin 81 mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 500 mg PO BID 10. Cilostazol 25 mg PO QPM 11. Cilostazol 50 mg PO QAM 12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 13. Ferrous Sulfate 325 mg PO DAILY 14. FoLIC Acid 1 mg PO DAILY 15. Furosemide 20 mg PO DAILY 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. Multivitamins 1 TAB PO DAILY 19. Mycophenolate Mofetil 500 mg PO BID 20. Omeprazole 40 mg PO BID 21. PredniSONE 5 mg PO DAILY 22. Promethazine 25 mg PO TID:PRN nausea 23. Ranolazine ER 500 mg PO BID 24. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 25. ___ SoloStar U-300 Insulin (insulin glargine) 24 units subcutaneous QAM 26. trimethobenzamide 300 mg oral TID:PRN nausea 27. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Cilostazol 25 mg PO QPM 7. Cilostazol 50 mg PO QAM 8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 9. Ferrous Sulfate 325 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. melatonin 10 mg oral QHS 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Mycophenolate Mofetil 500 mg PO BID 17. naftifine 2 % topical BID To soles of feet and between toe webs 18. Omeprazole 40 mg PO BID 19. PredniSONE 5 mg PO DAILY 20. Promethazine 25 mg PO TID:PRN nausea 21. Ranolazine ER 500 mg PO BID 22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 23. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 24. Toujeo SoloStar U-300 Insulin (insulin glargine) 24 units subcutaneous QAM 25. trimethobenzamide 300 mg oral TID:PRN nausea 26. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: - Anemia of chronic inflammation Secondary diagnosis: - End stage renal disease s/p renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because: - You were having episodes of passing out - Your blood counts were very low While you were admitted: - You had blood transfusions which improved your blood counts - Your blood pressure was checked with sitting and standing to make sure it was not dropping - Your home blood pressure medications were adjusted - You worked with our physical therapists - When your blood counts were stable, you were discharged home with close follow up with your cardiologist and blood doctor ___ you leave: - Please take all of your medications as prescribed - Please attend all of your follow up appointments as scheduled It was a pleasure to care for you during you hospitalization! Your ___ care team Followup Instructions: ___

10030753-DS-54

DS

2200-11-25 00:00:00

2200-11-26 13:18:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Ativan / carvedilol / amlodipine Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cath ___ History of Present Illness: INITIAL ED PRESENTATION: ======================= Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT ___ on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p ___ 4 (most recently ___, HFpEF (EF 55% ___, IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), scleroderma/CREST who presents with diarrhea and abdominal pain. The patient was recently treated with Bactrim for a UTI about a week ago. Around that same time, the patient began having diarrhea and abdominal pain. The pain is described as ___, located over the lower bilateral quadrants. It is intermittent without known triggers. Nothing makes it worse, including food or movements. She has also had profuse diarrhea, described as large volume episodes occurring almost every hour. It has been associated with fecal urgency. No hematochezia or melena. She reports decreased enteral intake over this time. No new nausea, vomiting, fever, chills, dysuria or hematuria. No history of similar symptoms or c.diff infections. No recent travel, sick contacts, new foods or medications. Patient was seen at ___ on ___. She was given 1L IVF with plan to follow up at ___ for repeat labs in a day. She continued to have symptoms. On ___, she developed new right-sided chest pain described as ___, dull/ache while sleeping. Her pain was unchanged with palpation, deep breaths, or movement and it felt similar to prior cardiac pain. She took SL nitro with resolution. She also began feeling lightheaded, particularly with bowel movements. Given her ongoing symptoms and new chest pain, she presented to the ___ ED. In the ED, initial VS were: T 97.6, HR 86, BP 126/73, RR 12, SpO2 100% RA NEUROLOGY CONSULT ___: ======================== Ms. ___ sister notes that while admitted here in the CCU, starting ___ hours ago, Ms. ___ began develop instances of pausing mid activity. She has a video that documents Ms. ___ eating soup; she is shown to pause mid bite with the spoon held in the air for ~6 seconds before returning to a conversation she was having, speaking fluently. This happened twice in the span of a ~30 second video. Her sister reports that Ms. ___ had no memory of these event at the time, was not frustrated by them. Nothing similar to this has happened in the past. Over the course of today, she has become less fluent, primarily only speaking in yes/no answers, and not always consistently. She also had been sleepy, often lying with her eyes closed but still awake. She has also started to experience body jerks which occur almost every minute in both the arms and legs. These have not changed in frequency since onset. Ms. ___ presented on ___ with dyspnea, cough, chest tightness and low-grade fever. She also had worsening leg edema and increased weight concerning for HF exacerbation (EF dropped from 55 to 47%, type 2 NSTEMI, and acute complicated cystitis. More recently on ___ Ms. ___ received a right heart catheterization for which she received conscious sedation with fentanyl. Prior to this Ms. ___ was hospitalized for ischemic colitis thought to be ___ hypoperfusion from HF. Following discharge, she stayed with her sister who noticed that Ms. ___ was much more confused than usual, not oriented to place, had trouble administering her insulin as well as taking her blood sugar regularly. She remained disoriented and requiring assistance for 1 week before starting to improve; in her second week at home she was able to start taking her insulin by herself, monitor her blood sugar regularly, was speaking coherently and was fully oriented. This improvement occurred over a week until Labor Day when she developed fever, SOB, CP prompting family to take her to ___. Ms. ___ sister notes that while admitted here in the CCU, starting 48 hours ago, Ms. ___ began develop instances of pausing mid activity. She has a video that documents Ms. ___ eating soup; she is shown to pause mid bite with the spoon held in the air for ~6 seconds before returning to a conversation she was having, speaking fluently. This happened twice in the span of a ~30 second video. Her sister reports that Ms. ___ had no memory of these event at the time, was not frustrated by them, and that the video well documents their frequency and duration. Nothing similar to this has happened in the past. In the past 24 hours Ms. ___ has begun to experience myoclonic jerks which occur ___ times each minute in both the arms and legs. These have not changed in frequency since onset. At this same time, Ms. ___ has become less articulate with her speech eventually becoming non-fluent and halted with large pauses when responding to questions. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___ DES to LAD ___ PCI of Cx and OM with ___ -___ renal disease ___ diabetes s/p L-sided living kidney transplant in ___ -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed ___ years ago -OSA -Pancreatic cyst Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: Admission Physical Exam: VS: T102.9 HR105 RR25 SPO2 99% 6LNC GEN: uncomfortable, thin cachectic female. older than stated age. mild distress. HEENT: PERRLA, EOMI. No erythema or exudate in posterior pharynx; dry mucous membranes. Neck: +JVD 10cm at 45 deg. +AJR. Resp: No increased WOB, Lungs CTAB, No wheezes or rhonchi. Crackles in bilateral bases. CV: Normal S1/S2. no murmurs rubs or gallops. Abd: Soft, mild suprapubic tenderness Nondistended with no organomegaly; no guarding. bulging flanks. MSK: ___ warm, with 1+ pitting edema to the knees bilaterally Skin: No rash, Warm and dry, No petechiae. 1+ ___ pulses in ___ b/l. Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves all 4 ext to command. =================================================== Discharge Physical Exam: 24 HR Data (last updated ___ @ 1217) Temp: 98.6 (Tm 98.6), BP: 138/72 (130-172/71-83), HR: 83 (80-90), RR: 16 (___), O2 sat: 96% (94-99), Wt: 122.3 lb/55.48 kg General: Awake, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx or on tongue Pulmonary: Breathing comfortably on RA Cardiac: WWP, no pallor nor cyanosis Abdomen: soft, NT/ND Extremities: No ___ edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to name, day, month, year, and ___. Able to perform DOWB and MOYB without errors, with serial subtraction of threes from 20, she makes one error and completes the task slowly. Language more spontaneous speech output today. Naming intact. Comprehension intact to simple two step commands. -Cranial Nerves: II, III, IV, VI: Bilateral pupils 5mm -> 4.5mm minimally reactive. EOMI intact. Frequent eye blinking. Left field of vision reduced to movement nasally, temporally, superiorly, inferiorly, right visual field also diffusely impaired and unable to count fingers in all visual fields. V: Sensation intact to light touch in all three distributions VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to instructions and 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 bilaterally. Occasional asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 4+ ___- 4 3 4 5 R 5 ___- 4 4+ 5 5 -Sensory: Sensation absent to light touch below b/l ankles, decreased temperature throughout. -DTRs: 2+ throughout -Coordination: Mild dysmetria with FNF bilaterally, in proportion to weakness/sensory loss. -Gait: Deferred Pertinent Results: ADMISSION LABS: ================ ___ 07:47PM BLOOD WBC-4.6 RBC-2.59* Hgb-8.2* Hct-26.7* MCV-103* MCH-31.7 MCHC-30.7* RDW-15.9* RDWSD-58.7* Plt ___ ___ 07:47PM BLOOD Neuts-75.5* Lymphs-5.2* Monos-16.7* Eos-1.1 Baso-0.4 Im ___ AbsNeut-3.49 AbsLymp-0.24* AbsMono-0.77 AbsEos-0.05 AbsBaso-0.02 ___ 07:47PM BLOOD ___ PTT-36.9* ___ ___ 07:47PM BLOOD Glucose-102* UreaN-60* Creat-2.7* Na-145 K-5.0 Cl-107 HCO3-23 AnGap-15 ___ 07:47PM BLOOD ALT-16 AST-25 CK(CPK)-129 AlkPhos-74 TotBili-0.2 ___ 07:47PM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.6 Mg-1.7 Important Interval Labs ======================= ___ 06:51AM BLOOD TSH-2.0 ___ 06:30AM BLOOD %HbA1c-6.5* eAG-140* ___ 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102 ___ 08:54AM BLOOD Cyclspr-64* Important Discharge labs ========================= ___ 07:30AM BLOOD Valproa-31* ___ 07:30AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.8* Hct-28.5* MCV-103* MCH-31.8 MCHC-30.9* RDW-15.1 RDWSD-57.0* Plt ___ ___ 06:45AM BLOOD ___ PTT-26.2 ___ ___ 07:30AM BLOOD Glucose-221* UreaN-63* Creat-3.0* Na-146 K-4.4 Cl-109* HCO3-27 AnGap-10 ___ 06:45AM BLOOD ALT-11 AST-9 AlkPhos-74 TotBili-<0.2 ___ 07:24AM BLOOD cTropnT-0.44* ___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 ___ 06:30AM BLOOD %HbA1c-6.5* eAG-140* ___ 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102 ___ 08:54AM BLOOD Ammonia-18 ___ 06:51AM BLOOD TSH-2.0 ___ 06:51AM BLOOD Vanco-13.3 ___ 07:30AM BLOOD Cyclspr-PND ___ 08:54AM BLOOD Cyclspr-64* Imaging ======== ___ TTE The estimated right atrial pressure is ___ mmHg. There is mild global left ventricular hypokinesis. The visually estimated left ventricular ejection fraction is 35-40%. Global longitudinal strain is depressed (-9.6 %; normal less than -20%) Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). There is Grade II diastolic dysfunction. Normal right ventricular cavity size with normal free wall motion. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. There is no pericardial effusion. IMPRESSION: 1) No structural cardiac source of embolism (e.g.patent foramen ovale/atrial septal defect, intracardiac thrombus, or vegetation) seen. 2) Moderate global LV systolic dysfunction both by LVEF and global longitudinal strain imaging with grade II LV diastolic dysfunction and elevated LVEDP. Compared with the prior TTE (images reviewed) of ___, visualized findings are similar., the findings are similar. ___ MRA neck w/o Within confines of 2D time-of-flight technique and limited field of view obscuring the mid to distal bilateral cervical internal carotid arteries: 1. Unremarkable MRA of the neck without evidence of stenosis of the cervical internal carotid arteries by NASCET criteria. 2. Additional findings as described above. ___ MRI MRA brain w/o 1. Acute/subacute on chronic thromboembolic ischemic changes in the right frontal and right parietal lobes as described detail above. 2. No acute intracranial hemorrhage. 3. Unchanged left SCA focal stenosis. Otherwise, patent circle ___ with no evidence of aneurysm formation. ___ RUQ us 1. Coarsened liver echotexture. This can be seen in the setting of early cirrhosis. 2. Surgically absent gallbladder. 3. At least 2 hypoechoic pancreatic cystic lesions (within the body and uncinate process) for which non emergent outpatient MRCP further characterization may be performed if not previously evaluated. 4. Trace left pleural effusion. 5. No ascites. ___ CT Head 1. No acute intracranial abnormality. 2. Re-demonstration of chronic findings, as above. ___ Cardiac R cath Elevated right heart filling pressure. • Preserved cardiac function. • Moderate pulmonary hypertension. • elevated filling pressures, pulmonary htn, PROMINENT v WAVES ON WEDGE TRACINGS ___ CT abd pelvis 1. Small bilateral pleural effusions with overlying atelectasis. Partially imaged lingula/inferior left upper lobe contains scattered ground-glass opacities which could be due to infection, but are not fully imaged. 2. Equivocal subtle perinephric stranding/haziness involving the left iliac fossa transplant kidney. Correlate with urinalysis to assess for infection. No hydronephrosis. 3. No bowel obstruction or bowel wall thickening. 4. Cardiac ventricular blood pool is hypodense in relation to the myocardium, suggesting underlying anemia. Brief Hospital Course: BRIEF SUMMARY ===================== ___ yo F with sig PMHx of Type 1DM, ESRD s/p LURT in ___ on cyclosporine/MMF, transfusion dependent anemia, CAD s/p ___ recently in ___, HFpEF with EF of 55% in ___, IPMN, HTN, scleroderma/crest, and multiple recurrent MDR UTI who presented with acute decompensated heart failure ___ inadequate PO diuresis, acute complicated cystitis further complicated by a likely type 2 NSTEMI. Ms. ___ was initially treated by the cardiology service where she was diuresed and underwent right heart cath on ___. Details of her cardiology course are below. She was transferred to Neurology on ___ after had acute mental status changes and twitching which were non-convulsive status. She was started on AEDs including keppra and valproic acid, monitored on EEG (___) and her seizures became well controlled. She had an MRI which showed multiple acute and subacute infarcts. She underwent stroke work-up which included risk factor screening (Alc 6.5, LDL elevated, echo normal without PFO). ACUTE ISSUES: ====================== #Acute Decompensated HFpEF: Last ECHO prior to admission was in ___ with EF 55%. BNP elevated to ___ at OS___ prior to transfer, previous admissions BNP elevated to ___. Likely etiology of this exacerbation was inadequate PO diuretic dosing. She was diuresed, requiring Lasix IV up to 100mg IV. Diuresis was complicated by a worsening ___. She was taken for a on ___ RHC which revealed Elevated right heart filling pressure, Preserved cardiac function, moderate pulmonary hypertension, elevated filling pressures, pulmonary htn and prominent V waves on wedge tracings. She continued to diurese and was transitioned back to her home regimen. # NSTEMI type II, & CAD s/p DES: Mrs. ___ is s/p multiple stents, most recently ___, anti-platelet therapy stopped in ___ per cardiology in advance of EUS/biopsy for pancreatic mass. ECG on admission with new lateral precordial TWI from prior, troponins elevated 0.21 -> 0.45. Received nitro and started on heparin gtt in ED. Not on ACE-I given CKD. A heparin gtt was discontinued after hospital day 1 and she was without further episodes of chest pain. She was continued on her home regimen of ranolazine, aspirin 81 mg, metop 6.25mg q6hr #Hypertension: History of labile, difficult to control BP. BPs frequently in 180s-190s during this admission. We uptitrated Hydral/isosorbide dinitrate to Hydral 75 q8 and isosorbide dinitrate 40mg TID. Given her chronic orthostatic hypotension, goal SBP was 140-160. #Acute Complicated Cystitis: Patient with a history of MDR E. Coli sensitive to cefepime. She had suprapubic tenderness and CT evidence of perinephric stranding. No leukocytosis, but patient febrile to 100.5F in ED. CT A/P in ED showed no bowel obstruction or bowel wall thickening. Also showed partially imaged lingula/inferior left upper lobe which contained scattered ground-glass opacitie, possibly ___ infection. Received Vanc/Flagyl in ED. Transplant nephrology following and recommended based on lung exam to add on atypical coverage and treat for a pneumonia. We sent a broad infectious workup including stool cultures, serum/stool CMV, C. diff, pjp smear and Urine culture negative. We treated for a presumed pnuemonia given her lung exam and fevers. Treatment included Cefepime (___) which was discontinued in the setting of seizures, vanc d/ced ___ after MRSA nares negative and Azithromycin 250mg daily (End date ___. She was afebrile during her time on the Neurology service. # ___ with ESRD s/p LURT ___, CKD 4: Renal transplant followed throughout the hospitalization. Pre-admission baseline Cr around 3.0, ISO chronic allograft dysfunction from diabetic nephropathy and grade 2 IFTA. During her time on cardiology her creatinine was elevated above baseline and slightly uptrending during hospitalization. Some of this was likely related to diueresis. FeUrea was 40 which was suggestive of intrinsic renal disease, has muddy brown casts and acanthocytes on urine microscopy c/w component of ATN on top of diabetic GN. She continued on cyclosporine, MMF and prednisone. Cyclosporine levels were trended daily. Goal cyclosporine level 50-100 per transplant nephrology. #Seizure and stroke: She triggered for acute mental status changes on HD#4 and HD#5. She was minimally responsive with diffuse myoclonic jerks. Her presentation initially appeared to wax and wane, then on ___ she became more persistently altered. CT head was negative. Neurology was consulted who recommended EEG to assess for subclinical status epilepticus which was confirmed. She received Valium (Ativan allergy) twice over that first 24 hours and was loaded/started on Keppra and Valproic Acid for seizure control which was obtained around ___. Her EEG had initially shown generalized 5 hz spike and wave complexes. She had an MRI which showed two subacute infarcts in the right periventricular pericollosal artery territory and punctate infarct in pons. Given distribution, highest suspicion was for small vessel etiology, though pericallosal infarct could also possibly be embolic. Given this and timing related to right heart cath, TTE with bubble was performed, which showed no e/o PFO. It was therefore felt that the infarcts are unlikely related to the right heart catheterization. MRA head/neck without severe stenosis. A1c 6.5, LDL 102, TSH 2.0. Telemetry without arrhythmia. Given LDL above goal, pravastatin was uptitrated to 30mg qhs in discussion with her outpatient neurologist. Higher intensity statin contraindicated given interaction with cyclosporine. She was continued on ASA 81mg daily. Cardiac embolus related to decreased EF cannot be ruled out, though is felt less likely. She was continued on valproate and keppra for seizures. She was discharged on keppra 500mg BID and Divalproex (DELayed Release) 750mg BID. #DM1 Her blood sugars were quite brittle throughout this hospitalization with frequent episodes of symptomatic hypoglycemia at BS readings of 80+. ___ was consulted for assistance with management of her insulin. # Chronic Anemia: Secondary to ESRD. Receiving weekly Epo infusions. #Gout: initially held allopurinol ___ given asymptomatic and possible UTI, but this was restarted on discharge. #Hypothyroidism: she continued on her levothyroxine 125 mcg #Scleroderma/CREST: continued on her home prednisone 5mg daily #GERD/Gastroparesis: Continued pantoprazole (esomeprazole NF) and promethazine # PAD: Initially held home cilastazol 50mg qAM and 25mg qPM, this was restarted on discharge. Transitional Issues ===================== Kidney transplant ------------------- [] Please check cyclosporine level(12 hrs after pm dose), BUN, Cr on ___ [] Goal cyclosporine trough 50-100 do not hold AM dose while waiting for trough. [] monitor urine output, patient has history of urinary retention. If retaining consider straight cath. Neuro (stroke and seizures) [] check valproate trough in 1 week (___), get LFTs and ammonia with this trough. Goal valproate 50-70, if LFTs or Ammonia are elevated please call neurology at ___. [] monitor for muscle aches. If develops would check CK. Pravastatin interaction with cyclosporine increases risk of rhabdomyolysis [] Seizure semiology: behavioral arrest. HFrEF ------- [] Continue to hold furosemide on discharge, please monitor daily weights and volume status. [] discharge weight: 55.48kg, 122.3lb [] please check orthostatics before making further changes to BP regimen, as has historically had significant orthostatic hypotension. ___ not tolerate significantly more BP medication [] If Cr worsens consider reducing insulin to avoid hypoglycemia d/t reduced clearance of insulin ======================================== 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. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 102) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [x] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist-- interaction with cyclosporine [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? (x) Yes - () No [reason () 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. If no, why not? (I.e. patient at baseline functional status) 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: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 50 mg PO BID 6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 7. esomeprazole magnesium 40 mg oral BID 8. Furosemide 20 mg PO DAILY 9. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 10. ___ Solostar U-300 26 Units Breakfast 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch ___ PTCH TD QAM 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Mycophenolate Mofetil 500 mg PO BID 15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 16. Pravastatin 10 mg PO QPM 17. Promethazine 25 mg PO Q6 HR-Q8HR 18. Promethazine ___ID:PRN nause 19. Ranolazine ER 500 mg PO BID 20. trimethobenzamide 300 mg oral Q6H:PRN 21. Aspirin 81 mg PO DAILY 22. Vitamin D ___ UNIT PO DAILY 23. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 24. Ferrous Sulfate 325 mg PO DAILY 25. melatonin 10 mg oral QHS 26. pen needle, diabetic 32 gauge x ___ miscellaneous Other 27. Sodium Bicarbonate 1300 mg PO BID Discharge Medications: 1. Divalproex (DELayed Release) 750 mg PO BID 2. HydrALAZINE 75 mg PO Q8H 3. Isosorbide Dinitrate 40 mg PO TID 4. LevETIRAcetam 500 mg PO BID 5. ___ Solostar U-300 26 Units Breakfast 6. Pravastatin 30 mg PO QPM 7. Allopurinol ___ mg PO DAILY 8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 9. Aspirin 81 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Calcium Carbonate 500 mg PO DAILY 12. Cilostazol 50 mg PO BID 13. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 14. Esomeprazole Magnesium 40 mg oral BID 15. Ferrous Sulfate 325 mg PO DAILY 16. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 17. Levothyroxine Sodium 125 mcg PO DAILY 18. Lidocaine 5% Patch ___ PTCH TD QAM 19. melatonin 10 mg oral QHS 20. Metoprolol Succinate XL 25 mg PO DAILY 21. Mycophenolate Mofetil 500 mg PO BID 22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 23. pen needle, diabetic 32 gauge x ___ miscellaneous Other 24. PredniSONE 5 mg PO DAILY 25. Promethazine 25 mg PO Q6 HR-Q8HR 26. Ranolazine ER 500 mg PO BID 27. Sodium Bicarbonate 1300 mg PO BID 28. trimethobenzamide 300 mg oral Q6H:PRN 29. Vitamin D ___ UNIT PO DAILY 30. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until directed by your MD Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: acute ischemic stroke type 2 NSTEMI Congestive heart failure exacerbation non-convulsive status epilepticus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___, You were admitted with trouble breathing. You had too much fluid in your body and it lead to shortness of breath and some stress on your heart. You had a right heart catheterization. You then developed continuous seizures without shaking, called non-convulsive status epilepticus. While figuring out why this happened, we discovered that you had two small areas of stroke in your brain. We cannot be 100% sure why the strokes happened. the possibilities are that it is either from the long term changes from diabetes, high blood pressure and high cholesterol, or it is related to the reduced function of your heart. We do not think it is from the right heart catheterization. Please follow up with Neurology and your primary care physician as listed below. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___

10030753-DS-55

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2200-12-23 00:00:00

2200-12-23 17:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan / carvedilol / amlodipine Attending: ___. Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with complex medical history notable for ESRD s/p LURT ___ on immunosuppression, CAD s/p ___ 4 (most recent ___, HFrEF (EF 35-40% ___, T1DM, severe poorly controlled HTN, scleroderma/CREST, who was brought to the ED by EMS after an episode of hypoglycemia and is now admitted for altered mental status and weakness iso a UTI. The patient had a recent admission at ___ ___ for decompensated heart failure. Her hospital course was complicated by NSTEMI, ___, and non-convulsive status epilepticus with workup that revealed acute and subacute strokes in the right periventricular pericollosal artery territory and punctate infarct in pons. She was discharged on Keppra and valproate and has not had any witnessed seizures since discharge. She also underwent RHC iso newly reduced EF to 37% and difficult volume management. RHC showed elevated filling pressures and pHTN and she was aggressively diuresed. Since her discharge on ___ she has felt generally weak and has had periods of confusion where she does not know the date or know where she is. The night before presentation her FSBGs were noted to be in the 400s. She received 10u SC insulin and in the AM she was noted to be hypoglycemic to the ___. The patient received 2mg IM glucagon and juice with improvement in her FSBG to 170s. She was taken by EMS to ___ for further management. In the ED, she was afebrile, HRs ___, BPs 200/90s but decreased to 160s/70s after home anti-HTN meds, and SpO2 98% RA. On initial exam she was somnolent, grade III systolic murmur, normal lung sounds, mild abdominal tenderness of LUQ, 1+ edema of b/l LEs, and she was AOx4 with no focal neurologic findings. Her EKG showed new lateral ST depressions. MB 6->4, and Trop 0.28 -> 0.16, asymptomatic. WBC 20 (normal at b/l), Hgb 11, Cr 2.5 (baseline 3.0), an otherwise normal chem-10, and lactate 1.6. UA was notable for Lg leuks, 178 WBCs, and many bact. Imaging included a CXR without e/o pna and a renal transplant US that showed improved intrarenal arterial flow, no hydronephrosis, and patent main renal vein. Renal transplant was consulted and recommended BP control with home medications, cyclosporine trough daily, and admission to medicine for further management of her confusion and AMS. ___ was also consulted for assistance with management of her DMI iso recent episode of hypoglycemia. In addition to her home antihypertensives and insulin per ___, she was started on ceftriaxone for a UTI (previous culture data from ___ w/ ecoli, sensitive to CTX). Transfer VS were: 97.6 121 169/93 21 95% RA On arrival to the floor, patient reports marked fatigue. She denies dysuria but endorses mild lower abdominal discomfort. She denies diarrhea or constipation. She has had nausea and poor appetite for the past week and had one episode of non-bloody, non-bilious vomiting the day prior to admission. She denies any recent chest pain, palpitations, or dyspnea. She has had no cough, rhinorrhea, fevers, or chills. She reports a mild headache without neck stiffness, vision changes, or photophobia. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: -CAD s/p PCI x4: LAD PTCA ___ DES to LAD and Cx/OM ___ DES to LAD ___ DES to Cx and OM ___ -Heart failure with reduced EF (35-40% ___ -L-sided living kidney transplant in ___ complicated by transplant nephropathy -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Autonomic dysfunction with orthostatic hypotension and supine hypertension -CVA ___ -Seizure disorder -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Chronic Nausea -Gout -OSA -Pancreatic cyst c/w IPMN -Dyslipidemia Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: ___ 0417 Temp: 98.1 PO BP: 168/78 R Lying HR: 118 RR: 22 O2 sat: 98% O2 delivery: Ra GENERAL: NAD, AOx3 HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: tachycardic, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, mild TTP of lower abdomen, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert/oriented x4, non-focal exam DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Temp: 98.4 PO BP: 180/77 HR: 81 RR: 16 O2 sat: 94% O2 delivery: Ra FSBG: 187 Constitutional: NAD HEENT: eyes anicteric, R sided pterygium, normal hearing, nose unremarkable, MMM without exudate CV: RRR ___ SEM, JVP 8cm Resp: CTAB GI: sntnd, NABS GU: no foley MSK: no obvious synovitis Ext: wwp, trace ___: mild skin tightening Neuro: A&O grossly, speech intact and fluent, CN grossly intact ___ LUE/LLE, 4+/5 RUE/RLE, SILT BUE/BLE, Psych: normal affect, pleasant Pertinent Results: ADMISSION LABS: =========== ___ 11:34AM BLOOD WBC-20.8* RBC-3.47* Hgb-11.1* Hct-34.6 MCV-100* MCH-32.0 MCHC-32.1 RDW-14.7 RDWSD-53.4* Plt ___ ___ 11:34AM BLOOD Neuts-92.0* Lymphs-1.3* Monos-5.8 Eos-0.1* Baso-0.1 Im ___ AbsNeut-19.13* AbsLymp-0.27* AbsMono-1.21* AbsEos-0.02* AbsBaso-0.03 ___ 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141 K-4.9 Cl-101 HCO3-27 AnGap-13 ___ 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141 K-4.9 Cl-101 HCO3-27 AnGap-13 ___ 11:34AM BLOOD ALT-11 AST-33 CK(CPK)-110 AlkPhos-72 TotBili-0.2 ___ 11:34AM BLOOD CK-MB-6 ___ 11:34AM BLOOD cTropnT-0.28* ___ 04:20PM BLOOD CK-MB-4 cTropnT-0.16* ___ 11:34AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.2 Mg-2.1 ___ 04:20PM BLOOD PTH-64 ___:02PM BLOOD Lactate-1.6 ___ 04:10PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 04:10PM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* ___ 04:10PM URINE RBC-5* WBC-178* Bacteri-MANY* Yeast-NONE Epi-3 INTERIM LABS: ========== ___ 06:30AM BLOOD Valproa-14* ___ 09:00AM BLOOD Cyclspr-<30* ___ 04:36PM BLOOD ___ pO2-196* pCO2-42 pH-7.43 calTCO2-29 Base XS-3 Comment-GREEN TOP ___ 08:02AM BLOOD Cyclspr-92* ___ 08:02AM BLOOD Valproa-54 DISCHARGE LABS: ============ ___ 05:25AM BLOOD WBC-6.3 RBC-2.95* Hgb-9.0* Hct-29.3* MCV-99* MCH-30.5 MCHC-30.7* RDW-19.3* RDWSD-70.7* Plt ___ ___ 07:26AM BLOOD Glucose-123* UreaN-51* Creat-3.2* Na-141 K-4.6 Cl-101 HCO3-32 AnGap-8* MICROBIOLOGY: ============== ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ Culture, Routine-FINAL IMAGING: ========= ___ CXR No focal consolidation to suggest pneumonia. Mild pulmonary vascular congestion, improved from the prior exam. ___ RENAL U/S 1. Improved intrarenal arterial flow with continuous diastolic flow now seen in the upper and lower pole intrarenal arteries, but questionable lack of diastolic flow in the interpolar region, as seen previously. Resistive indices in the upper and lower poles are mildly elevated. 2. No hydronephrosis. Patent main renal vein. ___ EEG This is an abnormal continuous EEG monitoring study because of mild slowing of the background activity, indicative of mild diffuse encephalopathy without specific etiology. Common causes are medication effect, infections or toxic/metabolic disturbances. There was intermittent focal attenuation and very mild slowing over the right hemisphere, indicative of subcortical dysfunction in that region. There were no epileptiform discharges or electrographic seizures. Compared to the prior day's recording, there is no significant change. ___ CT HEAD W/O CONTRAST 1. No new acute intracranial process. 2. Chronic findings, as above. ___ MRI 1. Interval evolution of subacute on chronic thromboembolic ischemic changes in the right cerebral hemisphere and right pons. 2. No new infarct or acute intracranial hemorrhage. No evidence for PRES. 3. Additional findings as described above. ___ CHEST XR In comparison with the study of ___, the there are lower lung volumes. Moderate enlargement of the cardiac silhouette is again seen with moderate pulmonary vascular congestion. Opacification at the right base silhouetting hemidiaphragm is consistent with pleural fluid and atelectatic changes at the base. Retrocardiac opacification suggests volume loss in the left lower lobe. No evidence of acute focal consolidation, though this would be difficult to unequivocally exclude in the appropriate clinical setting, especially in the absence of a lateral view. There is a spiculated opacification in the right upper quadrant of the abdomen, raising the possibility of a gallstone. Brief Hospital Course: Ms. ___ is a ___ year old woman with complex medical history notable for renal transplant in ___ on immunosuppression, CAD s/p ___ 4 (most recent ___, HFrEF (EF 35-40% ___, brittle T1DM, autonomic dysfunction with poorly controlled HTN and orthostatic hypotension, scleroderma/CREST, recent admission for acute on chronic HFrEF, course complicated by CVA and seizures, brought to the ED ___ from rehab after an episode of hypoglycemia, admitted for altered mental status and weakness presumed secondary to UTI. ACUTE ISSUES: =================== # Toxic Metabolic Encephalopathy # Generalized Weakness / Fatigue Since her discharge on ___ patient generally weak and reported periods of confusion where she did not know the date or know where she was. Sister/HCP reported she was somnolent since prior to discharge, sleeping all the time, not herself. Worsened after an episode of hypoglycemia, improved with treatment of UTI below. Suspected a multifactorial process, in part related to delirium from UTI, poor glycemic control, recent hospitalizations superimposed on numerous chronic medical problems and neurologic injury including seizure and strokes. Initially also concerned for post-ictal state vs seizure I/s/o hypoglycemia. Neurology was consulted, recommended EEG, which from ___ was w/o any evidence of seizure. Valproate was initially low likely i/s/o missing a dose in the ED, s/p one load remained in normal range. Keppra level was 48, but per neurology, this was okay and patient should continue keppra 500mg BID. CT head and MRI w/o any new acute strokes. Mental status returned to baseline by discharge. #DM type 1 c/b episode of hypoglycemia Blood sugar 400 at rehab, was given 10u SC insulin, then decreased to 50 and had AMS. Endorsed poor appetite, so was likely receiving inappropriate amount of insulin for how much she was taking in. Per sister, she has very brittle diabetes for a long time. ___ was consulted. BG were very labile, swings from low to high with minimal change to insulin regimen. Patient had continuous glucose monitor, sensor was lost in the hospital, replaced on ___. Discharged on lower amount of Levemir than previously (see below for full regimen). #E. coli UTI in transplanted kidney UA positive, w/ lower abdominal pain, leukocytosis to 20 (previously normal). Urine culture grew E. coli sensitive to ceftriaxone, resistant to cipro. Started IV ceftriaxone, transitioned to cefpodoxime ___ to complete a 10 day course. #Hypertensive Urgency Per outpatient nephrologist, goal SBP<180. Increased isosorbide dinitrate to 60 mg tid, Hydralazine to 100mg q8h and increased metoprolol XL to 50mg. SBPs remained elevated as high as 180s but further increases in BP meds limited by orthostasis. Follow up arranged with Cardiology and Neurology. #Orthostatic hypotension #Acute on chronic systolic heart failure #Acute kidney injury Initially had orthostasis, held diuretics, then developed edema/pulmonary edema. Edema improved with diuretics but then renal function worsened. Now appears dry to euvolemic, allowing for autoregulation for now, decreased lasix to twice weekly on discharge. Per discussion with transplant nephrology, given that Cr has peaked, safe for discharge with close follow up. Discontinued cilastozol (increased mortality in HF). #Autonomic Dysfunction Labile BPs and volume status as above. Followed by Neurology as outpatient. Etiology thought to be due to diabetes. Prior workup for other etiologies negative. #CAD ___ 4 (most recent ___ #Chest Pain Having intermittent chest pain, sometimes intermittent in nature. Troponin have been stable. From ___ cath, still have 70% lesion in D1, but EKG have been stable. Continued home statin, metop, asa, ranolazine. Of note, patient had DES placed ___ but was directed to stop taking ticagrelor in ___, which she had stopped for a procedure. Confirmed with outpatient cardiologist that ticagrelor is not necessary to continue. #Akathisia / Hyperactivity Patient noted to be moving her extremities continually after somnolence improved, had a hard time extinguishing the movement with volition. Likely medication effect (Phenergan most trimethobenzamide). Valproate level within normal limits. Symptoms improved since discontinuing phenergan and trimethobenzamide. Phenergan restarted on ___ w/o any adverse effects. #Chronic nausea Has has difficult to control nausea of unclear etiology on phenergan and trimethobenzamide, followed by GI as outpatient. Nausea appeared to correlate with episodes of hyperglycemia. Nausea was controlled with initially PRN Zofran, but became ineffective. Phenergan restarted on ___ w/o any adverse effects. Trimethobenzamide discontinued due to akithisia. #Blurry vision Has known cataract, diabetic retinopathy, followed by ___. Last seen by opthaomlogy on ___. Discussed with on-call opthalmology, no indication to be seen inpatient, but should have follow up with opthalmology in ___ weeks. No evidence of new strokes on head imaging this admission. #Anemia Has chronic anemia and receives epogen as outpatient and occasional blood transfusion. Hgb downtrending inpatient, likely in setting of iatrogenic blood draw and not receiving epogen. No melena/hematochezia or symptom to suspect acute drop. Iron studies c/w ACD likely iso of CKD. Received 1u PRBC on ___ for hgb of 6.6, with exaggerated response and hgb was stable. Epogen was restarted. Goal hgb >8 #BPPV Had vertigo on ___ with exam consistent with BPPV as diagnosed with ___. Improved with epley maneuver and meclizine. No concern for posterior stroke. CHRONIC ISSUES: ============ #Seizure Disorder Recent nonconvulsive status diagnosed on last hospitalization. Started Divalproate and Keppra during that hospitalization. EEG w/o any seizures as above, continued home AEDs. s/p 1 valproate load. #ESRD ___ T1DM and HTN s/p LURT (___) Has known chronic allograft dysfunction. Renal US in ED w/ improved intrarenal arterial flow and patent vasculature. Renal transplant was consulted. Continued immunosuppression as below. # Immunosuppression Continued Cyclosporine (25 mg q12h), MMF 500 mg bid and prednisone 5 mg daily. # Bone mineral ds Per Renal, continued Vitamin D, no indication for phos binders # Anemia Previously receiving weekly EPO injections but did not have the week before admission due to concern of seizure as a side effect. No inpatient indication for ESA. # Recent CVA MRI showed two subacute infarcts in the right periventricular pericollosal artery territory and punctate infarct in pons. Given distribution, highest suspicion was for small vessel etiology. Given this and timing related to right heart cath, TTE with bubble was performed, which showed no e/o PFO. It was therefore felt that the infarcts are unlikely related to the right heart catheterization. Continued home Asa. #Scleroderma w/ CREST syndrome. On immunosuppression as above #Gastroparesis/GERD/Hiatal hernia. Continued Omeprazole. #Gout. Continued allopurinol. #IPMN. Seen on recent EUS, needs outpatient followup. TRANSITIONAL ISSUES: ===================== [] recheck BMP on ___ or ___ to ensure stability of Cr [] Lasix restarted at 20mg twice weekly. Has bibasilar crackles on discharge, but did not aggressively diurese given Cr and predisposition to orthostasis [] discharge weight: 130.4kg [] Pt with brittle diabetes. Would only make small changes at a time to insulin regimen. Discharge insulin regimen: 12u glargine qam, Humalog ___ with meals [] please check orthostatics before making further changes to BP regimen, as has historically had significant orthostatic hypotension. ___ not tolerate significantly more BP medication [] Needs close follow up with ophthalmology and ___. [] If having repeated episodes of vertigo, likely peripheral and would benefit from vestibular ___ New medications: Meclizine PRN vertigo Changed medications: Hydralazine 75mg TID to ___ TID Isosorbide Dinitrate 40mg TID to 60mg TID Metoprolol XL 25mg to 50mg Held medications: ___ Stopped medications: Cilastozol #CODE: Full (presumed) #CONTACT: ___ ___: SISTER Phone number: ___ Cell phone: ___ More than 30 minutes were spent preparing this discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 4. Ferrous Sulfate 325 mg PO DAILY 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Lidocaine 5% Patch ___ PTCH TD QAM 7. Mycophenolate Mofetil 500 mg PO BID 8. Pravastatin 30 mg PO QPM 9. PredniSONE 5 mg PO DAILY 10. Promethazine 25 mg PO Q6 HR-Q8HR 11. Ranolazine ER 500 mg PO BID 12. Vitamin D ___ UNIT PO DAILY 13. Divalproex (DELayed Release) 750 mg PO BID 14. Metoprolol Succinate XL 25 mg PO DAILY 15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 16. pen needle, diabetic 32 gauge x ___ miscellaneous Other 17. Sodium Bicarbonate 1300 mg PO BID 18. trimethobenzamide 300 mg oral Q6H:PRN 19. Allopurinol ___ mg PO DAILY 20. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 21. Calcium Carbonate 500 mg PO DAILY 22. Cilostazol 50 mg PO BID 23. Esomeprazole Magnesium 40 mg oral BID 24. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 25. melatonin 10 mg oral QHS 26. LevETIRAcetam 500 mg PO BID 27. HydrALAZINE 75 mg PO Q8H 28. Isosorbide Dinitrate 40 mg PO TID 29. Furosemide 20 mg PO DAILY Discharge Medications: 1. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Polyethylene Glycol 17 g PO DAILY 4. Senna 8.6 mg PO BID 5. Furosemide 20 mg PO 2X/WEEK (MO,TH) 6. HydrALAZINE 100 mg PO Q8H 7. Glargine 12 Units Breakfast Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Isosorbide Dinitrate 60 mg PO TID 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Promethazine 25 mg PO Q8H:PRN nausea 12. Allopurinol ___ mg PO DAILY 13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 14. Aspirin 81 mg PO DAILY 15. Calcitriol 0.25 mcg PO DAILY 16. Calcium Carbonate 500 mg PO DAILY 17. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 18. Divalproex (DELayed Release) 750 mg PO BID 19. Esomeprazole Magnesium 40 mg oral BID 20. Ferrous Sulfate 325 mg PO DAILY 21. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 22. LevETIRAcetam 500 mg PO BID 23. Levothyroxine Sodium 125 mcg PO DAILY 24. melatonin 10 mg oral QHS 25. Mycophenolate Mofetil 500 mg PO BID 26. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 27. pen needle, diabetic 32 gauge x ___ miscellaneous Other 28. Pravastatin 30 mg PO QPM 29. PredniSONE 5 mg PO DAILY 30. Ranolazine ER 500 mg PO BID 31. Sodium Bicarbonate 1300 mg PO BID 32. Vitamin D ___ UNIT PO DAILY 33. HELD- trimethobenzamide 300 mg oral Q6H:PRN This medication was held. Do not restart trimethobenzamide until told by your doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Complicated UTI Toxic Metabolic Encephalopathy Akathisia ___ Phenergan Diabetes mellitus type 1 with hyperglycemia Autonomic dysfunction with supine hypertension and orthostatic hypotension Acute on chronic systolic heart failure Acute on chronic renal failure Renal transplant on chronic immunosuppression Secondary: Nausea Benign positional vertigo Seizure disorder Recent stroke Coronary artery disease status post percutaneous coronary interventions Chronic multifactorial anemia Chronic urinary retention Diabetic retinopathy and cataracts CREST syndrome GERD Hiatal hernia Gastroparesis History of gout 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 your blood sugar was very low after receiving some insulin and you were hard to wake up. You received antibiotics for a urinary tract infection and became more alert. You had more imaging of your brain including CT scan and MRI that showed no new strokes. The diabetes doctors worked with ___ to keep your blood sugar in a safe range. You received a new continuous glucose monitoring. You received a unit of blood, but became fluid overloaded and required Lasix. Your blood pressure medications were uptitrated. When you return to rehab, please: - we changed some of your medicines - see below - see below for your followup appontments It was a pleasure caring for you and we wish you the best, Your ___ Team Followup Instructions: ___

10030753-DS-56

DS

2201-03-04 00:00:00

2201-03-04 18:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Ativan / carvedilol / amlodipine Attending: ___. Chief Complaint: Dyspnea, Pedal Edema, Transfer Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT ___, anemia, CAD s/p ___ 4 (most recently ___, HFrEF (EF ~40%), IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), cryptogenic stroke, scleroderma/CREST who presents with worsening lower extremity edema, at the request of her primary cardiologist. The patient was recently here in ___, where she was managed for hypoglycemia. Baseline creatinine is ~3mg/dL; was biopsies in ___ which elucidated diabetic kidney disease, with Grade II IFTA, and moderate arteriosclerosis. In the setting of worsening lower extremity edema, the patient's Lasix was up-titrated to daily from, twice weekly dosing on ___. The patient notes she has gained about 10 pounds over the past month. She has remained volume overloaded, but barring any lower extremity edema, the patient denies symptoms suggestive of CHF such as SOB, cough, orthopnea, or PND. Notably, labile blood pressures have been difficult to manage, given diabetic dysautonomia; this has hindered diuresis in the past per documentation. An implantable loop recorder was placed given her history of cryptogenic stroke, with aim of detecting possible occult atrial dysrhythmia. Last underwent cardiac cath in ___, revealing elevated filling pressures, but as aforementioned, more aggressive diuresis has been hindered by labile BP's. Last echocardiogram revealed a depressed EF of 35-40, when prior TTE's had always suggested preserved systolic function. Repeat catheterization has been deferred given patient's advanced kidney disease. Various titrations of the home BP regimen have been undertaken in recent months. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA ___ DES to LAD and Cx/OM ___ DES to LAD ___ PCI of Cx and OM with ___ -___ renal disease ___ diabetes s/p L-sided living kidney transplant in ___ -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed ___ years ago -OSA -Pancreatic cyst -Non convulsive status epilepticus -stroke -BPPV Social History: ___ Family History: Mother-Multiple myeloma Sister and ___ Sister-RA Sister - Kidney cancer ___ disease Nephewsx2-Alopecia Daughter ___, celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: reviewed in OMR GENERAL: Caucasian female in NAD, alert and interactive. Appears older than her stated age. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally with bibasilar crackles noted. No wheezes. No increased work of breathing on RA. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: +BS, soft, slightly distended, but non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 1+ edema bilaterally to mid-shins. No clubbing or cyanosis. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rash. NEUROLOGIC: A&Ox3, no focal neurologic deficits. CN2-12 grossly intact. ___ strength throughout. DISCHARGE PHYSICAL EXAM: GENERAL: Ill appearing woman laying in bed, NAD HEENT: NCAT. NECK: JVP of ~10cm CARDIAC: Normal rate and rhythm. Loud S2. Grade ___ blowing systolic murmur. LUNGS: Crackles bilaterally at the bases. No wheezes or rhonchi. ABDOMEN: Soft, non-tender to deep palpation in all four quadrants. Distended. EXTREMITIES: Warm and well perfused. 1+ pitting edema bilaterally to mid shin. No clubbing or cyanosis. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: Alert. Oriented to self, place, and time. Sensation to light touch intact throughout. Motor function symmetric throughout. Pertinent Results: ADMISSION LABS: ================= ___ 07:44PM WBC-4.9 RBC-2.98* HGB-10.4* HCT-32.4* MCV-109* MCH-34.9* MCHC-32.1 RDW-14.7 RDWSD-58.2* ___ 07:44PM PLT COUNT-180 ___ 07:44PM NEUTS-76.7* LYMPHS-12.0* MONOS-8.7 EOS-1.6 BASOS-0.4 IM ___ AbsNeut-3.72 AbsLymp-0.58* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.02 ___ 07:44PM GLUCOSE-86 UREA N-57* CREAT-2.8* SODIUM-145 POTASSIUM-5.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-10 ___ 07:44PM cTropnT-0.28* ___ 07:44PM CK-MB-7 proBNP->70000* DISCHARGE LABS: ================== ___ 07:50AM BLOOD WBC-6.0 RBC-2.19* Hgb-7.6* Hct-24.4* MCV-111* MCH-34.7* MCHC-31.1* RDW-12.8 RDWSD-51.3* Plt ___ ___ 10:03AM BLOOD Neuts-82.9* Lymphs-8.1* Monos-8.1 Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.75 AbsLymp-0.56* AbsMono-0.56 AbsEos-0.02* AbsBaso-0.02 ___ 07:50AM BLOOD Plt ___ ___ 08:12AM BLOOD Glucose-137* UreaN-60* Creat-3.3* Na-145 K-4.6 Cl-107 HCO3-30 AnGap-8* ___ 08:12AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1 MICROBIOLOGY: ================ __________________________________________________________ ___ 12:56 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 10:05 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:30 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 3:25 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 11:50 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:44 pm BLOOD CULTURE #1. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ========= CHEST (PA & LAT)Study Date of ___ IMPRESSION: Mild basilar atelectasis without definite focal consolidation. Difficult to exclude trace pleural effusion, but no large pleural effusion is seen. No overt pulmonary edema. RENAL TRANSPLANT U.S. RIGHTStudy Date of ___ IMPRESSION: 1. Unremarkable appearance of the transplant kidney in the left lower quadrant with no hydronephrosis. 2. Patent renal transplant vasculature. The RIs remain elevated. The main renal artery demonstrates mild parvus tardus waveform and absent diastolic flow. 3. Bladder wall thickening suggesting hypertrophy or neuropathic bladder changes. Transthoracic Echocardiogram Report Date: ___ IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal cavity size and mild to moderate global systolic dysfunction. Increased PCWP. Mild mitral regurgitation. Mild aortic regurgitation. Mild tricuspid regurgitation. CT HEAD W/O CONTRASTStudy Date of ___ IMPRESSION: 1. No evidence for acute hemorrhage or acute major vascular territorial infarct. 2. Multiple chronic infarcts are again demonstrated. 3. Paranasal sinus disease. CHEST (PORTABLE AP)Study Date of ___ IMPRESSION: Compared to chest radiographs ___ through ___. Moderate cardiomegaly is larger and pulmonary vasculature is more engorged but there is probably no pulmonary edema. Elevation right lung base could be due to subpulmonic pleural effusion or right basal atelectasis. Skin fold should not be mistaken for left pneumothorax. MRA BRAIN W/O CONTRASTStudy Date of ___ IMPRESSION: 1. Multiple small acute or early subacute infarcts, in the right thalamus, right external capsule, right parietal cortex, and possibly in the right insular cortex. 2. 2 mm laterally projecting outpouching, right cavernous intracranial ICA, small infundibulum versus tiny aneurysm. 3. Areas of mild to severe luminal narrowing, bilateral posterior cerebral arteries, presumably due to underlying atheromatous disease, most severely affecting the left P4 PCA. There is nonetheless preserved distal PCA runoff bilaterally. 4. Otherwise, patent circle of ___ vasculature. No additional stenosis, aneurysm, or occlusion. 5. Multiple foci of supratentorial and infratentorial encephalomalacia, compatible sequelae of remote infarction. 6. Small chronic right periventricular white matter infarcts. 7. Multiple foci of chronic microhemorrhage; although there are a few supratentorial foci, these are most conspicuous in the brainstem, raising the possibility of hypertensive angiopathy. Brief Hospital Course: TO OUTSIDE PROVIDERS: ====================== ___ woman with PMHx significant for ESRD s/p LURT in ___, CAD s/p ___ 4 (most recent ___, HFrEF (EF 35-40% ___, T1DM, poorly controlled HTN, scleroderma/CREST, who was transferred from OSH for lower extremity edema with evidence of HFrEF exacerbation, and UTI in setting of h/o MDR UTIs, hospital course complicated by poorly controlled blood glucose, labile blood pressure, and new CVA. TRANSITIONAL ISSUES FOR PCP: ============================ [] MEDICATION CHANGES: ADDITIONS: ----------- clonidine 0.1 mg/24 hour torsemide 20 mg QD CHANGES (below is current regimen & stated reason for change): allopurinol ___ mg Q48H (based on renal function) cyclosporine 25 mg QAM + 50 mg QPM (per Renal based on levels and renal function) hydralazine 50 mg TID (for better BP control) isosorbide mononitrate 120 mg QD (for better BP control) levetiracetam 250 mg PO BID (based on renal function) sodium bicarbonate 650 mg BID (based on HCO3- levels, per Renal) HELD (all held to reduce pill burden, restart as necessary and tolerated): calcium carbonate 500 mg PO QD esomeprazole magnesium 40 mg PO BID ferrous sulfate 325 mg PO QD furosemide 20 mg PO QD meclizine 12.5 mg PO Q8H: PRN ranolazine ER 500 mg PO BID vitamin D ___ U PO QD melatonin 10 mg PO QHS [] Fluid status: On discharge, we think she is still slightly volume overloaded. We will start torsemide 20 mg daily, and we instructed her to take daily weights. Please re-evaluate her edema and creatinine and alter as necessary, eventually may need only Q48H dosing. [] HTN: Significant issue during hospitalization complicated by CVA. Discharge regimen is: clonidine 0.1 mg/24 hour torsemide 20 mg QAM hydralazine 50 mg TID isosorbide mononitrate 120 mg QAM metoprolol succinate 100 mg QHS Please adjust as necessary, may need increase in clonidine patch to 0.2 mg if continued hypertension. Consider ambulatory BP monitor to assess control throughout the day. ACUTE ISSUES: ============= # Volume overload: # ___ edema: # c/f HFrEF Exacerbation (EF 35-40% on TTE in ___: Patient with history of lower extremity edema but with labile BPs that often prevent adequate diuresis. Presented to cardiologist clinic with worsening ___ edema, found to have BNP >70000 on presentation to ___ ED. Also noted to be hypertensive as below in the ED, but unclear if this was precipitating factor of HFrEF exacerbation. Patient was diuresed with furosemide. Repeat TTE generally unchanged, estimated elevated PCWP. Volume overload also complicated by nephrotic syndrome. #Acute and subacute thalamic and external capsule infarcts: #Hypertensive angiopathy: Patient received MRI/MRA head which revealed new infarcts in deeper brain structures, concerning for hypertension as cause of infarcts. Pt was seen by neurology who recommended daily Aspirin and BP control for ongoing stroke prevention. #Hypertensive urgency: Patient presented with BP 201/110. Improved with anti-hypertensives and diuresis in ED. Patient reports compliance with medications and was normotensive at recent outpatient appointment, so unclear what precipitated high BP in ED. Pt has very labile BPs likely related to DM autonomic neuropathy that was difficult to manage even while inpt. Nephrotic syndrome may be contributing to HTN. Renal (time of flight) MRI was performed to evaluate for RAS and there was not evidence of arterial stenosis in vessels perfusing the transplanted kidney. Medications were titrated to improve pressures as listed in discharge medications. #Acute complicated cystitis, treated: Dysuria on admission, UA positive. UCx positive for Enterococcus. Given PCN allergy, decision was made to treat with vancomycin for 10 day course (given history of transplant) and this course was completed. ___: #ESRD ___ T1DM and HTN s/p LURT (___): #Nephrotic syndrome: Patient has chronic allograft dysfunction due to diabetic nephropathy, partial rejection with baseline Cr reportedly 3.0 though slightly lower on chart review. Patient has long history of nephrotic syndrome, biopsy proven ___ T1DM. Likely contributing to her edema. Cr increased above baseline, likely pre-renal ___ due to overdiuresis. Renal transplant was consulted for management. She was continued on her home immunosuppressants. SPEP/UPEP were negative. Renal assisted with fluid management, Cr returned to near baseline at d/c. #Type 1 DM: Very labile blood sugar with episodes of hypo- and hyperglycemia throughout hospitalization. ___ was consulted for assistance with management of blood sugars. Regimen as noted on d/c medications. CHRONIC ISSUES: =============== #Chronic nausea: Continue home anti-emetics, standing promethazine PRN and multiple medications held as they were contributing to pill burden and daily vomiting. #Scleroderma w/ CREST syndrome: On immunosuppression as above. #Gastroparesis/GERD/hiatal hernia: Continued home esomeprazole. #Seizure disorder: Nonconvulsive status diagnosed during previous admission and started on divalproate and levetiracetam at that time. Continued home divalproex ___ BID, levetiracetam 250mg BID (dose-reduced for renal function). #Macrocytic anemia: Chronic, secondary to ESRD, immunosuppression. Possibly a dilutional component from fluids. Was initially maintained on EPO, but was discontinued given new onset stroke. #Gout: -Continue home allopurinol. #Hypothyroidism: -Continue home levothyroxine. #Hyperlipidemia: -Continued home pravastatin. #BPPV: -Continued home meclizine PRN. GOC: We held many discussions with patient and her sister ___ about her many medical issues contributing to her declining quality of life with > 10 admissions during ___. Pt endorsed poor tolerance of having to take so many pills and waxing/waning confusion even at home. Pt often expressed wanting to be DNAR/DNI and would NEVER want a feeding tube. She was undecided about ever wanting dialysis. However, her sister ___ did not feel that these choices accurately represented the patient's perspective as they had a different conversation weeks before admission when they first filled out a MOLST. Palliative care followed and will continue to see her as an outpatient. I have reached out to her PCP to encourage ongoing conversations about her goals as she is very likely to get readmitted given her many medical problems that are difficult to manage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Calcium Carbonate 500 mg PO DAILY 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 6. Divalproex (DELayed Release) 750 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. LevETIRAcetam 500 mg PO BID 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. Pravastatin 30 mg PO QPM 12. PredniSONE 5 mg PO DAILY 13. Ranolazine ER 500 mg PO BID 14. Sodium Bicarbonate 1300 mg PO BID 15. Senna 8.6 mg PO BID 16. melatonin 10 mg oral QHS 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Esomeprazole Magnesium 40 mg oral BID 19. Promethazine 25 mg PO Q8H:PRN nausea 20. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea 21. Lidocaine 5% Patch 1 PTCH TD QAM 22. Fluticasone Propionate NASAL 2 SPRY NU QHS 23. Furosemide 20 mg PO DAILY 24. HydrALAZINE 50 mg PO BID 25. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS 26. Metoprolol Succinate XL 100 mg PO DAILY 27. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 28. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT RX *clonidine 0.1 ___ on skin. once a day Disp #*10 Patch Refills:*0 2. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Allopurinol ___ mg PO EVERY OTHER DAY 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 6. HydrALAZINE 50 mg PO TID 7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 8. LevETIRAcetam 250 mg PO BID 9. Metoprolol Succinate XL 100 mg PO QHS 10. Sodium Bicarbonate 650 mg PO BID 11. Aspirin 81 mg PO DAILY 12. Calcitriol 0.25 mcg PO DAILY 13. Divalproex (DELayed Release) 750 mg PO BID 14. Fluticasone Propionate NASAL 2 SPRY NU QHS 15. Levothyroxine Sodium 125 mcg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD QAM 17. Mycophenolate Mofetil 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 20. Pravastatin 30 mg PO QPM 21. PredniSONE 5 mg PO DAILY 22. Promethazine 25 mg PO Q8H:PRN nausea 23. Senna 8.6 mg PO BID 24. HELD- Calcium Carbonate 500 mg PO DAILY This medication was held. Do not restart Calcium Carbonate until told to restart by a doctor. 25. HELD- Esomeprazole Magnesium 40 mg oral BID This medication was held. Do not restart Esomeprazole Magnesium until told to restart by a doctor. 26. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was held. Do not restart Ferrous Sulfate until told to restart by a doctor. 27. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until told to restart by a doctor. 28. HELD- Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea This medication was held. Do not restart Meclizine until told to restart by a doctor. 29. HELD- melatonin 10 mg oral QHS This medication was held. Do not restart melatonin until told to restart by a doctor. 30. HELD- Ranolazine ER 500 mg PO BID This medication was held. Do not restart Ranolazine ER until told to restart by a doctor. 31. HELD- Vitamin D ___ UNIT PO DAILY This medication was held. Do not restart Vitamin D until told to restart by a doctor. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: heart failure stroke hypertensive emergency ___ ESRD UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. WHY WERE YOU ADMITTED? -You had lower extremity edema. WHAT HAPPENED WHEN YOU WERE HERE? -We thought you had fluid overload from heart failure so we worked on getting fluid out of your body. -Your blood pressure was very high we worked on controlling it. -We noted that you had what looked like strokes on your head imaging. WHAT SHOULD YOU DO WHEN YOU GO HOME? -Continue to take all of your medications as described in your discharge packet. -Please followup with all of your doctors, especially your primary care provider this week. Bring this handout. -Your primary care doctor should help you with your diuretics and blood pressure. -Weight yourself daily and write the values down. If your weight changes by a few pounds in 1 day, call your doctor for assistance. -Continue to check you blood pressure at home, making sure you are seated for 5 minutes before checking it, resting your arm on a table. Write down these values and bring them to your doctor's appointments. We wish you the best! Sincerely, Your ___ Medicine Team Followup Instructions: ___

10031358-DS-9

DS

2158-09-07 00:00:00

2158-09-07 17:14:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___. Chief Complaint: slurred speech, facial droop Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old male with history of DM, HTN, HLD, and noncompliance to meds for financial reasons, who developed right facial droop and slurred speech yesterday afternoon around 3pm. He says that he was feeling like himself yesterday, and he is not missing any part of the day. Around 3pm, he called his sister, and she could not understand any words that he was saying. He noticed that his speech was slurred, but he did not have any difficulty understanding others or getting words out. He then looked in the mirror, and he noted that the right side of his face was droopy. He thought that it was due to his diabetes because he has not taken his diabetes medications in over a year. His wife came home, and she noted that his speech was slurred and that his face was asymmetric. This morning, his wife woke up and realized that her friend had had a TIA where people could not understand what they were saying. She called his PCP who recommended an urgent visit in the clinic, but she decided to bring him to the ED. In ___, he had amputation of his toes on the right foot, and he was in rehab in ___. He tried to get up and get a cup of coffee, but he was connected to a wound vacuum on his heel. He tripped and fell, and his wife says that he hit the back of his head. She did not witness the fall, and she is not sure if he lost consciousness. He was transported to ___, where he was found to have a 4mm right parafalcine subdural hemorrhage. The next day at ___, he was reported to have a seizure. His wife was not present, and there is no description over the episode other than a "generalized tonic-clonic seizure". He was started on levetiracetam, but he has not been taking it for the past two months. He currently denies headache, loss of vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Otherwise, his general review of systems is negative. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma ___ esophagus Social History: ___ Family History: mGM with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: Admission Physical Exam: Vitals: 97.3 69 151/64 18 99% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Neck: Supple Pulmonary: No increased WOB Cardiac: RRR Abdomen: Soft, non-distended Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name days of the week backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. He was able to name both high and low frequency objects. Able to read without difficulty. Speech was 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. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right facial droop, symmetric strength in upper face 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. Pronation and mild drift on the right, orbiting of the right arm Delt Bic Tri WrE IO IP Quad Ham TA L 5 ___ ___ 5 5 R 5 ___ ___ 5 5 -Sensory: No deficits to light touch -DTRs: Bi Tri ___ Pat L 2 2 2 2 R 2 2 2 2 -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. Slightly slower finger tapping on the right. -Gait: non-ambulatory ========================================= DISCHARGE PHYSICAL EXAMINATION: Vitals: 98.4 97.7 99-123/40-60 ___ 18 98%RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Pulmonary: No increased WOB Abdomen: Soft, non-distended Neurologic: -Mental Status: Alert, oriented x 3. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 5 to 4mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right NLFF, symmetric strength in upper face IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Pronation and mild drift on the right, orbiting of the right arm Delt Bic Tri WrE IO IP Quad Ham TA L 5 ___ ___ 5 5 R 5 ___ ___ 5 5 -Sensory: No deficits to light touch -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. Slightly slower finger tapping on the right. -Gait: not tested Pertinent Results: ___ 05:20AM BLOOD WBC-9.2 RBC-4.15* Hgb-11.9* Hct-35.9* MCV-87 MCH-28.7 MCHC-33.1 RDW-13.0 RDWSD-40.4 Plt ___ ___ 02:30AM BLOOD WBC-11.4* RBC-3.96* Hgb-11.5* Hct-34.1* MCV-86 MCH-29.0 MCHC-33.7 RDW-12.9 RDWSD-39.8 Plt ___ ___ 06:15AM BLOOD WBC-11.0* RBC-4.41* Hgb-12.6* Hct-38.5* MCV-87 MCH-28.6 MCHC-32.7 RDW-13.3 RDWSD-41.4 Plt ___ ___ 05:20AM BLOOD Neuts-53.5 ___ Monos-13.2* Eos-4.0 Baso-1.0 Im ___ AbsNeut-4.92 AbsLymp-2.53 AbsMono-1.21* AbsEos-0.37 AbsBaso-0.09* ___ 06:15AM BLOOD Neuts-58.2 ___ Monos-11.4 Eos-4.0 Baso-0.9 Im ___ AbsNeut-6.40*# AbsLymp-2.72 AbsMono-1.26* AbsEos-0.44 AbsBaso-0.10* ___ 05:20AM BLOOD Plt ___ ___ 05:20AM BLOOD ___ PTT-29.5 ___ ___ 02:30AM BLOOD Plt ___ ___ 02:30AM BLOOD ___ PTT-29.5 ___ ___ 05:20AM BLOOD Glucose-233* UreaN-27* Creat-1.3* Na-134 K-4.1 Cl-99 HCO3-24 AnGap-15 ___ 02:30AM BLOOD Glucose-156* UreaN-23* Creat-1.4* Na-135 K-4.2 Cl-100 HCO3-22 AnGap-17 ___ 06:15AM BLOOD Glucose-304* UreaN-20 Creat-1.6* Na-134 K-5.8* Cl-99 HCO3-21* AnGap-20 ___ 06:15AM BLOOD ALT-16 AST-33 AlkPhos-74 TotBili-0.4 ___ 06:15AM BLOOD Lipase-50 ___ 06:15AM BLOOD cTropnT-<0.01 ___ 05:20AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.8 ___ 02:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7 Cholest-203* ___ 06:15AM BLOOD Albumin-3.7 ___ 02:30AM BLOOD %HbA1c-8.5* eAG-197* ___ 02:30AM BLOOD Triglyc-396* HDL-38 CHOL/HD-5.3 LDLcalc-86 ___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ CT HEAD W/O CONTRAST 1. 13 mm hemorrhage in the left putamen, compatible with hypertensive hemorrhage. 2. Paranasal sinus inflammatory disease. ___ CXR No acute cardiopulmonary process. ___ MR HEAD W/O CONTRAST 1. Stable left putaminal hematoma with mild surrounding edema and no significant effect or midline shift. No acute infarct. 2. No visualization of the right distal V3 or V4 segments of the vertebral artery with a diminutive distal right V4 segment seen. This may represent a diminutive vessel versus occlusion. A MRA can be acquired for further evaluation if clinically indicated. 3. Paranasal sinus disease. 4. Prominence of the posterior nasopharyngeal soft tissues, which may represent prominent adenoids. Recommend correlation with direct visualization. Brief Hospital Course: Mr. ___ is a ___ year old male with history of DM, HTN, HLD, and noncompliance to medications for financial reasons who is admitted to the Neurology stroke service with right facial droop and slurred speech the day prior to admission secondary to an acute intraparenchymal hemorrhage in the Left basal ganglia. Aspirin was held initially. His stroke was most likely secondary to medication noncompliance for the 2 months prior to admission due to financial difficulties. ASA 81 daily will be restarted upon hospital discharge. He should continue his home metoprolol and HCTZ for blood pressure control. His deficits improved prior to discharge and the only notable weakness was in the right nasolabial fold. He was seen by ___, OT, and speech and swallow therapy. He will be discharged home with outpatient speech therapy. His intraparenchmal hemorrhage risk factors include the following: 1) DM: A1c 8.5% 2) Poorly controlled hypertension 3) Obesity Since he has not taken his meds for the two months prior to hospital admission, his Seroquel was restarted at the much lower dose of 100mg qhs. The Seroquel may be uptitrated as an outpatient as per his PCP or psychiatrist. The Seroquel was not restarted at his prior dose of 600mg qhs because this may have resulted in a dangerous possibility of getting a prolonged Qtc syndrome and somnolence, among other possible side effects. AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. 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 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Glargine 60 Units Bedtime aspart 8 Units Breakfast aspart 8 Units Lunch aspart 8 Units Dinner 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. QUEtiapine extended-release 600 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. Aspirin 81 mg PO DAILY 11. Cyanocobalamin 50 mcg PO DAILY 12. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Simvastatin 40 mg PO QPM RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Sertraline 50 mg PO DAILY RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Hydrochlorothiazide 25 mg PO DAILY RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. FoLIC Acid 1 mg PO DAILY 7. Cyanocobalamin 50 mcg PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 10. RX *quetiapine 100 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Vitamin D ___ UNIT PO DAILY 12. LeVETiracetam 750 mg PO BID RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Outpatient Speech/Swallowing Therapy 1. PO diet: thin liquids, regular solids, Pills: whole in thin liquids 2. Standard aspiration precautions, including: Small bites, chew thoroughly 3. Speech tx upon discharge 14. 70/30 16 Units Breakfast 70/30 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (70-30) AS DIR 16 Units before BKFT; 10 Units before DINR; Disp #*30 Syringe Refills:*0 15. KwikPen Needles KwikPen Needles 30 Discharge Disposition: Home Discharge Diagnosis: Intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized due to symptoms of facial droop and slurred speech resulting from an acute bleed in your brain (intraparenchymal hemorrhage). 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. Bleeding in the brain can have many different causes, so we assessed you for medical conditions that might raise your risk. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Diabetes High blood pressure High cholesterol Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___

10031575-DS-20

DS

2171-03-29 00:00:00

2171-03-29 20:57:00

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, chest pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ woman with HTN, IDDM, HLD with heart failure (unknown EF) diagnosed ___ at ___ here with worsening dyspnea on exertion, lower extremity edema. She was initially presented to ___ ___ and was diagnosed with heart failure. She was diuresed in the hospital and improved. She had poor adherence on follow up, stopped taking 60mg po Lasix when she was discharged. She did continue to take on metoprolol and lisinopril. She does not weigh herself. Presents with gradually worsening dyspnea on exertion, lower extremity edema, PND, orthopnea for two months, but most noticeably over the last 2 weeks. She cannot walk up a flight of stairs without stopping several times due to dyspnea, she cannot walk >1city block at a time due to dyspnea, which resolves with rest. Her lower extremities have become progressively swollen over the last few months, but now feel "tight" and heavy. She also reported an isolated episode of sharp chest pain awakening her from sleep last night which lasted seconds and resolved without intervention. Location L anterior chest with radiation to her left arm. No association with palpation, position. She denies current chest pain/pressure, or chest pressure that increases with predictable activity or resolves with rest. She was given sublingual nitro x1 in ambulance. Of note, she is a longstanding diabetic, diagnosed ___ years ago. Over the last ___ years has gotten better control. Knows she has retinopathy, severe neuropathy. Has never been told had kidney problems before. She has an opthalomologist but never has seen podiatry. She notes history of foot wound that was "cut" by PCP in ___. She describes being prescribed a 14 day course of augmentin for this wound. She does not remember being told it was related to diabetes. In the ED initial vitals were: 97.6 90 138/83 20 100% Nasal Cannula BP notable for 170-190's/70's-100's Labs/studies notable for: ___: 10773, Trop-T 0.04, CK 426, MB 5 Cr 1.6 (unknown baseline), Chem 10 otherwise unremarkable Hg 10.9, WBC, PLT wnl UA 300 prtn RBC 163, Blood Mod LUE Ultrasound ___: No evidence of deep vein thrombosis in the left upper extremity. CXR ___: No definite focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. No acute cardiopulmonary process. BEDSIDE TTE by cards fellow ___: some LVH, mild MR, AI, TR, trivial effusion, unable to clearly assess wall motion. Patient was given: IV Furosemide 80 mg Vitals on transfer: VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA On the floor the patient reports fatigue but denies dyspnea, chest pressure, nausea, vomiting. Past Medical History: - Diabetes mellitus, A1C 7.2% on admission (___), complicated by neuropathy - Hypertension - Hyperlipidemia - HF pEF, diagnosed during hospitalization at ___ (___) - R foot ulcer Social History: ___ Family History: Cousin with ICD placement, ___ No family history of early MI, cardiomyopathies, or sudden cardiac death. Physical Exam: == ADMISSION PHYSICAL EXAMINATION == VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA I/O: -/540in ED +NR Weight: 126.2kg, unknown dry weight GENERAL: Well developed, well nourished female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 13cm with head of bed at 30 degrees CARDIAC: laterally displaced PMI. Regular rate and rhythm. Normal S1, S2. diastolic murmur. No rubs, or gallops. No thrills or lifts. LUNGS: Respiration is unlabored with no accessory muscle use. Breath sounds limited by habitus. Crackles to bases, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. EXTREMITIES: 4+ pitting edema to thighs B/L, 1+ extending to umbilicus. Warm, well perfused. No clubbing, cyanosis. L>R arm swelling. SKIN: R foot with 1cm punched out, ~3mm deep ulcer with foul smell emanating, but no overt. No rashes. NEURO: decreased sensation to light touch to feet B/L. == DISCHARGE PHYSICAL EXAMINATION == VITALS: T 97.2, BP 135-145/79-88, HR 72-85, RR 18, SpO2 98/RA WEIGHT: 106.1 kg -> 107 kg I/O: 24hr 1100/2175, 8h 100/800 GENERAL: well-appearing obese female, NAD HEENT: moist membranes, PERRL NECK: JVP elevated to 7-8cm at 45 degrees, thyromegaly R>L CARDIAC: RRR, ___ high pitched SEM at RUSB, heard throughout rest of precordium LUNGS: distant breath sounds, CTAB ABDOMEN: Normoactive BS throughout, non tender EXTREMITIES: WWP, 2+ pitting edema to knees b/l. R heel - wrapped in guaze, dressing is clean/dry Pertinent Results: == ADMISSION LABS == ___ 11:45AM BLOOD WBC-6.1 RBC-3.96 Hgb-10.9* Hct-34.2 MCV-86 MCH-27.5 MCHC-31.9* RDW-13.9 RDWSD-43.5 Plt ___ ___ 11:45AM BLOOD Neuts-63.8 ___ Monos-6.4 Eos-1.3 Baso-0.5 Im ___ AbsNeut-3.88 AbsLymp-1.69 AbsMono-0.39 AbsEos-0.08 AbsBaso-0.03 ___ 11:45AM BLOOD ___ PTT-31.8 ___ ___ 11:45AM BLOOD Glucose-83 UreaN-16 Creat-1.6* Na-141 K-3.4 Cl-107 HCO3-28 AnGap-9 ___ 11:45AM BLOOD CK(CPK)-426* ___ 11:45AM BLOOD CK-MB-5 ___ ___ 11:45AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.6 Iron-58 == NOTABLE INTERVAL LABS == ___ 05:55PM BLOOD ALT-12 AST-18 LD(LDH)-303* CK(CPK)-559* AlkPhos-91 TotBili-0.2 ___ 06:29AM BLOOD CK(CPK)-328* ___ 11:45AM BLOOD calTIBC-233* Ferritn-27 TRF-179* ___ 11:45AM BLOOD %HbA1c-7.2* eAG-160* ___ 11:45AM BLOOD TSH-6.1* ___ 03:00PM BLOOD T4-7.4 ___ 11:45AM BLOOD RheuFac-14 ___ CRP-4.9 ___ 03:00PM BLOOD PEP-AWAITING F FreeKap-86.8* FreeLam-52.2* Fr K/L-1.66* IFE-PND == IMAGING == -- ___ CXR No acute cardiopulmonary process. -- ___ UNILAT UPPER EXTR ULTRASOUND No evidence of deep vein thrombosis in the left upper extremity. -- ___ TTE The left atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 55%). The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is absent transmitral A wave c/w impaired left atrial mechanical function. Mild to moderate (___) mitral 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 a trivial pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and low normal global left ventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Mildly dilated thoracic aorta. Increased PCWP. Absent transmitral A wave. The symmetric left ventricular hypertrophy with increased PCWP and absent transmitral A wave and multivalvular regurgitation are suggestive of an infiltrative process (e.g., amyloid). -- ___ CARDIAC MRI The left atrial AP dimension is mildly increased with moderate left atrial elongation. The right atrium is moderately dilated. There is normal left ventricular wall thickness with normal mass. Normal left ventricular end-diastolic dimension with SEVERELY increased left ventricular end-diastolic volume and moderately increased end-diastolic volume index. There is mild global left ventricular hypokinesis with relative preservation of apical function. The left ventricular cardiac index is normal. There is uniformity in regional T2. Early gadolinium enhancement images showed no enhancement. There is no late gadolinium enhancement (absence of scar/fibrosis). Mildly increased right ventricular end-diastolic volume index with mild global free wall hypokinesis and low normal ejection fraction. Normal origin of the right and left main coronary arteries. Mildly increased ascending aorta diameter (normal BSA indexed ascending aorta diameter) with normal aortic arch diameter and mIldly dilated descending thoracic aorta (normal BSA indexed descending aorta diameter). Mildly increased abdominal aorta diameter (normal BSA indexed abdominal aorta diameter). Moderately increased pulmonary artery diameter with mildly increased BSA indexed PA diameter. The # of aortic valve leaflets could not be determined. There is no aortic valve stenosis. Mild aortic regurgitation is seen. There is moderate mitral regurgitation. There is moderate tricuspid regurgitation. There is a small circumferential pericardial effusion. Pericardial thickness is normal. There is a small right pleural effusion. IMPRESSION: Normal left ventricular wall thickness and global mass. Moderately dilated left ventricular cavity with mild global hypokinesis. No evidence of myocardial edema, inflammation, infiltration or scar/fibrosis. Mildly dilated right ventricular cavity with low normal free wall motion. Moderate mitral regurgitation. Moderate tricuspid regurgitation. These findings are most c/w a non-ischemic dilated cardiomyopathy. ___ Imaging THYROID U.S. Heterogeneous hypervascular thyroid gland compatible with thyroiditis. No discrete nodules identified. == DISCHARGE LABS == ___ 04:25AM BLOOD WBC-6.6 RBC-4.20 Hgb-11.4 Hct-36.1 MCV-86 MCH-27.1 MCHC-31.6* RDW-14.1 RDWSD-43.8 Plt ___ ___ 04:25AM BLOOD Plt ___ ___ 04:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0 Brief Hospital Course: This is a ___ year old woman with a PMH notable for hypertension, hyperlipidemia, history of heart failure (NOS) and type II diabetes mellitus (on insulin), who presented with massive ___ edema, concerning for heart failure, found to have signs suggestive of infiltrative cardiac disease on TTE. # Acute on chronic heart failure with preserved ejection fraction: diagnosed ___ at ___ [records obtained, in paper chart -- notable for EF 56%, grade II diastolic dysfunction, dry weight 110 kg]. TTE concerning for restrictive physiology and possible infiltrative process, such as amyloidosis. Cardiac MRI obtained, which demonstrated what is almost certainly dilated cardiomyopathy due to hypertension. No evidence of infiltrative disease on cardiac MRI. Presented massively overloaded on examination. Aggresively diuresed with furosemide gtt, then furosemide boluses, and finally oral torsemide. Initially held lisinopril given elevated Cr, but appears baseline. Slowly restarted & uptitrated, given degree of hypertension & proteinuria. Metoprolol was stopped, given preserved EF and possible constrictive physiology. - Discharge weight: 106.5 kg, 234.8 lbs - Discharge Cr: 2.1 - Discharge diuretic regimen: torsemide 100mg BID # Type II NSTEMI: perhaps demand in setting of volume overload and CHF, as above. Started on aspirin 81 mg daily and atorvastatin 40 mg HS. Once euvolemic, stress test showed no focal ischemia or perfusion defects. # Hypertension: quite elevated on admission (180s+). Lisinopril 40mg used, as above. Started on amlodipine and isosorbide mononitrate, which she tolerated well with satisfactory improvement of BP. # Renal failure: likely chronic, with possible acute component. Significant proteinuria, with Pr/Cr 11.1. Possible etiologies include diabetic nephropathy, cardiorenal syndrome and hypertensive nephropathy. Creatinine 2.1 at discharge; it was stable at this level for ~1 week prior to discharge. # NEUROPATHIC HEEL ULCER: not infected. Likely diabetic. Dressed per wound care recs. Debrided at bedside on ___ by podiatry. Will follow-up with podiatry as outpatient. # TYPE II DIABETES: FSG generally under good control. Glargine decreased to 28U at bedtime with Humalog sliding scale at meals and bedtime. # ELEVATED CK: unclear etiology, resolved. # THYROMEGALY: TSH>6, T4 normal. Thyroid US with vascular congestion. Discussed case with endocrine, who recommends outpatient endocrine follow-up. Follow-up appointment is scheduled. # IRON DEFICIENCY: Given history of CHF and iron studies indicative of deficiency, she was given IV iron while in house, and should have iron studies rechecked as an outpatient. TRANSITIONAL ISSUES: ==================== [ ] f/u with podiatry for neuropathic ulcer [ ] f/u with endocrine for radiographic thyroiditis [ ] Chem ___ at ___ NP appointment next week [ ] f/u with Dr ___ in ___ office after seeing ___ NP [ ] Daily weights, call ___ office if increase >3 pounds in one day [ ] recheck iron studies as an outpatient to ensure proper repletion with IV Iron while in house - Discharge weight: 106.5 kg = 234.8 lbs - Discharge Cr: 2.1 - Discharge diuretic regimen: torsemide 100mg BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Glargine 41 Units Bedtime 4. Gabapentin 100 mg PO TID 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 6. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 3. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg Once tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 5. Torsemide 80 mg PO BID RX *torsemide 20 mg Four tablet(s) by mouth Once in the morning and once in the evening Disp #*240 Tablet Refills:*0 6. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Lisinopril 40 mg PO DAILY 10.straight cane DX: diabetic ulcer and chronic foot pain PX: good ___: 12 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: acute on chronic diastolic heart failure, R foot ulcer, diabetes mellitus (type II, on insulin) Secondary diagnoses: elevated CK 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 too much fluid in your body. You received a medicine called "Lasix" or furosemide, to help remove the extra fluid from your body. You also had extensive testing of your heart to find out why you have "heart failure." This showed that your heart failure is likely related to your high blood pressure. You also were seen by the podiatrists ("foot doctors") because of the wound on the bottom of your right foot. They cleaned it, and recommended that you follow-up with them in their ___ urgent ___ center one week after discharge (___). We noticed that your thyroid gland in your neck is bigger than usual. We did some testing of the thyroid, which showed that it is working normally. Our endocrine doctors ___ for the thyroid gland) will see you in the office in a few weeks to check in on your thyroid. If you notice any difficulty in swallowing, changes in your voice, racing heart or heart fluttering, please call their office to tell them your symptoms. Be sure to take ALL of your medicines as prescribed. Follow up with your doctors, as scheduled below. Be sure to weigh yourself every day! Weigh yourself first thing in the morning, after you have gone to the bathroom. When you were discharged, your weight was 234.8 lbs. If your weight goes up by more than 3 lbs in one day, or 5 lbs in one week, call ___ to speak with our cardiology team about your weight change. It was a pleasure taking care of you! We wish you the very best. Your ___ Cardiology Team Followup Instructions: ___

10031575-DS-25

DS

2173-03-12 00:00:00

2173-03-15 15:45:00

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: None History of Present Illness: ___ pmhx of HFpEF (EF 55% ___, HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain. Pt awoke from sleep at 3:30am on ___ with chest pain described as sharp substernal, non-pleuritic, radiating to R arm. + nausea and diaphoresis initially, not recurrent. Has been constant since then with some mild improvement by the time of arrival to the floor. Patient has never had this chest pain before. No increased leg swelling. Weight stable on torsemide 80/40, no report of dietary indiscretion. Patient does have three pillow orthopnea at baseline. No abdominal pain, no diarrhea or dysuria, no blood in stool or urine, no severe headache, no double vision, no sore throat. No cough, no congestion. Past Medical History: - Diastolic CHF, LVEF 55% ___, possibly related to HTN. Diagnosed ___ at ___. - History of CVA - treated at ___, left sided hemiparesis, ___, no residual deficits - Diabetes mellitus, A1C 7.2% (___), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation ___ years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: ___ Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age ___. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: ADMISSION EXAM: VITALS: 98.7, 154/85, 73, 18, 100% RA GEN: tired, NAD HEENT: MM tacky to mildly dry CV: RRR nl s1/s2 no mrg, no reproduction of CP on palpation PULM: CTA b/l no wrc GI: S/ND/NT EXT: Non-edematous, warm DISCHARGE EXAM: Temp: 99 PO BP: 140-150s/90s HR: 90s RR: 18 O2 sat: 96% O2 delivery: RA GEN: cooperative, NAD HEENT: dry mucous membranes, mild gum inflammation on left side of mouth, no pharyngeal erythema NECK: JVP ~8cm at 30 degrees. CV: RRR nl s1/s2 no mrg PULM: CTA b/l, no crackles or wheezing ABD: S/ND/NT EXT: No ___ edema bilaterally, warm Pertinent Results: ADMISSION LABS: ___ 09:38PM BLOOD WBC-11.1* RBC-4.22 Hgb-11.9 Hct-38.3 MCV-91 MCH-28.2 MCHC-31.1* RDW-13.2 RDWSD-43.6 Plt ___ ___ 09:38PM BLOOD Neuts-74.6* ___ Monos-4.6* Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.30* AbsLymp-2.19 AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03 ___ 09:38PM BLOOD Glucose-95 UreaN-62* Creat-2.8* Na-142 K-5.0 Cl-108 HCO3-21* AnGap-13 ___ 09:38PM BLOOD CK(CPK)-81 ___:38PM BLOOD CK-MB-2 proBNP-237* ___ 09:38PM BLOOD cTropnT-0.02* ___ 03:00AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 03:00AM BLOOD TotProt-6.7 Calcium-9.5 Phos-3.4 Mg-2.0 ___ 03:00AM BLOOD PEP-NO SPECIFI FreeKap-110.0* FreeLam-34.7* Fr K/L-3.17* DISCHARGE LABS: ___ 09:30AM BLOOD WBC-10.5* RBC-3.63* Hgb-10.2* Hct-32.9* MCV-91 MCH-28.1 MCHC-31.0* RDW-13.3 RDWSD-44.5 Plt ___ ___ 07:51AM BLOOD Glucose-91 UreaN-39* Creat-2.4* Na-140 K-5.0 Cl-109* HCO3-17* AnGap-14 ___ 07:51AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.6 PERTINENT IMAGING: CT NECK W/O CONTRAST ___: 1. Lucency around the roots of previously treated ___ 14, with associated left facial cellulitis. No drainable fluid collection. Reactive lymphadenopathy. 2. Mildly enlarged and heterogeneous thyroid gland. No focal nodule identified. 3. Likely dental disease related left maxillary and ethmoid sinus opacification. CHEST XRAY ___: In comparison with the study of ___, there are lower lung volumes. Cardiomediastinal silhouette is stable and there is no vascular congestion, pleural effusion, or acute focal pneumonia. CARDIAC PERFUSION STUDY ___: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. Compared to the prior study of ___, cavity size and systolic function have normalized. CHEST XRAY ___: No acute cardiopulmonary process. Brief Hospital Course: TRANSITIONAL ISSUES ====================== [ ] Discharge weight: 251 lbs [ ] Discharge Creatinine: 2.4 [ ] Restart home lisinopril as Cr returns to baseline and K within normal limits [ ] Consider pyrophosphate scan [ ] Discharged on oral Augmentin [ ] Patient discharged to follow up with OMFS at ___ on ___ for tooth extraction. PATIENT SUMMARY AND HOSPITAL COURSE: ====================================== ___ pmhx of HFpEF (EF 55% ___, HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain and ___ on CKD. # Sepsis secondary to dental abscess/tooth infection: Patient was noted to have worsening L sided maxillary tooth pain with associated facial swelling. Panorex imaging was obtained and evaluated by dental team. Findings showed extensive caries in left upper single molar with concern for acute exacerbation of chronic apical abscess for which she was started on oral penicillin on ___. Later that day, patient spiked a fever to 102.9F with associated rigors, sinus tachycardia to the 130s. She was started on IV vancomycin/ceftazidime/metronidazole that was narrowed to vanc/ceftriaxone/metronidazole later. ID and OMFS were consulted. OMFS recommended extraction for source control at close outpatient follow up in dental clinic. At discharge, patient was narrowed to PO Augmentin DS 875-125mg per ID recs for 10 days. # Chest pain Patient initially admitted to the ___ service for chest pain with several cardiac risk factors (HTN, DM, HLD). Chest pain was substernal, sharp, nonradiating, nonexertional, ___ on admission; chest pain stopped ___ evening. Trop 0.02 on admission, <0.01 subsequently. No ecg changes. Given cardiac risk factors, patient underwent perfusion stress study which showed normal myocardial perfusion. Given aspirin 325mg, then continued on aspirin 81mg daily. Home atorvastatin increased to 80mg QHS. Chest pain resolved spontaneously without intervention. # Chronic HFpEF (EF 55% ___: Patient was admitted with chest pain, felt to be euvolemic to slightly overloaded on exam. On hospital day 1, she received Torsemide 80mg x1 with bump in creatinine. Given her ___ and positive orthostatic hypotension, her diuretics were subsequently held during admission with improvement in creatinine. Of note, home Torsemide was most recently 80mg QAM and 40mg QPM. Given ___ on admission, this was concerning for over-diuresis. Will be discharged on home diuretic dose given improvement in Cr at time of discharge. - Patient continued on home hydralazine, spironolactone, amlodipine, imdur at discharge. Lisinopril held at time of discharge. Discharge weight 251 lbs. Discharge Creatinine 2.4. # Concern for amyloidosis TTE in ___ showed LVH with increased PCWP. Concern for infiltrative process (eg, amyloid). Serum free light chains, SPEP, UPEP negative. Consider pyrophosphate spect as outpatient if suspicion high enough for cardiac amyloidosis. # ___ on CKD (b/l 1.9-2.3): Cr 2.8 on admission. ___ felt likely to be pre-renal secondary to over-diuresis and infection ___ dental abscess. Held home torsemide and gave gentle IVF with improvement. Cr on discharge 2.4. Plan to restart home torsemide on discharge. # HTN Initially held home lisinopril, spironolactone in the setting of ___. Continued home amlodipine, imdur, and hydralazine. Restarted all home meds except lisinopril on discharge. Lisinopril should be restarted as outpatient as Cr improves and K is confirmed within normal limits (K 5.0 on discharge). Patient refused further lab draws prior to discharge. # DMII ## peripheral neuropathy ## retinopathy Continued home long acting 60 HS, home humalog 15 with dinner, and SSI. Also continued home gabapentin. # CODE: Full # CONTACT/HCP: ___ Relationship: Husband Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 100 mg PO BID 7. HydrALAZINE 25 mg PO TID 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 11. Spironolactone 25 mg PO DAILY 12. Torsemide 40 mg PO QPM 13. TraZODone 25 mg PO QHS:PRN insomnia 14. Humalog 15 Units Dinner tresiba 60 Units Bedtime 15. Torsemide 80 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth once a day Disp #*10 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Every 6 hours as needed Disp #*6 Tablet Refills:*0 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO BID 9. HydrALAZINE 25 mg PO TID 10. Humalog 15 Units Dinner Tresiba 60 Units Bedtime 11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 13. Spironolactone 25 mg PO DAILY 14. Torsemide 80 mg PO DAILY 15. Torsemide 40 mg PO QPM 16. TraZODone 25 mg PO QHS:PRN insomnia 17. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until your creatinine improves Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Sepsis due to dental abscess SECONDARY DIAGNOSIS: ====================== Acute on chronic kidney Disease Orthostatic hypotension Chronic Diastolic Heart Failure Chest Pain 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 at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had chest pain and some kidney damage. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You underwent a stress test which showed normal blood flow to your heart. - You had tooth pain due to an infection around your tooth and needed IV antibiotics. - The dentist saw you and you will need an extraction of your tooth. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs in one day. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. - Your discharge weight: 251 lbs. You should use this as your baseline after you leave the hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___

10031687-DS-10

DS

2141-05-02 00:00:00

2141-05-03 13:27:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: R foot swelling/pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with DM2, HTN, HLD, CKD, CAD s/p PCI, and chronic sCHF with acute onset of atraumatic R foot swelling and pain x 1 day. Completely asymptomatic otherwise, denies chest pain, shortness of breath. Not a smoker, no cancer history, ambulates at baseline though he was recently admitted ___ to ___ for EGD/colonoscopy and acute on chronic kidney disease. In the ED, initial vital signs were 99.0 82 122/58 16 98%. LENIs were positive for right lower extremity thrombus extending from the right femoral vein, into the popliteal vein, and into one of the posterior tibial veins. Patient was given heparin and acetaminophen. Transfer vital signs were 97.7 70 167/74 14 100%. On the floor, patient reports reasonable pain control in his foot. Past Medical History: # HTN # DM2 # Hypercholesterolemia # CKD Stage III (baseline creatinine 1.5-1.9) # Hypothyroidism # CAD s/p PCI - LCx stent (___) - Instent restenosis, LCx and OM rotational atherectomy (___) - RCA stent (___) - LHC/RHC (___): Coronary arteries are normal. Mod biventricular diastolic dysfunction. Mod pulmonary hypertension. # chronic sCHF: - Echo (___): EF 50%, mild AI/MR, regional HK basal inferior and inferoseptal hypokinesis - EF ___, LV hypokinesis, MR, AR (___) # mod chronic dCHF (RV and LV) # Pulm HTN: Pulm BP ___ # s/p Dual chamber pacemaker (___) # Appendectomy # Hernia repair # Questionable GIB (unable to find details in chart), s/p normal EGD and colonoscopy ___ # BPH Social History: ___ Family History: -DM II, HTN -No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 145/77, 81, 98% 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, ronchi CV: Regular rhythm, normal S1/S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, trace b/l edema R>L especially in foot, tender to palpation in R foot Skin: no lesions Neuro: A&Ox3, CNs ___ intact, strength and sensation grossly intact Psych: pleasant, appropriate DISCHARGE PHYSICAL EXAM: Vitals: 98.3 - 169/94 - 58 - 16 - 99% ra General: Alert, NAD HEENT: Sclera anicteric, MMM Neck: supple Lungs: CTAB, no w/r/r CV: Regular rhythm, ___ systolic murmur heard throughout precordium Abdomen: soft, non tender, non-distended Ext: Warm, well perfused, no CCE. L thigh very tender to palpation. Apppears minimally swollen, but not erythematous or warm. Femoral pulses and DPs are ___ Neuro: sensation intact bilateral ___ ___ Results: ADMISSION LABS: ___ 03:19PM BLOOD WBC-8.0# RBC-4.48* Hgb-11.5* Hct-34.9* MCV-78* MCH-25.6* MCHC-32.8 RDW-14.3 Plt ___ ___ 03:19PM BLOOD Glucose-226* UreaN-33* Creat-1.9* Na-140 K-3.5 Cl-97 HCO3-29 AnGap-18 ___ 03:19PM BLOOD UricAcd-12.0* ___ 07:40AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9 DISCHARGE LABS: ___ 06:59AM BLOOD WBC-12.9* RBC-3.79* Hgb-10.2* Hct-31.5* MCV-83 MCH-26.9* MCHC-32.3 RDW-15.6* Plt ___ ___ 06:59AM BLOOD Glucose-64* UreaN-25* Creat-1.3* Na-140 K-4.6 Cl-105 HCO3-25 AnGap-15 ___ 06:59AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.4 Joint Fluid ___ 03:05PM JOINT FLUID WBC-73 RBC-20* Polys-31* Lymphs-32 ___ Macro-37 ___ 03:05PM JOINT FLUID Crystal-NONE Culture- No growth to date MICRO: Urine URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 16 I AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING: LENIs ___: Right lower extremity DVT starting in the mid femoral vein, extending into the popliteal vein and into one of the posterior tibial veins. Peroneal veins are not visualized in either leg. There is no DVT in left leg. CT Ab/Pelvis ___ IMPRESSION: Large left-sided retroperitoneal hematoma with blood insinuating throughout the left iliopsoas muscle and anteriorly in the retroperitoneum/left anterior pararenal space to the level of thigh. ABIs FINDINGS: Doppler waveform analysis reveals triphasic waveforms at the common femoral, superficial femoral, popliteal arteries bilaterally and monophasic waveforms at the DP and ___ bilaterally. ABIs are 0.7 bilaterally. Pulse volume recordings show normal waveforms in the thigh and calf bilaterally. There is dampening at the ankle level bilaterally. IMPRESSION: Bilateral tibial arterial disease. CT Lower extremity IMPRESSION: No CT evidence of osteomyelitis. No joint effusion. No enlarged bursal collection in the region of the pes anserine tendons. In the setting of high clinical concern for osteomyelitis, consider bone scan as it is more sensitive. Brief Hospital Course: ___ with DM2, HTN, HLD, CKD, CAD s/p PCI, and chronic sCHF with acute onset of atraumatic R foot swelling and pain x 1 day, found to have RLE DVT. # DVT: appears unprovoked, no risk factors besides recent hospitalization and age. Lovenox contraindicated given CKD. He was started on heparin on ___, and when found to have a stable Hct (given questionable history of GI bleed in the past), he was started on Coumadin 2mg daily on ___. Unfortunately, INR was very resistant, so dose uptitrated all the way to 25 mg with the help of a hematology consult. Alternative anticoagulants were deferred given renal failure. Patient then developed a retroperitoneal bleed (see below), and all anticoagulation was stopped and IVC filter was placed. Per hematology, he would benefit from being started on warfarin again given DVT was unprovoked. This will be discussed as an outpatient. #RP Bleed- patient developed acute groin pain and was light-headed and dizzy while being bridged to warfarin. BPs at the time dropped to ___. CT abdomen/pelvis showed large left retroperitoneal bleed. All anticoagulation was held. He was given a total of 3 units pRBCs and Hct stabilized and patient was asymptomatic. # Oligoarticular Arthritis: Patient developed severe L knee pain shortly after the RP bleed, and also was experiencing bilateral ankle pain. We first ruled out vascular compression from hematoma with ultrasound which was negative for fluid collection. ABIs were obtained which showed bilateral tibial disease but nothing acute. Rheumatology was consulted for concern of gout who tapped the L knee joint which was unremarkable, but thought the clinical likelihood was high given hospital course and high uric acid level. Hence empirically treated him with a steroid course. His pain was persistent on 30 mg steroids, so CT Lower extremity was obtained which showed no evidence of other acute processes. # UTI x 2: reportedly with dark foul-smelling urine on ___ but otherwise asymptomatic. UCx grew pan-sensitive Proteus >100k despite negative UA. Because this may be at least partially responsible for uncontrollable sugars, he was started on cipro 500mg bid x 7 days (___). He was then found to have another + urine culture in the setting of uncontrolled sugars with E.coli. He was treated for a 10 day course of ceftriaxone IV, later transitioned to PO cefpodoxime upon discharge. # DM2: requiring >30U insulin per day for several days while home sitagliptin and glipizide were held. Lantus was started in addition to humalog insulin sliding scale, and his home oral hypoglycemics were restarted. Patient periodically required higher doses of insulin during RP bleed and then was started on prednisone which required ISS and NPH insulin. # CKD with ___. Patient's home diuretic was held which improved creatinine. This was restarted upon discharge at half the preadmission dose of 40 mg (from 80 mg) # HTN: normotensive, was continued on carvedilol, isosorbide, and ramipril. # sCHF: torsemide managed as above # Hypothyroidism: chronic, continued on levothyroxine 25 daily # CAD: chronic, continued on plavix 75 daily # HLD: chronic, continued on pravastatin 40 daily # ? mild dementia: chronic, continued on donepezil 10 qhs # GERD: chronic, continued on ranitidine 300 daily TRANSITIONAL ISSUES: ****Patient was hyperglycemic in the setting of medical issues and steroid burst. Please taper off all insulin after steroid taper ends on ___. He is already on his PO antidiabetics**** # Patient should be taking cefpodoxime THROUGH ___ # Code: Full (discussed with patient) # Contact: daughter ___ and wife ___, ___- # PCP to arrange IVC filter removal in ___ weeks after placement. # Torsemide held for most of admission, restarted on day of discharge at half of preadmission dose for 40 mg (from 80mg) # Patient to discuss risks/benefits of anticoagulation after IVC filter removed. # Pt discharged on prednisone taper for gout # Pt started on ISS and glargine this admission for hyperglycemia associated with steroids. Blood sugars should be followed by PCP and also at rehab Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 25 mg PO BID 2. Donepezil 10 mg PO HS 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Pravastatin 40 mg PO DAILY 6. Ranitidine 300 mg PO HS 7. Ramipril 10 mg PO DAILY 8. Torsemide 80 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. GlipiZIDE 5 mg PO BID 11. Nitroglycerin SL 0.3 mg SL PRN cp 12. sitaGLIPtin *NF* 25 mg Oral daily Discharge Medications: 1. Carvedilol 25 mg PO BID 2. Clopidogrel 75 mg PO DAILY 3. Donepezil 10 mg PO HS 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Ramipril 10 mg PO DAILY 8. Ranitidine 300 mg PO HS 9. Torsemide 40 mg PO DAILY 10. GlipiZIDE 5 mg PO BID 11. sitaGLIPtin *NF* 25 mg Oral daily 12. Nitroglycerin SL 0.3 mg SL PRN cp 13. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth q 12 hrs Disp #*8 Tablet Refills:*0 14. Senna 1 TAB PO BID constipation 15. Humalog 0 Units Bedtime NPH 8 Units Breakfast NPH 0 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 16. PredniSONE 10 mg PO DAILY Take on ___ then stop. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Deep vein thrombosis Gout Retroperitoneal Bleed SECONDARY: diabetes mellitus hypertension hyperlipidemia chronic kidney disease coronary artery disease chronic systolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care at ___. You were diagnosed with a blood clot in your right leg (deep vein thrombosis, or DVT) that was causing your right foot pain. Because this can be very dangerous if untreated, you were treated with blood thinners. Unfortunately, you had some internal bleeding and the blood thinners needed to be stopped. Instead, we placed an IVC (inferior vena cava) filter in you to prevent the clot from moving to your lungs. You also suffered from gout during this admission, for which prednisone was started. We also treated you for a urinary tract infection. Please continue to take the prednisone- you will need to take 1 dose of 10 mg on ___ and then off. Please take cefpodoxime for THROUGH ___ Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___

10031687-DS-11

DS

2141-06-05 00:00:00

2141-06-06 23:42:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: new LLE DVT Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ yo male with a prior h/o HTN, DM2, CAD, CHF, and anemia who was admitted on ___ with acute onset of atraumatic R foot swelling and pain x1 day. He was found to have no evidence of PE, but ___ of RLE demonstrated a thrombus extending from the right femoral vein into the popliteal ___ and into one of the posterior tibial veins. There was no evidence of thrombosis in the LLE. The thrombus was though to be unprovoked. He was initially managed on heparin with intended bridge to coumadin. He began coumadin at 2.5 mg, uptitrated to 10mg x11 days which brought his INR to 1.3. Hematology was consulted for resistant INR and he was uptitrated to 25 mg with the help of hematology. The patient then developed a retroperitoneal bleed for which he required 3 units pRBCs. Anticoagulation was stopped, and a retrievable IVC filter was placed with plans to remove it in ___ weeks. He was discharged to ___ in ___. On ___ he presented to ___ clinic with severe left upper thigh pain. This had been present since his left sided RP bleed, but had not improved and had worsened over the past few days. The pain had been waking him at night. His left knee pain, attributed to gout on his last admission, continues to be very painful. His right leg was feeling better, but on exam he had bilateral edema and fatigue. He denied SOB, chest pain at that time. Hematology was concerned for new thrombosis given that he is at high risk for clot since he was off anticoagulation and placement of IVC filter is inherently prothrombotic event and can instigate severe ___ clotting. Bilateral ___ showed RLE DVT extending from the common femoral vein down to the popliteal vein, and 2 new RLE thrombi, one extending from the proximal superficial femoral vein down to the mid portion of the vein, and a second in the left popliteal vein. The patient was subsequently referred to the ___ ED. Past Medical History: # HTN # DM2 # Hypercholesterolemia # CKD Stage III (baseline creatinine 1.5-1.9) # Hypothyroidism # CAD s/p PCI - LCx stent (___) - Instent restenosis, LCx and OM rotational atherectomy (___) - RCA stent (___) - LHC/RHC (___): Coronary arteries are normal. Mod biventricular diastolic dysfunction. Mod pulmonary hypertension. # chronic sCHF: - Echo (___): EF 50%, mild AI/MR, regional HK basal inferior and inferoseptal hypokinesis - EF ___, LV hypokinesis, MR, AR (___) # mod chronic dCHF (RV and LV) # Pulm HTN: Pulm BP ___ # s/p Dual chamber pacemaker (___) # Appendectomy # Hernia repair # Questionable GIB (unable to find details in chart), s/p normal EGD and colonoscopy ___ # BPH Social History: ___ Family History: -DM II, HTN -No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.8 168/60 65 16 99RA General: pleasant well appearing elderly gentleman lying in bed, interactive, comfortable, no resp distress HEENT: nc/at, sclera anicteric Neck: supple CV: regular rate and rhythm no m/r/g Lungs: clear to ausc bilaterally no crackles no wheezes Abdomen: no tenderness to palp, bowel sounds present GU: deferred Ext: thin, RLE 2+ pitting edema and visibly larger than LLE, tenderness to alpation on anterior and lateral L proximal thigh w/o overlying lesions Neuro: alert, oriented x3 though at first said year ___, speech fluent, linear, appropriate, moving all 4 extremities Skin: no rashes DISCHARGE PHYSICAL EXAM: Vitals: 98.6 140/64 63 20 99RA General: Chronically ill appearing elderly gentleman laying awake in bed. A&Ox3. In NAD HEENT: o/p somewhat dry Neck: Radiation of murmur heard bilaterally Cardiac: III/IV systolic murmur heard diffusely. No rubs or gallops. Consistent with prior cardiology note from ___ clinic. Lungs: CTAB Abd: Soft, NT, ND, no r/g Ext: 2+ pitting edema of the RLE to the mid calf, trace edema of the LLE at the foot. Single flaky non-erythematous, non tender lesion of the left anterior shin. ___ and DP pulses were non-palpable but heard on doppler. Now only slightly stronger on the right. Pertinent Results: ADMISSION LABS: ___ 06:45PM BLOOD WBC-6.5 RBC-3.96* Hgb-10.6* Hct-33.3* MCV-84 MCH-26.9* MCHC-31.9 RDW-15.3 Plt ___ ___ 06:45PM BLOOD Neuts-58.3 ___ Monos-9.5 Eos-2.8 Baso-0.5 ___ 06:45PM BLOOD ___ PTT-30.4 ___ ___ 06:45PM BLOOD Plt ___ ___ 06:45PM BLOOD Glucose-151* UreaN-27* Creat-1.6* Na-142 K-4.0 Cl-101 HCO3-29 AnGap-16 PERTINENT LABS: ___ 08:00AM BLOOD WBC-8.1 RBC-4.40* Hgb-11.7* Hct-36.6* MCV-83 MCH-26.5* MCHC-31.9 RDW-15.3 Plt ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD ___ PTT-34.2 ___ DISCHARGE LABS: ___ 08:00AM BLOOD WBC-8.1 RBC-4.40* Hgb-11.7* Hct-36.6* MCV-83 MCH-26.5* MCHC-31.9 RDW-15.3 Plt ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD Glucose-105* UreaN-24* Creat-1.4* Na-141 K-4.1 Cl-102 HCO3-29 AnGap-14 ___ 08:00AM BLOOD Calcium-9.4 Phos-2.5* Mg-2.1 MICROBIOLOGY: None IMAGING: Bilateral lower extremity venous doppler study (___): IMPRESSION: Bilateral lower extremity DVT. On the right, it extends from the common femoral vein down to the popliteal vein. On the left, the DVT extends from the proximal superficial femoral vein down to the mid portion of the vein. The distal portion of the left superficial femoral vein is patent but echogenic thrombus is noted in the left popliteal vein. These findings were discussed with the nurse ___ Dr. ___ on the phoneat 2 p.m. on ___. Brief Hospital Course: Mr. ___ is a ___ w/ Hx of DM2 c/b CKD stage 3, CAD s/p PCI, CHF, HTN, anemia, and recent diagnosis of RLE DVT (s/p RP bleed on coumadin, IVC filter placement) who presented to ___ clinic on ___ with new ___ pain, found to be new ___ DVT, and was admitted. ACTIVE DIAGNOSES: # New LLE DVT - Risk factors include relative immobility, age, and Hx of DVT on the R. Pt presented with L thigh pain, was found to have new LLE on ___ duplex. Pt remained hemodynamically stable and had no objective findings of PE. - Given that IVC filter had been placed on ___ for RLE DVT and pt had no Si/Sx suggestive of PE, CT chest was not pursued. In addition, this would not have altered management, as patient was already being anticoagulated. - On admission, patient was started on a heparin drip. Given history of RP bleed on Coumadin and Hx of CKD, Rivaroxiban was chosen in consultation with Hematology as a suitable oral anticoagulant for this patient. - He was switched from heparin gtt to rivaroxiban during this admission and tolerated the medication well. - Pt to follow with Dr. ___ in clinic after discharge. Plan is to have filter removed as an outpatient, which will be arranged during ___ f/u appointment with heme (see transitional issues below). - Patient to undergo outpatient work-up for coumadin resistance, follow-up scheduled with Hematology. # CHRONIC DIAGNOSES # Prior RLE DVT - Anticoagulation with Rivaroxiban as above - IVC filter placed on last admission, see transitional issues below # Oligarticular arthritis - Not an active issue during this hospitalization - pt developed L knee pain shortly after RP bleed during last hospitalization. Had extensive w/u that ruled out vascular compression from hematoma. - Rheum tapped knee and felt that gout was most likely etiology despite unrevealing tap. Was treated empirically with steroids, CT demonstrated no other cause. # DM2 - The patient's blood sugar was well-managed with insulin during this admission - During his previous admission, persistent hyperglycemia requiring >30 U insulin per day was an issue ___ pt not being able to continue non-formulary medication (Januvia). - This problem was not significant on this admission; the pts blood sugar was only occasionally as high as low 200s. # CKD - Not an active issue on this hospitalization, stable on home medications # HTN - Not an active issue on this hospitalization, stable on home medications # Congestive heart failure - Not an active issue on this hospitalization, stable on home medications # Hypothyroidism - Not an active issue on this hospitalization, stable on home medications # CAD - Not an active issue on this hospitalization, stable on home medications - Per discussion with cardiology, pt's Plavix was discontinued, as his stents had been placed in the remote past and was no longer indicated, particularly in the setting of Hx of RP bleed. - Started on ASA 81 mg # HL - Not an active issue on this hospitalization, stable on home medications # Mild dementia - Not an active issue on this hospitalization, stable on home medications # GERD - Not an active issue on this hospitalization, stable on home medications TRANSITIONAL ISSUES # Plan for IVC filter removal was discussed with ___ fellow and ___ attending and is as follows: - To be done in outpatient setting. This will be arranged on ___ heme f/u appointment. - He has an Eclipse IVC filter placed ___ per ___ attending who put this in, ___ months is a reasonable timeframe to remove this type of IVC filter. # Medication changes - Plavix was stopped, ASA 81 was started Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 12.5 mg PO BID 2. Clopidogrel 75 mg PO DAILY 3. Donepezil 10 mg PO HS 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Pravastatin 40 mg PO DAILY 6. Ramipril 10 mg PO DAILY 7. Ranitidine 300 mg PO HS 8. Torsemide 80 mg PO DAILY 9. GlipiZIDE 5 mg PO BID 10. sitaGLIPtin *NF* 25 mg Oral daily 11. Senna 1 TAB PO BID constipation 12. Nitroglycerin SL 0.3 mg SL PRN cp 13. Isosorbide Mononitrate (Extended Release) 90 mg PO QHS 14. Terazosin 2 mg PO HS Discharge Medications: 1. Carvedilol 12.5 mg PO BID 2. Donepezil 10 mg PO HS 3. GlipiZIDE 5 mg PO BID 4. Isosorbide Mononitrate (Extended Release) 90 mg PO QHS 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Ramipril 10 mg PO DAILY 8. Ranitidine 300 mg PO HS 9. Senna 1 TAB PO BID constipation 10. Torsemide 80 mg PO DAILY 11. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*90 Tablet Refills:*0 12. Rivaroxaban 15 mg PO DAILY RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 13. Nitroglycerin SL 0.3 mg SL PRN cp 14. sitaGLIPtin *NF* 25 mg Oral daily 15. Terazosin 2 mg PO HS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: - LLE DVT Secondary diagnoses: - preexisting RLE DVT s/p IVC filter - RP bleed on coumadin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was our pleasure caring for you at ___. You were admitted to the hospital because you developed a new blood clot in your left leg. Because you developed a bleeding complication on blood thinners during your previous hospitalization, we treated you with a different blood thinner that is less likely to cause bleeding problems. You tolerated this new blood thinner without any problems and were discharged home. Please weigh yourself every morning, and call your physician if your weight goes up more than 3 lbs in one day. Thank you for allowing us to participate in your care. Followup Instructions: ___

10031687-DS-12

DS

2141-06-15 00:00:00

2141-06-15 11:52:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Mechanical Fall Major Surgical or Invasive Procedure: None History of Present Illness: This patient is a ___ year old male with a prior h/o HTN, DM2, CAD (s/p PCI ___ and ___, CHF (s/p BiV Pacemaker in ___, CKD Stage III (secondary to hypertensive nephrosclerosis), and anemia who presented to the ED s/p a fall. He was recently admitted from ___ for RLE DVT (transitioned from heparin to coumadin and course was c/b RP bleed). He was discharged with an IVC filter off anticoagulation. He was admitted again from ___ for LLE DVT and he was started on rivaroxiban. He now presents after having sustained a fall at home. Per the patient, he "slid" down last night and spent the evening trying to get off the ground back into his chair. He lives at home with his wife and daughter but said he did not want to ask them for help. He ultimately was able to get himself back into his chair after considerable effort. In the ED, his VS were 98.4 62 135/53 16 97% ra. He was evaluated for fall with negative NCHCT, and pelvic/c-spine XR. His CXR and UA were normal. His labs were significant for acute on chronic renal insufficiency with a Cr of 2 (baseline Cr 1.3). On the floor, the patient complained of left knee and thigh pain, which he says was evaluated in previous admissions and was found NOT to be gout. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. 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: # Bilateral ___ DVTs (___) - RB bleed on Coumadin. On Rivaroxiban. S/P IVC Filter. # HTN # DM2 # Hypercholesterolemia # CKD Stage III (baseline creatinine 1.5-1.9) - secondary to HTN # Hypothyroidism # CAD s/p PCI - LCx stent (___) - Instent restenosis, LCx and OM rotational atherectomy (___) - RCA stent (___) - RHC (___): Coronary arteries are normal. Mod biventricular diastolic dysfunction. Mod pulmonary hypertension. # chronic sCHF (s/p BiV Pacemaker in ___: - Echo (___): EF 50%, mild AR/MR, moderate TR, regional HK basal inferior and inferoseptal hypokinesis # mod chronic dCHF (RV and LV) per ___ cath # Pulm HTN: Pulm BP ___ # Appendectomy # Hernia repair # Questionable GIB (unable to find details in chart), s/p normal EGD and colonoscopy ___ # BPH Social History: ___ Family History: -DM II, HTN -No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.8, 154/72, 68, 18, 98% General: NAD, lying comfortably in bed HEENT: dry mucous membranes, EOMI Neck: JVP non-elevated CV: Pacemaker pocket c/d/i. RRR. ___ LLSB systolic murmer, ___ holosystolic murmur at apex radiating to axilla Lungs: CTAB Abdomen: soft, nt, nd Ext: mild erythema and warmth over medial aspect of left knee. no palpable effusion. TTP over that area and also over posterolateral left thigh. no palpable cord decreased ROM in left knee. DISCHARGE PHYSICAL EXAM: Vitals: 98.1 HR 77 BP 146/72 R 18 97% on RA General: NAD, lying comfortably in bed HEENT: MMM, EOMI Neck: JVP non-elevated CV: Pacemaker pocket c/d/i. RRR. ___ LLSB systolic murmer, ___ holosystolic murmur at apex radiating to axilla Lungs: CTAB Abdomen: soft, nt, nd Ext: left knee without erythema or tenderness. no palpable effusion. Improved ROM. Pertinent Results: Admission Labs: ___ 01:10PM GLUCOSE-259* UREA N-41* CREAT-2.0* SODIUM-143 POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-29 ANION GAP-25* ___ 01:10PM WBC-10.2 RBC-4.23* HGB-11.0* HCT-34.2* MCV-81* MCH-26.0* MCHC-32.1 RDW-14.6 ___ 01:10PM NEUTS-65 BANDS-0 ___ MONOS-11 EOS-1 BASOS-1 ___ MYELOS-0 ___ 01:10PM PLT SMR-NORMAL PLT COUNT-176 ___ 01:10PM CK(CPK)-226 Discharge Labs: ___ 05:45AM BLOOD WBC-8.4 RBC-3.81* Hgb-10.1* Hct-30.9* MCV-81* MCH-26.5* MCHC-32.7 RDW-14.5 Plt ___ ___ 05:45AM BLOOD Plt ___ ___ 05:45AM BLOOD Glucose-159* UreaN-26* Creat-1.6* Na-139 K-4.2 Cl-99 HCO3-32 AnGap-12 ___ 05:45AM BLOOD CRP-73.4* ___ 05:45AM BLOOD ESR-58* ___ 05:45AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9 UricAcd-13.3* LEFT KNEE RADIOGRAPHS, THREE VIEWS: There is no fracture or malalignment. Mild narrowing of the medial compartment is similar to prior examination. Small osteophytes along the superior aspect of the patella are unchanged. Dense vascular calcifications are noted. No joint effusion is seen on the cross-table lateral view. IMPRESSION: Mild degenerative changes without acute traumatic injury. CT C-SPINE: 1. No evidence of fracture or traumatic malalignment. 2. Finding suggesting paralysis of the left vocal cord, correlate with symptoms or direct visualization. 3. Heterogeneous left lobe of thyroid with 4 mm nodule for which a nonurgent ultrasound evaluation could be performed if clinically indicated. LENIs: Bilateral lower extremity DVT with minimal improvement since the prior study. 1. On the right the thrombus extends from the proximal superficial femoral vein down to popliteal vein, slightly improved on the prior exam when thrombus was also seen in the common femoral vein. 2. On the left, the thrombus extends from the distal superficial femoral vein into the popliteal vein. The previously seen thrombus within the proximal and mid superficial femoral vein is not visualized. Brief Hospital Course: This patient is a ___ year old male with a prior h/o HTN, DM2, CAD (s/p PCI), CHF (BiV pacing, EF 50%), B/L ___ DVT (on rivaroxiban), Stage III CKD who presented to the ED s/p a fall with left knee and thigh pain. On admission, his vital signs were stable and his exam was benign. His labs were significant for acute on chronic renal insufficiency with a Cr of 2 (baseline Cr 1.3). ACTIVE DIAGNOSES: #Mechanical Fall - The patient denies having "fell" but instead reports that he "slid" down to the ground, never losing consciousness, nor injuring any part of his body. His physical exam was benign, except for chronic L knee and thigh pain. Knee radiagraphs were obtained and were negative for acute fracture. Imaging was significant for a negative NCHCT and negative pelvic/c-spine XR. ___ evaluated the patient and felt that he presented below his baseline and required mod/max assist for sit<>stand transfers and contact guard assist for all mobility and would benefit from rehab following discharge. #Acute on Chronic Kidney Injury - Admission labs significant for Cr 2 (baseline 1.3) His physical exam was consistent with dehydration. Given his fall, we checked a CK, which was normal to rule out rhabdo. We held Ramipril and Torsemide and treaded him with gentle IVF. He responded well and we restarted his medication at discharge. #Left knee and thigh pain - This patient reported tenderness on the medial aspect of his left knee, which is apparently consistent with prior admissions (see ___ discharge summary, when he had a negative Rheum work-up for Gout). It is not entirely clear what is causing this pain as prior aspiration was negative for cyrstals, though rheum still felt it was most consistent with gout last admission. We decided to empirically institute another short course of steroids, and his knee pain seemed to improve (though it was always quite mild). Notably, his labs on this admission were significant for elevations in Uric Acid (13.3), CRP (73) and ESR (58). Given his kidney function, we did not treat with NSAIDS, but instead used Acetaminophen, a Lidoderm Patch, and Prednisone 30 mg daily x 2 doses which provided relief. He is discharged to take 20 mg for 2 days, 10 mg for 1 day, and 5 mg for 2 days of Prednisone. More concerning to him was his thigh pain, which extended from his inguinal area down the lateral aspect of his thigh. On review of his CT from ___, it seems very likely that this pain is sciatica from compression of the nerve by a very large RP hematoma, clearly demonstrated on CT in ___. We reassured him that this pain should improve with time. #DM2/Hyperglycemia - Pt had a fingerstick in mid ___ while after being treated with steroids. Treated with ISS. Restarted on Home DM meds (Glipizide, Sitagliptin) at discharge with an ISS to be used while he he continues a steroid taper. CHRONIC DIAGNOSES #Bilateral DVTs s/p IVC filter (___) - ___ with RLE DVT in ___ and was started on Coumadin complicated by an RP bleed so an IVC filter was placed and he was discharged off anticoagulation. Readmitted in ___ with LLE DVT so patient was started on Rivaroxiban. On this admission, LENIs were repeated which demonstrated slight improvement in both ___ DVTs. Rivaroxaban was continued. #CHF (systolic and diastolic, EF 50% in ___, mild AI/MR, moderate TR, s/p BiV Pacemaker in ___ - We initially held Ramipril and Torsemide in setting of acute on chronic kidney injury. These were restarted at discharge. We continued the patient's Carvedilol and Isordil for HTN. #CAD - s/p PCI in ___ and ___ Not an active issue on this admission. Continued patient on Aspirin #HL Not an active issue on this admission. Continued patient on home dose of Pravastatin #Hypothyroidism Not an active issue on this admission. Continued on levothyroxine. #Dementia Not an active issue on this admission. Continued on Donepezil #GERD Not an active issue on this admission. Continued on Ranitidine #Constipation Not an active issue on this admission. Continued on Senna #BPH Not an active issue on this admission. Continued on Terazosin TRANSITIONAL ISSUES # Plan for IVC filter removal as follows: - To be done in outpatient setting. This will be arranged on ___ heme f/u appointment. - He has an Eclipse IVC filter placed ___ per ___ attending who put this in, ___ months is a reasonable timeframe to remove this type of IVC filter. # Medication changes - Isosorbide Mononitrate decreased back to 60 mg QHS - Started Acetaminophen 650 mg TID and Lidoderm Patch - Prednisone taper 20 mg for 2 days, 10 mg for 1 day, 5 mg for 2 days - Use Insulin Sliding Scale while patient takes steroid Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 12.5 mg PO BID 2. Donepezil 10 mg PO HS 3. GlipiZIDE 5 mg PO BID 4. Isosorbide Mononitrate (Extended Release) 90 mg PO QHS 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Ramipril 10 mg PO DAILY 8. Ranitidine 300 mg PO HS 9. Senna 1 TAB PO BID constipation 10. Torsemide 80 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Rivaroxaban 15 mg PO DAILY 13. Nitroglycerin SL 0.3 mg SL PRN cp 14. sitaGLIPtin *NF* 25 mg Oral daily 15. Terazosin 2 mg PO HS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Donepezil 10 mg PO HS 4. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Pravastatin 40 mg PO DAILY 7. Ramipril 10 mg PO DAILY 8. Ranitidine 300 mg PO HS 9. Rivaroxaban 15 mg PO DAILY 10. Senna 1 TAB PO BID constipation 11. Terazosin 2 mg PO HS 12. Torsemide 80 mg PO DAILY 13. GlipiZIDE 5 mg PO BID 14. Nitroglycerin SL 0.3 mg SL PRN cp 15. sitaGLIPtin *NF* 25 mg Oral daily 16. Acetaminophen 650 mg PO TID 17. Lidocaine 5% Patch 1 PTCH TD DAILY pain apply 12 hours on and 12 hours off Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute on Chronic Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair. Discharge Instructions: You came to the hospital because you had slipped and had trouble getting up on your own due to pain. We evaluated you for fracture but there was no evidence of this on your x-rays. You were having left leg pain, which we treated with pain medication. We believe you are having pain related to a prior bleed in your abdomen when you were taking Coumadin in ___. You were also admitted because of abnormal kidney function. We temporarily stopped your medications that can affect your kidney function (Ramipril and Torsemide). We treated you with fluids and your kidney function improved. You are being discharged to an extended care facility for rehab. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___

10031850-DS-15

DS

2137-03-14 00:00:00

2137-03-14 16:06:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Buttock/Perineal Pain Major Surgical or Invasive Procedure: ___: Exam under anesthesia, incision and drainage of horseshoe supralevator abscess, ___ placement of posterior anal fistula. ___: Exam under anesthesia, perineal debridement, placement of drains, flexible sigmoidoscopy to 30 cm. ___: Laparoscopic sigmoid colectomy with end colostomy ___ procedure) and perineal debridement. History of Present Illness: ___ presents from her rehab facility with leukocytosis and a complaint of intermittent buttock and perineal pain. Her daughter believes her symptoms of pain began ___ days ago. She has waxing and waning mental status and endorses no other clear symptoms. REctal exam was quaiac positive, with gross purulence, fluctuance. Opening to left of anal verge with active extravasation of frank pus. Perianal and perineal induration and moderate erythema. CT showed Bilateral large subcutaneous air-fluid collections concerning for abscesses. Past Medical History: -Large right frontal and left mesial temporal masses, likely meningiomas. Has been seen by Dr. ___ recommended surgical resection but patient refused -HTN -HLD -___ -s/p CCY -thyroid disease Social History: ___ FAMILY HISTORY: no history of seizures or strokes Family History: No known family history of brain tumors or thyroid problems Physical Exam: Exam at Discharge: Elderly female patient, ___ speaking (limited ___, refusing to get out of bed today, lying in bed, gas in ostomy appliance, foley catheter with clear yellow urine, pain controlled AFVSS Neuro: Waxing and Waning mental status, alert to self, deemed incompetent by psych CV: RRR Pulm: no issues Abd: obese, lap sites well healed and closed with dermabond, colostomy pink Rectal area wound: large surgical wound over left and right gluteal area deeper and up to labia on the right side with setons, red granulating tissues with yellow slough Ext: No edema Pertinent Results: ___ 05:40AM BLOOD WBC-14.7* RBC-3.31* Hgb-9.8* Hct-29.6* MCV-90 MCH-29.7 MCHC-33.1 RDW-16.2* Plt ___ ___ 06:45AM BLOOD WBC-16.0* RBC-3.16* Hgb-9.3* Hct-27.8* MCV-88 MCH-29.5 MCHC-33.5 RDW-16.2* Plt ___ ___ 07:00AM BLOOD WBC-18.7* RBC-3.32*# Hgb-9.7*# Hct-29.7* MCV-90 MCH-29.3 MCHC-32.8 RDW-15.9* Plt ___ ___ 07:10AM BLOOD WBC-17.9* RBC-2.37* Hgb-7.0* Hct-21.0* MCV-89 MCH-29.4 MCHC-33.2 RDW-15.5 Plt ___ ___ 04:20AM BLOOD WBC-20.0* RBC-2.53* Hgb-7.3* Hct-22.2* MCV-88 MCH-28.7 MCHC-32.7 RDW-15.6* Plt ___ ___ 05:32AM BLOOD WBC-21.6* RBC-2.51* Hgb-7.3* Hct-22.5* MCV-90 MCH-28.9 MCHC-32.3 RDW-14.4 Plt ___ ___ 05:34AM BLOOD WBC-25.9* RBC-2.75* Hgb-8.0* Hct-24.5* MCV-89 MCH-29.3 MCHC-32.8 RDW-14.8 Plt ___ ___ 02:20PM BLOOD WBC-28.7*# RBC-3.39* Hgb-9.9* Hct-29.7* MCV-88# MCH-29.4 MCHC-33.4 RDW-14.4 Plt ___ ___ 05:40AM BLOOD Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:10AM BLOOD Plt ___ ___ 07:10AM BLOOD ___ ___ 04:20AM BLOOD ___ ___ 05:32AM BLOOD ___ ___ 05:34AM BLOOD ___ PTT-28.6 ___ ___ 05:50PM BLOOD ___ PTT-34.2 ___ ___ 04:40AM BLOOD Glucose-167* UreaN-20 Creat-0.8 Na-134 K-5.5* Cl-101 HCO3-24 AnGap-15 ___ 03:53AM BLOOD Glucose-147* UreaN-14 Creat-0.7 Na-135 K-4.0 Cl-100 HCO3-24 AnGap-15 ___ 06:50AM BLOOD Glucose-173* UreaN-17 Creat-0.7 Na-132* K-5.0 Cl-98 HCO3-24 AnGap-15 ___ 04:11AM BLOOD Glucose-193* UreaN-29* Creat-0.9 Na-135 K-5.4* Cl-102 HCO3-23 AnGap-15 ___ 04:37AM BLOOD Glucose-173* UreaN-29* Creat-0.8 Na-133 K-4.2 Cl-99 HCO3-24 AnGap-14 ___ 04:26AM BLOOD Glucose-136* UreaN-29* Creat-0.8 Na-133 K-5.5* Cl-100 HCO3-21* AnGap-18 ___ 04:45AM BLOOD Glucose-172* UreaN-31* Creat-0.7 Na-132* K-4.8 Cl-101 HCO3-24 AnGap-12 ___ 04:30AM BLOOD Glucose-183* UreaN-28* Creat-0.7 Na-131* K-4.6 Cl-101 HCO3-24 AnGap-11 ___ 06:15AM BLOOD Glucose-131* UreaN-18 Creat-0.8 Na-132* K-4.7 Cl-101 HCO3-25 AnGap-11 ___ 04:01AM BLOOD Glucose-121* UreaN-22* Creat-0.6 Na-135 K-3.7 Cl-102 HCO3-25 AnGap-12 ___ 03:45AM BLOOD Glucose-192* UreaN-23* Creat-0.6 Na-134 K-3.6 Cl-102 HCO3-25 AnGap-11 ___ 05:00AM BLOOD Glucose-178* UreaN-16 Creat-0.6 Na-135 K-3.4 Cl-102 HCO3-26 AnGap-10 ___ 04:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.5* ___ 03:53AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.6 ___ 06:50AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.4* ___ 04:11AM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.9 Mg-1.8 ___ 04:37AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.9 ___ 04:26AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9 ___ 04:45AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 ___ 04:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 ___ 06:15AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.8 ___ 04:01AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6 ___ 07:10AM BLOOD TSH-6.4* ___ 07:00AM BLOOD Vanco-11.7 CT ABD & PELVIS WITH CONTRAST Study Date of ___ 3:33 ___ IMPRESSION: 1. Bilateral perianal fistulas with large bilateral ischioanal fossa abscesses and marked subcutaneous gas extending into the perineal soft tissues and into the left gluteus, new from ___. Clinical correlation is recommended as findings are concerning for Fournier's gangrene. 2. No acute intra-abdominal process. 3. Intraluminal aortic thrombus with approximately 50% focal stenosis, unchanged from the prior study. 4. Sigmoid enhancing lesion is concerning for a neoplasm, unchanged from ___. Recommend correlation with colonoscopy. 5. 7mm left lower lobe pulmonary nodule. If there is no prior CT already documenting long term stability, recommend follow up CT in 6 months from the ___ study if pt has no risk factors for malignancy. If pt has risk factors, follow up in 3 months from the ___ study is recommended. Brief Hospital Course: The patient was admitted to the Acute Care Surgery Service from the Emergency department with a large perirectal abscess which extended from the perirectal area to the labia. The ___ white blood cell count was 28.7 and she had significant pain. Given the appearance of the abscess on CT scan, including the large amount of air seen in the subcutaneous tissues, the patient was taken to the operating room with Dr. ___ on ___. The abscess was drained, ___ drain and setons were placed, the wound was packed and the patient was given intravenous antibiotics (Please see operative note for further detail). The patient was transferred to the ___ inpatient service. Antibotic therapy was continued on the inpatient unit. The patient frequently refused intravenous narcotic pain medications from the nursing staff. However, the patient appeared to be in significant pain and would cry out with repositioning. On ___, the Colorectal Surgery Service was notified of the patient and consulted. Dr. ___ the patient the following morning and accepted the patient to the inpatient Colorectal Surgery Team. Dr. ___ extensively to the ___ family on the phone regarding the possible need for a diverting colostomy to give the patient a chance to heal the wound and the ___ serious condition. The patients mental status waxes and wanes at baseline. Antibiotic coverage was broadened to Vancomycin and Zosyn. She was taken to the operating room for exam under anesthesia, debridement, and dressing change on ___. The wound was irrigated, two Malecot drains were placed, and the wound was packed (Please see operative note for details). Drainage from the wound was sent for culture. The patient tolerated this well. Antibiotics were continued throughout this time and the ___ WBC had come down to 21 on the morning of hospital day four. The ___ family again were counseled on the surgical option of diverting colostomy. On ___, the patient was brought for a laparoscopic sigmoid colectomy with end colostomy ___ procedure) and perineal debridement. This was tolerated without complication (please see operative report for further details). ___ Malecot drains which required flushing were placed in the operating room and the wound required extensive gauze packing. Psychiatry was asked to evaluate the patient for competency on ___ and deemed the patient competent to make her own decisions. Throughout the weeks following, the patient intermittently accepted medications by mouth, pain medications, and fluids/nutrition by mouth. She removed the Malecot drains from the wound on her own and repeatedly removed the colostomy appliance. She was not cooperative with care. The patient was educated by the nursing staff with use of the ___ Interpreter as well as surgical attending who speaks ___. The antibiotic therapy was narrows to Zosyn only. On ___ psychiatry returned to evaluate the ___ competency and at this time, deemed her incompetent. The lack of patient cooperation was very concerning to the nursing and surgical team as the patient had an large wound and without antibiotic therapy and nutrition the wound would certainly get infected and this could be devastating for the patient. A family meeting was organized and the ___ situation was explained to the daughter and son-in-law. With psychiatry and social work input, the family decided to pursue guardianship in order to consent for additional surgical , placement in a rehabilitation facility and also if code status was to be addressed. Because of stress in the home related to the daughters children, it was decided with the help of the ___ legal team that guardianship would be pursued for the daughter by the ___ legal team to expedite the process as the patient required a G-Tube for enteral feedings. While guardianship was being pursued a PICC line was placed at the bedside and TPN was initiated. She continued to intermittently refuse medications and other nursing care. The wound was irrigated twice daily and the dressings were changed to to best of the nursing and surgical staff's ability. Zosyn was continued until ___ when after careful discussion, it was decided that the patient had completed her course of treatment. A PICC line was placed on ___ for TPN. Patient pulled on the PICC line on ___ and thus a CXR was ordered to evaluate the position of the line. The PICC line was replaced however it was discontinued prior to discharge to the rehabilitation facility. Restraints for the ___ left arm were required as the patient continued to pull at her PICC line and ostomy bag in a chronic but non-agitated confusional state. Restraints were minimized for the ___ comfort. The patient continued on TPN and increased PO intake was encouraged over the coming week while the patient awaited legal guardianship. She was able to increasingly take PO and strict calorie counts were taken to assess her need for continued TPN. After careful discussion with nutrition, Dr. ___ the ___ family TPN was discontinued and the patient intermittently took food. Because of the increase in PO intake a feeding tube was not placed and the TPN was discontinued. The ___ home diabetes medications were not continued as the patient did not have reliable PO intake. The patient was given subcutaneous insulin. On the afternoon of ___ the Colorectal Surgery team was notified that guardianship was awarded to the ___ daughter and that a rehabilitation hospital had agreed to accept the patient. She was discharged with wound care orders as appropriate. Dr. ___ writer, the surgical team, social work, case management, and nursing met with the ___ family multiple times throughout this admission. The Foley catheter was left in place for discharge, however, a voiding trial can be attempted at the rehabilitation facility. Medications on Admission: Actos 15 mg daily Colace 50 mg twice a day Tricor 48 mg tablet Tylenol ___ mg tablet levothyroxine 150 mcg daily metformin 1,000 mg twice a day omeprazole 40 mg daily Flagyl 500 mg Twice Daily Levaquin 500 mg Daily Glipizide 5 mg Twice Daily Discharge Medications: 1. Acetaminophen 1000 mg PO TID do not give more than 3000mg of tylenol daily 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC TID 4. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. OxycoDONE Liquid 2.5-5 mg PO Q4H:PRN pain 8. Tricor *NF* (fenofibrate nanocrystallized) 48 mg Oral daily Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Fournier's Gangrene/Extensive horseshoe perirectal abscess Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to ___ with a large horseshoe abscess of the perirectal area requiring extensive debridement and placement of drains. A diversion of your colon and a colostomy was performed in order to help your gangrenous abscess heal. You were given antibiotics and daily dressing changes to the affected area were performed. The dressings will continue to be changed by the nursing staff at the rehabilitation facility. You had decreased drive and ability to take oral food. You recieved TPN for a time, and as your tolerance of food increased this was stopped. It is important you continue to eat healthy foods and stay as hydrated as possible. Please continue to care for the colostomy as instructed by the nursing team. Followup Instructions: ___

10032176-DS-14

DS

2133-08-17 00:00:00

2133-08-19 19:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Depakote / lisinopril / Topamax / Ultram / hydrochlorothiazide Attending: ___. Chief Complaint: Dyspnea, cough, headache, diarrhea Major Surgical or Invasive Procedure: Colonoscopy and EGD History of Present Illness: ___ year old lady with history of HTN, COPD, IDDM, hypothyroidism, DVT who presented with diarrhea, SOB, and headache x ___ days, found to have severe Hyponatremia. Patient presented for routine PCP check up today, but was complaining of shortness of breath, diarrhea, pounding headache, and ___ edema R>L x 10 days. She reported tan watery diarrhea, ___ episodes/ day, not associated with abdominal pain, nausea or vomiting. She has not had any recent travel or dietary/water source changes. Lives in senior housing so she thinks that maybe half of her apartment complex has diarrhea at baseline. Her appetite had been poor, and additionally reported minimal fluid intake; she has continued to take HCTZ. She endorses lightheadedness for the last several days. In addition, she notes cough ongoing for weeks, non productive, no fevers, no chills. She reports dyspnea with difficulty lying flat due to shortness of breath, also with progressive ___ edema over the last week and half with RLE>LLE. She does have history of DVT many years ago in setting of a "tumor removal" from her leg. Initial vitals at PCP office BP 102/58, Pulse 80, Temp 98.1 °F (36.7 °C), Resp 18, SpO2 97%, and was sent to ___ for further evaluation. At ___, she was noted to have SpO2 90% on RA, no focal neurological deficits on exam, but 2+ ___ edema. Evaluation there remarkable for: Na 115, K 5.4, BUN/Cr ___, LFTS WNL, BNP 522, TSH 4.2 (upper limit of normal), random cortisol 13.9, negative influenza A/B. CTH and CXR WNL (no reports available for review). In the ED, initial vitals were: 97.7 HR 60 BP 182/80 SpO2 99% 2L NC - Exam notable for: "Clinically dry, no crackles on exam, bilateral ___ edema" - Labs notable for: WBC 6.5 Hgb 9.6 Plt 181 114| 80 | 13 ------------- 4.8 | 22 | 0.7 Lactate 1.0 Serum osm 240 Uosm 427 Na 89 Cr 52 Pr/Cr 1.0 U/A >182 WBC, 4 RBC, few bacteria Epi 1 - Imaging was notable for: No new imaging obtained - Patient was given: 250 mL NS bolus Review of systems was negative except as detailed above. Past Medical History: Seizure disorder Hypertension COPD IDDM GERD Hyperlipidemia History of DVT Social History: ___ Family History: Noncontributory Physical Exam: PHYSICAL EXAM ON ADMISSION: GENERAL: Pleasant elderly lady breathing comfortably in no acute distress HEENT: MMM, no JVD at 90 degrees CARDIAC: Normal rate, regular rhythm, no m/r/g appreciated PULMONARY: Diffuse expiratory wheezes throughout all lung fields ABDOMEN: Soft, nontender, distended/obese, no fluid wave apprecaited EXTREMITIES: 2+ tight edema in bilateral ___, RLE>LLE; cap refill >2s SKIN: No rashes appreciated NEURO: AO x 4, moves all 4 extremities symmetrically and with purpose DISCHARGE EXAM: General: Laying down in bed, alert and conversive HEENT: Moist mucous membranes. No pharyngeal exudates or erythema. Lungs: Low lung volumes with minimal air movements. Clear to auscultation bilaterally. CV: Normal rate, regular rhythm, no m/r/g appreciated ABDOMEN: Abdomen soft, nontender, nondistended Ext: No bilateral edema appreciated in lower extremities Neuro: A&Ox3 Pertinent Results: ___ LABS: ============== ___ 08:57PM BLOOD WBC-6.5 RBC-3.73* Hgb-9.6* Hct-27.7* MCV-74* MCH-25.7* MCHC-34.7 RDW-15.9* RDWSD-42.7 Plt ___ ___ 08:57PM BLOOD Neuts-62.2 ___ Monos-8.8 Eos-1.4 Baso-0.2 Im ___ AbsNeut-4.05 AbsLymp-1.73 AbsMono-0.57 AbsEos-0.09 AbsBaso-0.01 ___ 08:57PM BLOOD Plt ___ ___ 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114* K-4.8 Cl-80* HCO3-22 AnGap-12 ___ 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114* K-4.8 Cl-80* HCO3-22 AnGap-12 ___ 08:57PM BLOOD cTropnT-<0.01 ___ 08:57PM BLOOD proBNP-525* ___ 08:57PM BLOOD TotProt-6.9 Calcium-9.4 Phos-3.7 Mg-1.5* ___ 09:01PM BLOOD Lactate-1.0 Na-114* DISCHARGE LABS: ___ 04:20AM BLOOD WBC-7.5 RBC-3.61* Hgb-9.0* Hct-29.3* MCV-81* MCH-24.9* MCHC-30.7* RDW-18.0* RDWSD-51.2* Plt ___ ___ 04:20AM BLOOD Plt ___ ___ 04:20AM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-141 K-3.8 Cl-98 HCO3-29 AnGap-14 ___ 04:20AM BLOOD Calcium-9.3 Phos-4.9* Mg-1.9 ___ 04:20AM BLOOD IgA-122 ___ 04:20AM BLOOD tTG-IgA-PND STUDIES: ========= BILAT LOWER EXT VEINS PORT Study Date of ___ No evidence of deep venous thrombosis in the right or left lower extremity veins. Subcutaneous edema is noted in the calves bilaterally. TTE ___ Mild symmetric biventricular hypertrophy with normal left ventricular cavity size and regional/global biventricular systolic function. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Moderate pulmonary artery systolic hypertension with elevated right atrial pressure. EGD ___ Normal mucosa in the whole esophagus Esophageal hiatal hernia Erosions in the antrum (biopsy) Normal mucosa in the whole examined duodenum Colonoscopy ___ Normal mucosa in the whole colon (random biopsies) Polyp (4mm) in the descending colon (polypectomy) Diverticulosis of the whole colon Recommend repeat colonoscopy in ___ years Brief Hospital Course: Ms. ___ is a ___ with history of HTN, COPD, IDDM, hypothyroidism, DVT who originally presented with diarrhea, SOB, and headache x ___ days, found to have severe hypervolemic hyponatremia that improved with diuresis and discontinuation of her hydrochlorathiazide. She was found to have iron deficiency anemia and dysphagia for which she underwent EGD and colonoscopy without pertinent findings. ACTIVE ISSUES ======================= #Hypotonic, Hypervolemic Hyponatremia Admitted with severe hyponatremia to 111. Etiology was mostly hypervolemia due to diastolic heart failure exacerbation and HCTZ use. We d/c'd HCTZ and placed a fluid restriction and initiated pharmacologic diuresis with loop diuretics until the patient was euvolemic. Patient originally had symptomatic headaches, confusion, and shortness of breath; these all improved with diuresis. Renal was consulted and made recommendations about an outpatient diuretic regimen with torsemide 10 mg PO QD. The patient's Na normalized to 141 by discharge and she was asymptomatic. #Heart failure with preserved ejection fraction Patient originally presented with severe bilateral lower extremity edema, orthopnea, shortness of breath, and severely elevated BNP. LENIs were negative. Responded well to diuresis as above. Was euvolemic at discharge. Discharge weight: 110.4 kg. Discharge Cr: 0.8. #Anemia Hgb remained consistently low with microcytic pattern during admission. Ferritin was low-normal and TIBC was high-normal. Patient also described ongoing weight loss and change in stool patterns (alternating diarrhea/constipation + worm-like stools). Last colonoscopy in ___ included removal of 17 polyps and recommendation for follow-up colonoscopy in ___ year, which patient did not get. She received both a colonoscopy and an EGD as an inpatient. Had one colonic polyp removed and random biopsies sent. EGD was notable for mild gastritis with antral erosions (no stricture). #Change in stool habits Patient reported 10 days of watery diarrhea prior to admission. She also described change in stool formation ("worm/pebble-like"). Diarrhea was likely viral gastroenteritis given time course. C diff was negative. After admission patient was constipated for 1 week. This resolved with a bowel prep that was done in preparation of an inpatient colonoscopy to evaluate for iron deficiency anemia (see above). IgA levels and transglutaminase antibodies were sent, both negative. #Dysphagia Patient complained of discomfort while swallowing during admission. Was evaluated by speech and swallow who found no oropharyngeal pathology. EGD showed mild gastritis, no evidence of esophageal stricture. #Klebsiella UTI Patient had UA concerning for infection upon admission, speciated to Klebsiella. Was treated with ceftriaxone x 3 days with good result. Subsequently denied urinary discomfort. #Vulvovaginal candidiasis #Urinary retention Patient had vaginal discharge and inner groin rash consistent with candidiasis. Responded very well to PO fluconazole and miconazole powder. Pt originally had Foley upon admission which was discontinued. Pt had one day of urinary retention which later resolved. Likely was due to UTI / prolonged Foley placement. # Hypoxia/dyspnea Patient had acute on chronic dyspnea during hospitalization. Has 40 pack year smoking history and COPD. Generally felt with activity. CXR without evidence of pulmonary edema, pneumonia, or pleural effusion. LENIs negative as above. Patient's oxygenation improved with 2L NC, later weaned to RA. She was also given standing Duonebs. #Hyperglycemia Patient was managed on an insulin sliding scale. PO anti-hyperglycemics were held. #Sore throat Patient complained of sore throat that was managed with throat lozenges and chloraseptic spray with good response. Likely a viral pharyngitis. No erythema or exudates on exam. #Hypomagensia Patient had hypomagnesmia upon admission that normalized with administration of MgSO4. CHRONIC ISSUES ======================== # History of seizures: Continued home keppra # Hypertension: Home losartan was increased from 25 to 50 mg PO QD. Eventually may benefit from increasing home losartan to 100 mg but holding off currently i/s/o ongoing diuresis; continue metoprolol # Hyperlipidemia: Continued home pravastatin. # Diabetes: Received insulin SSI while in house. # Hypothyroidism: Continued home levothyroxine 175 mcg. Transitional issues [ ] HFpEF: patient to be discharged on PO torsemide 10 mg QD as maintenance diuretic. Please adjust PRN to maintain weight and euvolemic status. Discharge dry weight 110.4 kg. Discharge Cr 0.8. [ ] GI biopsies: F/u on pathology from colonoscopy random biopsies and polypectomy. F/u on EGD biopsy pathology of antral erosions. [ ] Mild gastritis: counsel patient to avoid NSAIDS given hx of microcytic anemia and gastritis on EGD [ ] Weight loss, poor appetite: patient should receive age-appropriate cancer screening and PHQ-9 screening as outpatient for follow-up for poor appetite and weight loss. Patient endorsed weakness, confusion, poor appetite for several weeks prior to admission. ? if this was due to low sodium that had been present for some time. She denied symptoms of depression. [ ] Patient noted to have iron deficiency anemia throughout hospitalization. Colonoscopy and EGD revealed one polyp and mild gastritis. Pt should have follow up for ongoing anemia with monitoring of symptoms. Greater than ___ hour spent on care on day of discharge. #CODE STATUS: Full, limited trial #CONTACT: Son ___ ___ Pt's son ___, is alternate: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Ibuprofen 800 mg PO Q12H:PRN Pain - Mild 3. Levothyroxine Sodium 175 mcg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. LevETIRAcetam 1000 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Pravastatin 40 mg PO QPM 10. Gabapentin 600 mg PO TID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. glimepiride 2 mg oral BID 14. Aspirin 81 mg PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Heparin 5000 UNIT SC BID 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob 4. Miconazole Powder 2% 1 Appl TP TID:PRN Rash 5. Multivitamins 1 TAB PO DAILY 6. Nicotine Patch 14 mg/day TD DAILY 7. Losartan Potassium 50 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Aspirin 81 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Gabapentin 600 mg PO TID 12. glimepiride 2 mg oral BID 13. LevETIRAcetam 1000 mg PO BID 14. Levothyroxine Sodium 175 mcg PO DAILY 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Omeprazole 40 mg PO DAILY 18. Pravastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnosis Hypervolemic Hyponatremia Secondary diagnosis Iron deficiency anemia Constipation Vaginal candidiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you had a headache, shortness of breath, and diarrhea. We found that you had very low sodium levels in your blood. This is called hyponatremia. - You also had anemia (low blood levels) with low iron levels. WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you diuretics to lower the amount of fluid in your body. - You got a upper endoscopy and colonoscopy that found some irritation in the esophagus. There was one polyp in the colon. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10032409-DS-15

DS

2129-05-06 00:00:00

2129-05-07 02:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Combivent Attending: ___. Chief Complaint: Wrist fracture Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ with history of COPD on 3L o2 at home, diabetes, and forgetfulness suggestive of dementia, presents 1 day s/p fall down stairs. She presented herself to ___ today where she was noted to have pain in her left wrist, shoulder, and bilateral knees. . At ___ a distal ulnar fracture was identified on XR and she was sent to the emergnency room for further evaluation. her initial vitals were 97.7 120, 168/94, 20 100 on 4L. The patient reported s ___ pain in left wrist, ___ pain in right shoulder, ___ pain in b/l knees. . Per ED records, the patient does not recall incidents surrounding fall, but is also a poor historian. She denies loss of consciousness, but cannot provide any details regarding slipping or how she woke up. She denies urinary or stool incontinence, chest pain, palpitations, confusion, headache, dizziness, or any other symptoms. After discussion with her daughter, the fall was clearly witnessed and occurred after the patient missed a step while going down stairs. There was no evidence of presyncopal period or syncopy upon fall. . An EKG demonstrated sinus tach at 106, normal axis, normal intervals, no St--Twave abnormalities. X-rays showed the fracture of the ulna, and right shoulder no fracture, b/l knees no fracture. . The patient was noted to have an episode in the ED where on pulse oximetry she was tachycardic to 147 with an O2 sat of 79. An EKG was obtained, unchanged from admission. trop <0.01. . She was then put on face mask, HR came down to 100s, was given morphine 4mg IV, and when HR remaimed stable, was taken off oxygen and patient maintained o2 sat 95 (RA). She takes 3L home O2 for COPD, and when put on 3L NC, satting 100%. . A d-dimer was elevated but the patient was unable to get a PE CT secondary to potential dye allergy. She was guaiac negative and started on heparin with plan for V/Q scan subsequently. . The patient was evaluted by orthopedics who splinted the left wrist with volar splint; no need for reduction. Very edematous; per ortho, should have wrist elevated on 10 pillows. A head CT demonstrated no intracranial abnormality and a CXR demonstrate no acute changes. . Vitals on transfer 140/85 84 18 97(3L). . . REVIEW OF SYSTEMS: Denies fever, 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: - Oxygen-dependent COPD (3LPM), status post respiratory arrest in ___ for which she was intubated, had a prolonged hospital and rehab stay, and was also treated for pneumonia - Hypertension - Diabetes - Hyperlipidemia - osteoporosis with compression fractures - Tobacco abuse - Schizoaffective disorder - Tardive dyskinesia - Chronic uritcaria - Depression - Colonic adenoma - s/p tonsillectomy - s/p prophylactic appendectomy at time of hysterectomy - s/p total abdominal hysterectomy (pt has ovaries) Social History: ___ Family History: Mother: ___, heart disease, hypertension, diabetes, anemia Sister: ___ cancer Father: ___, TB, passed away in ___ Daughter: ___ Physical ___: VS - Afebrile, BP 151/89, HR 94, RR 21, O2-sat 100 2L% GENERAL - Elderly, well-appearing in NAD, comfortable, appropriate HEENT - NC/AT, s/p cataracts bilaterally, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, LUNGS - CTA bilat, poor air movement with increase I/E ratio, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - Slight edema and tenderness over the knees bilaterally. No c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - patient with scattered urticaria over right arm. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&O x 1. Gait not tested. Other than pupiles remainder of CN II-12 appear grossly intact. Pertinent Results: ___ 04:00PM ___ PTT-26.6 ___ ___ 04:00PM PLT COUNT-283 ___ 04:00PM NEUTS-87.1* LYMPHS-9.9* MONOS-1.7* EOS-1.2 BASOS-0.1 ___ 04:00PM WBC-9.1# RBC-4.95 HGB-13.1 HCT-39.5 MCV-80* MCH-26.6* MCHC-33.3 RDW-14.2 ___ 04:00PM D-DIMER-1254* ___ 04:00PM CALCIUM-9.7 PHOSPHATE-2.9 MAGNESIUM-2.1 ___ 04:00PM cTropnT-<0.01 ___ 04:00PM estGFR-Using this ___ 04:00PM GLUCOSE-246* UREA N-9 CREAT-0.7 SODIUM-131* POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-27 ANION GAP-13 ___ 06:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 06:52PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:50AM BLOOD WBC-6.7 RBC-4.76 Hgb-12.7 Hct-39.0 MCV-82 MCH-26.7* MCHC-32.6 RDW-14.4 Plt ___ ___ 05:50AM BLOOD Plt ___ ___ 05:50AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-137 K-4.6 Cl-102 HCO3-26 AnGap-14 ___ 04:00PM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9 ___ 04:00PM BLOOD D-Dimer-1254* ___ 06:52PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:52PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG . Radiology studies from ___: . wrist 3 view xray IMPRESSION: 1. Comminuted intra-articular distal radial fracture. 2. Mildly displaced ulnar styloid fracture. . Shoulder: no acute fracture or dislocation . Knee AP/Lat/oblique THREE VIEWS, RIGHT KNEE: No acute fracture or dislocation. There is a small joint effusion. No suspicious lytic or sclerotic lesions. THREE VIEWS, LEFT KNEE: There is no acute fracture or dislocation. There is a small joint effusion. No suspicious lytic or sclerotic lesions. Mild vascular calcifications. There is minimal lateral patellar subluxation bilaterally. IMPRESSION: No acute fracture or dislocation. . Head CT: IMPRESSION: No CT evidence for acute intracranial process . CXR Frontal and lateral views of the chest are obtained. Lungs remain relatively hyperinflated. There is persistent mild blunting of the right costophrenic angle, and a trace pleural effusion cannot be excluded. No focal consolidation is seen. There is no evidence of pneumothorax. The cardiac silhouette remains enlarged with left ventricular configuration, similar to prior. The aorta is calcified and tortuous. Prominence of the right hilum is stable. Brief Hospital Course: ___ y/o female with dementia, COPD, and wrist fracture s/p fall. . # Wrist fracture: Evaluted by orthopedics and splinted. xrays show nondisplaced fracture, no surgical intervention needed at this time. Treated pain with tylenol and oxycodone standing. Pt is not good candidate for prn medications due to baseline dementia making it difficult for her to communicate need for pain meds. She was evaluated by ___ and had trouble ambulating with walker, so it was suggested that she complete course of rehab. In terms of pt's fall. It was purely mechanical (witnessed by family member who is a very reliable historian). Pt was worked up with head/neck CT, CXR, shoulder and knee xrays, all of which were negative. Pt will follow up with repeat xrays in ortho-clinic on ___. She was discharged with splint. . # Tachcardia/Hypoxia: Was most likely secondary to acute pain and chronic COPD. No evidence of right heart strain on exam. Oxygenation resolves quickly with baseline O2, suggesting lack of shut physiology. Elevated d-dimer is not specific generally and especially not so in an elderly patient s/p fall. Nothing in history suggests change in O2 status from baseline. Per Wells criteria patient with value of 1.5 putting pre-test prob of PE at 3.6%. She was maintained on tele (without significant arrhythmias) throughout hospitalization and O2 sats were wnl on home dose of o2. . # COPD: Patient at baseline. Continue combivent, fluticasone, per home regimen. . # Dementia/TD: Pt was maintained on home olanzapine, perphenazine. Her tetrabenazine was held during hospitalization given risk for severe sedation in conjunction with opiate pain medications. . # GERD: maintained on omeprazole/Ranitidine . # Cardiac: Pt was maintained on home medication regimen. She is on simvastatin and diltiazem, which can potentially cause rhabdomyolysis and myositis. We dicharged her on 20mg pravastatin and the rest of her home medications. . # DM: Mantained on ISS in ___ and was discharged on home medication regimen. . # Urticaria: pt has chronic hives/urticarial rash likely secondary to MGUS. Reports that nebulizers have contributed to urticaria but did observe exacerbation of hives with nebulizers during hospitalization. Hives come and go along arms bilaterally and back. Sarna cream was given with relief. She was maintained on her home dose of fexofenadine 180mg BID. . Full code Transitional: - follow up with ortho ___, repeat xrays Medications on Admission: 1) Albuterol 2) Clonazepam 3) Diltiazem 180 daily 4) Fexofenadine 5) Fluticaxone 6) Glargine 7) Lispro 8) Atrovent 9) Combivent 10) Losartan 11) Metformin 12) Nystatin 13) Olanzapine 14) Omperaqzole 15) pERPHENAZINE 16) rANITIDINE 17) sIMVASTATIN 18) Tetrabenazine. Discharge Medications: 1. Dulera 100-5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 2. ipratropium-albuterol ___ mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 5. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 7. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. perphenazine 8 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous three times a day. 13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 7 days. 14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 15. oxycodone 5 mg Tablet Sig: 0.25 Tablet PO Q8H (every 8 hours) for 7 days: hold for respiratory depression and sedation. 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze. 17. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze. 18. pravastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day. 19. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty (20) units Subcutaneous at bedtime. 20. metformin 500 mg Tablet Extended Rel 24 hr Sig: Two (2) Tablet Extended Rel 24 hr PO once a day. 21. tetrabenazine 25 mg Tablet Sig: One (1) Tablet PO at bedtime: please hold this medication until pt stops taking oxycodone . Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: nondisplaced distal radial fracture ulnar styloid fracture COPD urticaria Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, ___ was a pleasure taking care of you. You were admitted to the hospital with a wrist fracture. Orthopedics placed a splint on your arm and we treated your pain with oxycodone and tylenol. Pt evaluated you and think that you are unsafe to ambulate at home and you will require rehab. . We have made the following changes to you medications: 1. Start oxycodone 1.25mg by mouth three times daily for pain for seven days 2. Start tylenol ___ by mouth every 8hrs for pain 3. Start pravastatin 20mg by mouth once daily 4. Stop simvastatin 5. Hold tetrabenazine 25 mg until you stop taking oxycodone . We have arranged follow up appointments for you below. Followup Instructions: ___

10032409-DS-18

DS

2129-07-29 00:00:00

2129-07-30 08:59:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Combivent / Losartan / Levofloxacin / hydrochlorothiazide Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ F with history COPD on 3L oxygen, DM on insulin, HTN, schizoaffective disorder, tardive dyskinesia recently admitted in ___ s/p syncopal event who was sent in by ___ from ___ for confusion and tachycardia. Per report from PCP, ___ she had been having memory difficulty x 2 weeks and altered mental status progressively worsening for past week. At ___ office she was noted to be tachycardic to 110 and hypertensive also with encephalopathy and difficulty following commands. Sent to ED for evaluation for underlying infectious process, urinary, respirtory or hepatic sources. Patient denies chest pain, orthopnea or PND but reports shortness of breath, labored breathing. . In discussion with granddaughter, ___, the patient has been experiencing frequent short term memory defecits. She forgot how to use her walker, has to be isntructed to eat, forgot how to turn the water faucet off. These memory deficits have been progressive for past few days. . In the ED, initial vitals 98.2 ___ 16 98% 2l. CT head showed No acute intracranial process. No hemorrhage. No fracture. Age related atrophy and chronic small vessel ischemic disease. CXR with Stable appearance of the chest, without evidence for acute disease. EKG in the ED SR 88, NA/NI, c/w prior. Vitals prior to transfer 98.4, 77, 132/45, 18, 98% RA . On arrival to floor, patient hypertensive but stable with O2 sats in mid-90s%. She appears to have labored breathing, using accessory muscles but maintaining O2 sats in 92-96% range on RA. . ROS: per HPI, denies fever, 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: - Oxygen-dependent COPD (3LPM), status post respiratory arrest in ___ for which she was intubated, had a prolonged hospital and rehab stay, and was also treated for pneumonia - Hypertension - Diabetes - Hyperlipidemia - Osteoporosis with compression fractures - Dementia - Chronic MGUS - Tobacco abuse - Schizoaffective disorder - Tardive dyskinesia - Chronic uritcaria - Depression - Colonic adenoma - s/p tonsillectomy - s/p prophylactic appendectomy at time of hysterectomy - s/p total abdominal hysterectomy (pt has ovaries) - mechanical fall resulting in fractured left wrist and discharged on ___ Social History: ___ Family History: - Family History:Mother: ___, heart disease, hypertension, diabetes, anemia - Sister: ___ cancer - Father: ___, TB, passed away in ___ - Daughter: ___ Physical ___: Admission Exam: VS - 98.4 ___ 20 94%RA W:78.1kg GENERAL - Chronically ill appearing ___ yo F who appears to have labored breathing with accessory muscle use. She is not speaking full sentences because of SOB. She is alert and oriented to person place and time but endorses difficult short term memory, she asked me to repeat my name multiple times. HEENT - NCAT, tongue tremulous, numbness on right side of face. NECK - supple, no ___, no thyromegaly, no JVD, no carotid bruits LUNGS - Reduced air movement throughout, diminished breath sound over left posterior lung fields, increased on right side but still poor air movement. Lungs are clear withut wheezes, rales or rhonchi in areas that are moving air well. No egophany, resonant to percussion HEART - S1 S2 clear and of good quality, RRR, no MRG ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - Awake, A&Ox3, CN V sensory defecits on right, tremulous with intention tremor and tongue tremor. Dysmetria on finger to nose but moving all extremities. Inattentive with inability to complete days of week backwards. Tearful and self-aware of confusion Pertinent Results: Admission Exam: ___ 12:30PM BLOOD WBC-7.7 RBC-4.86 Hgb-12.8 Hct-41.0 MCV-84 MCH-26.2* MCHC-31.2 RDW-15.0 Plt ___ ___ 12:30PM BLOOD Neuts-78.6* Lymphs-16.6* Monos-2.6 Eos-1.7 Baso-0.4 ___ 12:30PM BLOOD ___ PTT-26.5 ___ ___ 12:30PM BLOOD Glucose-202* UreaN-8 Creat-0.6 Na-137 K-4.2 Cl-100 HCO3-28 AnGap-13 ___ 12:30PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.7 Mg-2.0 ___ 12:30PM BLOOD ALT-23 AST-17 AlkPhos-110* TotBili-0.3 ___ 12:30PM BLOOD cTropnT-<0.01 ___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Discharge Labs: ___ 06:00AM BLOOD WBC-6.3 RBC-4.47 Hgb-11.7* Hct-37.8 MCV-85 MCH-26.1* MCHC-30.9* RDW-15.1 Plt ___ ___ 06:00AM BLOOD ___ PTT-27.7 ___ ___ 06:00AM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-140 K-3.9 Cl-101 HCO3-29 AnGap-14 ___ 06:00AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0 Microbiology: - RPR ___ Negative Reports: - CT Head ___ 1. No acute intracranial process. 2. Chronic small vessel ischemic disease. 3. Age-related atrophy. 4. Hypodensities in the bilateral thalami, left greater than right, and genu of the right internal capsule that are unchanged compared to ___ suggesting small old lacunar infarcts. CXR PA/LAT ___ The heart is mildly enlarged. The aorta is mildly tortuous and calcified. There is blunting of the right costophrenic sulcus but similar to prior studies, suggesting scarring. To a lesser degree, there is also blunting of the left costophrenic sulcus that appears unchanged. Hemidiaphragms are flattened suggesting mild hyperinflation. There is no definite pleural effusion or pneumothorax ___ Neurophysiology EEG IMPRESSION: Abnormal EEG due to mild diffuse background slowing and disorganization, indicative of a mild diffuse encephalopathy which is etiologically non specific. There were no epileptiform features. ___ Radiology MR ___ W/O CONTRAST IMPRESSION: No acute infarct seen. Moderate brain atrophy and moderate small vessel disease. Chronic lacunes in the basal ganglia. No acute infarcts. Brief Hospital Course: ___ F with history COPD on 3L oxygen, DM on insulin, HTN, schizoaffective disorder, tardive dyskinesia sent in to the ED for increasing confusion and forgetfullness. # Encephalopathy: Acute short term memory loss without obvious preceeding event. Inattention on exam but oriented indicating most likely delirium versus acute progression of dementia. Acute onset and with possible stepwise decline is curious for vascular dementia. CT head also showing some small vessel ischemic disease which may be consistent with vascular dementia. MRI head did not show acute process or acute stroke. In addition, chronic psychiatric disease with dopaminergic medications may be exacerbating her clinical status. Toxic-metabolic work up all negative except for low TSH but FT4 is 1.0. B12, Folate and RPR all normal/negative. After reading prior neuro notes she did not seem far off from baseline. Neurology was consulted who requested an EEG which showed mild diffuse background slowing and disorganization, indicative of a mild diffuse encephalopathy which is etiologically non specific. There were no epileptiform features. Final diagnosis was polypharmacy induced encephalopathy. Benadryl was discontinued, Clonazepam tapered down and discontinued and Tetrabenzaprine dose halved. Plan to discontinue Tetrabezaprine all together but patient requested it continued. Neuro also felt she definatively has sleep apnea which is likely contributing to poor morning arousability. CPAP was started on the floor and continued as an outpatient. # COPD: Oxygen-dependent COPD (3LPM), s/p respiratory arrest in ___ with protracted intubation course. Labored, tachypnic breathing on admission though without oxygen requirement. After being placed back on home O2 of 2L NC her respiratory status improved and she maintained O2 sats in >95%. Continued home regimen of Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN, Fluticasone Propionate NASAL 1 SPRY NU DAILY, Ipratropium Bromide Neb 1 NEB IH Q6H, Dulera *NF* (mometasone-formoterol) 100-5 mcg BID and supplemental O2 at 2L NC. No acute exacerbation during admission. Patient is on Azithromycin chronically as an outpatient, unclear if this can be continued, defer to outpatient pulmonary for that decision. # Glycosuria: 1000 Glu on UA. Serum glucose only 200 so unclear why she is spilling so much glucose. Possibly Fanconi syndrome though patient with normal renal function, phosphate and bicarb slightly elevated. Elevated bicarb likely compensating for chronic CO2 retention, no evidence of RTA to look for Fanconi's. Dilute urine may also indicate she is not concentrating appropriately. Repeat urine continued to show glycosuria. This can be monitored as an outpatient. # Hypertension: Chronic, uncontrolled, asymptomatic at this point, not being treated as an outpatient. Allergy to ACE-I and ARBs which would be first line given possibly renal dysfunction with glycosuria. Consider starting Chlorthalidone as an outpatient. # Diabetes Mellitus: Type II, insulin dependent, complicated by vascular disease. Continued Lantus 20 units QHS and QACHS ___ and HISS, held Metformin while inpatient # Schizoaffective disorder: On typical antipsychotics complicated by movement disorders and tardive dyskinesia. Consider changing medications as there may be contributing to AMS deterioration. Discontinued Clonazepam 1 mg PO/NG QHS due to lethargy but continued Perphenazine 8 mg PO/NG QHS, Olanzapine 5 mg PO HS, Tetrabenazine 25 mg Oral QHS TRANSITIONAL ISSUES: - Treat hypertension as an outpatient, consider starting Chlorthalidone - Continue to titrate down and discontinue antipsychotics/anticholinergics as an outpatient, this is likely contributing to encephalopathy - Patient started on CPAP - CODE STATUS: Full - CONTACT: HCP is Grand___: ___ ___, Daughter ___: ___ ___ on Admission: - diltiazem HCl 240 mg Capsule, Extended Release Daily - ipratropium-albuterol ___ mcg/actuation ___ IH Q6hours:prn - albuterol sulfate 2.5 mg /3 mL (0.083 %)nebs Q4-6hrs:prn for shortness of breath or wheezing. - senna 8.6 mg Tablet PO BID as needed for constipation. - camphor-menthol 0.5-0.5 % Lotion QID:prn - olanzapine 5 mg Tablet PO HS - Dulera 100-5 mcg/actuation HFA Aerosol 2 Inhalation q12h - tetrabenazine 25 mg PO qhs - pravastatin 20 mg Tablet PO DAILY - fluticasone 50 mcg/actuation Spray Nasal DAILY - insulin lispro 100 unit/mL sliding scale - insulin glargine 100 unit/mL Twenty (20) U QHS - metformin 1,000 mg PO twice a day. - azithromycin 250 mg daily - Perphenazine 8 mg PO/NG QHS - Clonazepam 1 mg PO/NG QHS - Ranitidine 300 mg PO/NG HS Discharge Medications: 1. DILT-XR 240 mg Capsule,Ext Release Degradable Sig: One (1) Capsule,Ext Release Degradable PO once a day. 2. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 3. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous ASDIR: Use ASDIR by your sliding scale. 4. CPAP Positive Airway Pressure for OSA: Indication Known OSA Nasal CPAP: CPAP level: Auto setting, 5-20 cm H2O; Supp O2: 3 L/min Rate, spontaneous 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. perphenazine 8 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Dulera 100-5 mcg/actuation HFA Aerosol Inhaler Sig: One (1) IH Inhalation BID (2 times a day). 10. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___ Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every ___ hours as needed for SOB/Wheezing. 12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Topical four times a day as needed for rash. 13. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Dulera 100-5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation twice a day. 15. tetrabenazine 12.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 16. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous three times a day: per sliding scale. 17. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. 18. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 19. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Encephalopathy Chronic obstructive pulmonary disease Obstructive sleep apnea Secondary: Schizoaffective Disorder Mood disorders Tardive Dyskinesia hypertension Type 2 insulin dependent diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___, It was a pleasure treating you during this hospitalization. You were admitted to ___ because of increasing confusion and forgetfullness at home. Infectious and metabolic work up did not show any specific cause for your encephalopathy. Neurology was consulted and you completed an electroencephalograpm, which showed that you were not having any seizures. Our neurologists felt that your confusion was likely caused by a combination of excess sedating medication, which we have stopped, and sleep apnea, a medical condition that causes you to stop breathing briefly many times a night during sleep. The following changes to your medications were made: - STOP Clonazepam (Klonopin) as this may worsen your confusion - STOP Benadryl (diphenhydramine) as this may worsen your confusion - REDUCE your Tetrabenazine from 25mg to 12.5 mg (one half tablet) every night - START using your CPAP machine every night, as much as possible, when you sleep. - No other changes were made to your medications, please continue taking as previously prescribed Followup Instructions: ___

10032409-DS-19

DS

2130-01-21 00:00:00

2130-01-21 14:57:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Losartan / Levofloxacin / hydrochlorothiazide Attending: ___. Chief Complaint: weakness, confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a h/o COPD on ___, s/p resp arrest in ___, HTN, DM, dementia, schizoaffective d/o, tardive dyskinesia presents for worsening ambulation, confusion, dyspnea. Per pt's family, pt doing well until a few days ago. More recently, she has been slower to respond, has had difficulty walking to the bathroom and is requiring more assistance. She has urinary incontinence at baseline, but has had increased in voiding and incontinence. Two nights ago, pt went to bathroom, daughter found her sitting in the bathtub. Daughter does not believe she fell, she asked patient what was wrong, but patient was unable to recall events. Pt had one episode of near fall 3days ago and yesterday, where she felt like her knees would give away. She was found sitting on the ground watching TV. Pt stated that her knees gave away, family does not think she had LOC or hit her head. Yesterday, pt also told her daughter her breathing was "not good," dyspnea improved w/ CPAP. At baseline, communicates w/ simple few word sentences, but now appears slower to respond to questions; she used to walk w/ walker but has not used it recently. She is compliant with her CPAP at night. Daughter thinks she had subjective fevers, but no documented fevers. No chills. Daughter cares for pt at home. Otherwise, no cough, abdominal pain, diarrhea at home, slurred speech, clumsiness, objective weakness. In the ED, VS: 98.3 72 143/71 20 100% 15L. Neuro: nonfocal; Lungs: R base ?crackles. CT head- neg for bleed; VBG: 7.41/47; CXR: ? PNA on R. She received azithro, cftx, and asa. Currently, denies pain or shortness of breath ROS: 12 point review of system is also + for constipation, chronic tardive dyskinesia, otherwise negative. Past Medical History: - Oxygen-dependent COPD (3LPM), status post respiratory arrest in ___ for which she was intubated, had a prolonged hospital and rehab stay, and was also treated for pneumonia - Hypertension - Diabetes - Hyperlipidemia - Osteoporosis with compression fractures - Dementia - Chronic MGUS - Tobacco abuse - Schizoaffective disorder - Tardive dyskinesia - Chronic uritcaria - Depression - Colonic adenoma - s/p tonsillectomy - s/p prophylactic appendectomy at time of hysterectomy - s/p total abdominal hysterectomy (pt has ovaries) - mechanical fall resulting in fractured left wrist and discharged on ___ Social History: ___ Family History: - Family History:Mother: ___, heart disease, hypertension, diabetes, anemia - Sister: ___ cancer - Father: ___, TB, passed away in ___ - Daughter: ___ Physical ___: On Admission: VS: 98.8, 138/78, 80, 20 99% 2L GEN: Responds to most questions w/ simple few word sentences, constricted affect, repetative lip smacking HEENT: OP clear, MMM NECK: Supple, No JVD CV: RR, no murmurs/rubs/gallops RESP: Sparse scattered wheeze, no dullness, symetric expansion of chest ABD: Soft NT, ND GU: No CVAT EXTR: wwp, no edema Neuro: CN2-12 intact, cogwheel rigidity, strength ___ throughout, sensation to LT intact, nl FNF, gait deferred, neg babinski, no pronator drift On Discharge: VS: Tm 98.5 BP 169/85 HR 97 RR 20 SaO2 96%3L GEN: Alert, Responding appropriately to questions, Oriented x 3 HEENT: OP clear, MMM NECK: Supple CV: RRR, no m/r/g RESP: CTA B, diminished BS throughout, no w/r/r ABD: S/NT/ND NEURO: Non-focal Pertinent Results: Admission Labs: ___ 03:30PM BLOOD WBC-9.4 RBC-4.58 Hgb-12.5 Hct-37.8 MCV-83 MCH-27.3 MCHC-33.1 RDW-15.3 Plt ___ ___ 03:30PM BLOOD Neuts-72.4* ___ Monos-3.4 Eos-1.5 Baso-0.1 ___ 03:30PM BLOOD Glucose-232* UreaN-16 Creat-0.8 Na-141 K-4.0 Cl-103 HCO3-28 AnGap-14 ___ 03:30PM BLOOD ALT-21 AST-26 AlkPhos-96 TotBili-0.2 Discharge Labs: ___ 06:25AM BLOOD WBC-14.5* RBC-4.55 Hgb-12.4 Hct-38.6 MCV-85 MCH-27.3 MCHC-32.1 RDW-16.7* Plt ___ ___ 06:25AM BLOOD Glucose-120* UreaN-29* Creat-0.8 Na-141 K-4.0 Cl-104 HCO3-29 AnGap-12 ___ 06:25AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.2 ___ 09:00PM BLOOD CK(CPK)-158 ___ 04:00AM BLOOD CK(CPK)-150 ___ 03:30PM BLOOD cTropnT-<0.01 ___ 09:00PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-62 ___ 04:00AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 07:30AM BLOOD VitB12-___ Folate-15.3 ___ 07:30AM BLOOD TSH-0.43 ___ 06:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06:20PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 ___ 06:20PM URINE Mucous-RARE ___ URINE CULTURE - negative ___ BLOOD CULTURE - negative x 2 CXR ___ - FINDINGS: AP upright and lateral views of the chest are provided. Evaluation through the lower lung is limited due to underpenetrated technique. Allowing for this, no definite signs of pneumonia or CHF. No large effusions are seen. Aorta is unfolded. The heart size is within normal limits. The bony structures appear intact. IMPRESSION: Limited, negative. CT Head ___ - FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarction. There is no shift of normally midline structures. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. Ventricular and sulci are prominent, compatible with age-related involutional changes. Imaged paranasal sinuses and mastoid air cells are well aerated. There is no fracture. IMPRESSION: No acute intracranial process. UE U/S ___ - FINDINGS: There is normal gray scale appearance with compression, color Doppler flow, and spectral Doppler waveforms of the right subclavian, axillary, and brachial, basilic, and cephalic veins. Numerous thyroid cysts in the right thyroid lobe are incompletely assessed. IMPRESSION: No DVT in the right upper extremity. CXR ___ - Heart size is top normal. Mediastinum is within normal limits. Lungs are essentially clear. No pleural effusion or pneumothorax is seen. IMPRESSION: No evidence of acute cardiopulmonary abnormality demonstrated. CTA CHEST ___ - Dense atherosclerotic mural calcifications are present along the thoracic aorta. The aorta is of normal caliber without aneurysm or dissection. Contrast bolus is suboptimal for evaluation of the subsegmental pulmonary arteries. The main, lobar, and segmental pulmonary arteries are opacified without filling defect. A linear hypodensity through a right lower lobe medial basal subsegmental pulmonary artery (4:106, 502a:65), which is not expanded, may be artifactual. Bovine arch is incidentally noted. CHEST: The visualized portion of the thyroid is unremarkable. No axillary, supraclavicular, mediastinal, or hilar lymphadenopathy. Dense calcification is present in the left anterior descending, circumflex, and right main coronary arteries. The heart is mildly enlarged. Trace pericardial effusion is similar to prior. Mild to moderate upper zone predominant centrilobular emphysema is similar to ___. 4 mm perifissural right middle lobe nodule is stable since ___. No new pulmonary nodule. There is bibasilar dependent atelectasis, similar to prior. No focal consolidation, pleural effusion, pneumothorax, or pneumomediastinum. Airways are patent to subsegmental levels. The esophagus is normal. This study is not tailored for evaluation of the subdiaphragmatic organs. Within this limitation, the visualized upper abdominal organs are unremarkable. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Quality of contrast bolus allows exclusion of pulmonary emboli up to the segmental pulmonary arteries. Filling heterogeneities within the pulmonary arteries beyond this level are equivocal. Curvilinear hypodensity within a right lower lobe medial basal subsegmental pulmonary artery may be artifactual, but a subacute pulmonary embolism is not entirely excluded. 2. Mild upper zone predominant centrilobular emphysema. 3. Mild cardiomegaly. Three-vessel coronary artery calcification. 4. 4-mm right middle lobe perifissural pulmonary nodule, with demonstrated two year stability since ___. Brief Hospital Course: ___ with a h/o COPD on 3___, s/p resp arrest in ___, HTN, DM, dementia, schizoaffective d/o, tardive dyskinesia presents for worsening ambulation, confusion, dyspnea. # Altered Mental Status: Concern for slowing of speech and slowness to respond on admission, though it appears per communication with PCP and family that this has been a subacute to chronic process. UA unremarkable for UTI, and CXR limited but w/o evidence of pna. Electrolytes were normal. CT head w/o bleed, and neuro exam w/o focal deficits. Patient was not delerious, but could converse really in few word responses. Psych was consulted and they recommended continuing to hold the Olanzapine. She seemed to tolerate the Perphenazine. While this can cause TD, they recommended outpatient ___ with her psychiatrist. Neuro was consulted for AMS and concern for possible truncal weakness. They found no reason to EEG or MRI. Per review of old psych notes, pt has had word finding and memory difficulties. H/o schizoaffective d/o. TSH, B12 and Folate were normal. Initially tetrabenzapine was discontinued. However, pt's family reports that pt needs this medication for her tardive dyskinesias. Mental status was continuing to improve at the time of fall. # Worsening ambulation, fall: No focal defecits on neuro exam, head CT unremarkable. ___ & OT consults were placed. The patient is being discharged to rehab for continued physical therapy. # Urinary inc, frequent voiding: UA/Ucx neg. Foley catheter placed in ED was taken out. Could be related to underlying cognitive impairment. Per family happened 1 month ago as well. # Acute on chronic COPD exacerbation-Pt with severe COPD on 3L NC at baseline. Pt appeared to be at her baseline status ___ word sentences and intermittent tachypnea that family reported was worse in the evenings. Pt did have several episodes of acute dyspnea/tachypnea often in the evenings during admission. EKG's were unchanged. Cardiac enzymes were normal. CTA of the chest did not show any large PE and there were never any clinical signs of pneumonia. It was discovered that combivent had erroneously been on the patient's medication allergy list. She had been taking this medication QID at home without any difficulities. She was therefore, started on steroids and nebulizer therapy. With this, her respiratory status improved. # DM 2: Pt was continued on home lantus, ISS was continued. Metformin was held while in-house and restarted on discharge. Of note, Lantus was uptitrated ___ hyperglycemia in the setting of steroids. This will likely need to be readjusted after her steroid burst is complete. #HTN - Home diltiazem was continued. Hydralazine was added/uptitrated for better blood pressure control. BP was still noted to be elevated at the time of discharge. If blood pressure remains elevated, diltiazem will likely need to be further increased. #Schizoaffective d/o - Olanzapine stopped #Sleep Apnea - on CPAP TRANSITIONAL ISSUES: - Pt with new leukocytosis on the day of discharge. Asymptomatic, afebrile. Likely related to steroid burst. Please repeat CBC ___ days after discharge to ensure stability. - Please monitor BP's and uptitrate diltiazem as needed. - Please monitor fingersticks. Lantus has been increased for better glucose control. However, after steroid burst is complete, pt's Lantus dose will likely need to be decreased. - Pt with a cognitive neuro ___ appt scheduled for ___ ___. Also with an upcoming ___ appt (see follow-up information). - Pt will need PCP ___ appointment at the time of discharge from rehab. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/CaregiverwebOMR. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob 2. Azithromycin 250 mg PO Q24H 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Glargine 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Albuterol-Ipratropium 2 PUFF IH Q4H:PRN sob 6. MetFORMIN XR (Glucophage XR) 500 mg PO BID Do Not Crush 7. Dulera *NF* (mometasone-formoterol) 100-5 mcg/actuation Inhalation bid 8. Nystatin Cream 1 Appl TP BID to redness of under skin folds 9. Perphenazine 8 mg PO QHS 10. Pravastatin 20 mg PO DAILY 11. Ranitidine 300 mg PO HS 12. tetrabenazine *NF* 12.5 mg Oral daily itch 13. Senna 1 TAB PO BID:PRN constipation 14. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 175 mg Oral bid 15. Diltiazem Extended-Release 360 mg PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob 2. Azithromycin 250 mg PO Q24H 3. Diltiazem Extended-Release 360 mg PO DAILY 4. Dulera *NF* (mometasone-formoterol) 100-5 mcg/actuation Inhalation bid 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Perphenazine 8 mg PO QHS 7. Pravastatin 20 mg PO DAILY 8. Ranitidine 300 mg PO HS 9. Senna 1 TAB PO BID:PRN constipation 10. MetFORMIN XR (Glucophage XR) 500 mg PO BID Do Not Crush 11. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 175 mg Oral bid 12. Nystatin Cream 1 Appl TP BID to redness of under skin folds 13. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. HydrALAzine 75 mg PO Q6H Hold for SBP <140. 15. PredniSONE 60 mg PO DAILY Duration: 3 Days for three more days, ending ___ 16. Albuterol-Ipratropium 2 PUFF IH Q6H 17. tetrabenazine *NF* 12.5 mg HS daily Discharge Disposition: Extended Care Facility: ___ for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Schizoaffective disorder Tardive dyskinesia Physical deconditioning Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge to Rehab - Estimated length of stay > 30 days. Discharge Instructions: You were admitted with report of mental slowing. There was no evidence of infection, no witnessed or suspected seizure activity. Your Olanzapine (zyprexa) was discontinued under recommendation of inpatient psychiatry team and you should ___ with your outpatient psychiatrist. In addition, you developed an acute exacerbation of your COPD and were treated with steroids and nebulizer therapy. You were alert and oriented though deconditioned. Physical and occupational therapy evaluated you. You are being discharged to a rehab facility to help you build up your strength. Please continue your Oxygen and CPAP use as per outpatient provider ___. Medication changes: - Start prednisone 60 mg daily for 3 more days (ending on ___ - Start hydralazine for your blood pressure - We increased your insulin while you are on steroids. Your insulin requirement will likely decrease after your steroid course is complete. Followup Instructions: ___

10032725-DS-20

DS

2143-03-25 00:00:00

2143-03-25 18:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: altered mental status, hemiplegia Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Ms. ___ is a ___ woman with a history of endometrial cancer with recently discovered poorly differentiated lesion to the right femur, s/p open reduction internal fixation on ___ on prophylactic lovenox therapy presented with altered mental status and hemiplegia. ___ was found at her facility tonight unreponsive and hemiparetic on the left with severe weakness, was at her baseline two hours prior. . Of note patient was recently hospitalized from ___ with episode of chest pain. No clear source was identified, however patient was noted to new metastatic lesions of the lung, femur, and adrenals on imaging. She was noted to have hypercalcemia which was managed with pamidronate. She completed her outpt workup for RLE mass which underwent open reduction and internal fixation. She was subsquently started on carboplatin, received one dose, with plans to follow up as outpt for ___ tx. She subsquently underwent 5 rounds of radiation tx to her right femur for pain control. Palliative care was also consulted for assistance with pain management. . In the ___ ED, vital signs were stable. Pt was noted to be drowsy with left sided hemiplegia, tachycardia, and RLE edema. Exam with L sided weakness, with some resistance to gravity. She was able to follow simple commands, alert and oriented to self and month. Code stroke was called at 2:53A. Due to initial concern for septic emboli from her surgical site she was treated with 1gm Vancomycin. CT head demonstrated multiple hyperdense lesions with surrounding edema thought to be hemorrhagic conversion of mets. Neurology will follow. Ortho also consulted for evaluation of RLE edema, thought to be related to recent surgery. RLE Xray with no acute pathology. ___ showed no DVT, CTA also ruled out PE. Compartment syndrome was thought to be highly unlikely. Vital signs on transfer HR 116 BP163/97 O2 sat 100% RA. . . On the floor, pt is very somnulant and not able to respond to questions. Past Medical History: Onc: - TAH/BSO/Lymphadenectomy on ___ that revealed FIGO stage I, grade ___ endometrioid carcinoma. - Imaging from ___: bilateral hilar adenopathy up to 2cm, right adrenal nodule, multiple bilateral lesions in the kidneys, a 1.4 cm subcutaneous soft tissue nodule in the right inguinal region, andmultiple 1-cm right inguinal lymph nodes. 5X5X22 cm right distal femoral mass with soft tissue extension. - Femoral mass pathology poorly differentiated carcinoma "compatible with" endometrial carcinoma. -Hypertension -Hypercholesterolemia -DM -Back surgery on L5/S1 in ___ Social History: ___ Family History: The patient's father died from cancer (type unknown). She has no family history of clotting disorders or heart disease. Physical Exam: ADMISSION EXAM: Vitals: T:100.1 BP:109 P:121/86 R:21 O2:100% RA General: obtunded, unresponsive to sternal rub, nailbed pressure HEENT: Sclera anicteric, pupils small but reactive bilaterally, resists passive eye opening on the right, but not on the left. mouth open. oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, 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: foley in place Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous, twice the size of LLE, but edema nonpitting. small well healing incisions, at the right trochanter and right lateral femoral head. Neuro: pupils reactive, unable to assess other cranial nerves as pt not responsive, left facial droop. minimal to absent gag reflex. has tone in the RUE, protects arm when dropped, makes some spontaneous movements of the hand and arm. LUE flaccid. no posturing. reflexes minimal bilaterally. babinski equivocal bilaterally. . DISCHARGE EXAM General: More responsive this AM, able to follow commands HEENT: Sclera anicteric, pupils small but reactive bilaterally, oropharynx clear Lungs: Clear to auscultation anteriorly, 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: foley in place Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous, twice the size of LLE, but edema nonpitting. small well healing incisions, at the right trochanter and right lateral femoral head. Neuro: pupils reactive, strength is ___ on the right UE. Is not moving RLE due to pain. Cannot move left side. Facial droop on left. Pertinent Results: ADMISSION LABS: ___ 01:20AM BLOOD WBC-23.8* RBC-4.44 Hgb-11.5* Hct-33.2* MCV-75* MCH-25.9* MCHC-34.6 RDW-16.4* Plt ___ ___ 01:20AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-3.4 Eos-0.3 Baso-0.3 ___ 01:20AM BLOOD ___ PTT-35.0 ___ ___ 07:31AM BLOOD Glucose-153* UreaN-26* Creat-1.1 Na-135 K-4.5 Cl-100 HCO3-22 AnGap-18 ___ 07:31AM BLOOD ALT-3 AST-20 AlkPhos-166* TotBili-0.2 ___ 07:31AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.8 Mg-2.3 ___ 07:31AM BLOOD TSH-0.56 ___ 01:40AM BLOOD Glucose-148* Na-136 K-4.4 Cl-97 calHCO3-24 ___ 04:17AM BLOOD Lactate-1.7 . No Labs obtained on discharge. . EEG: This is an abnormal continuous ICU video EEG study because of diffusely suppressed and slow background indicative of a moderate to severe encephalopathy. The frontally predominant delta frequency activity can be seen in toxic/metolic disturbances, but may also be seen in midline or subcortical dysfunction, including hydrocephalus. Thus, clinical correlation is recommended. No epileptiform discharges or electrographic seizures were present in the record. A note was made of sinus tachycardia and occasional premature wide complex beats. . CT head: IMPRESSION: Multiple hyperdense masses involving both the superficial and deep white matter and deep gray matter, with an area of vasogenic edema in the left occipital lobe. Differential diagnosis is broad, though findings are most likely secondary to hemorrhagic metastases given the clinical history. Other possibilities, though less likely include hemorrhagic infarcts secondary to dural venous or cortical venous thrombosis, spontaneous hemorrhage from complication of anticoagulation (given the recent history of orthopedic surgery), lymphoma or infection. Further characterization with MRI of the brain is recommended Brief Hospital Course: Mrs ___ is a ___ y/o f with metastatic poorly differentiated carcinoma who was admitted for AMS and new left hemiplegia found to be likely d/t newly diagnosed malignant metastases to brain (multiple lesions) with hemorrhage into right thalamic lesion. After consultation with the oncology team and patient's family decision was made to focus care on comfort and patient was discharged home with hospice. ALTERED MENTAL STATUS (AMS) – patient was transientently intubatied for airway protection to allow for disgnostic testing. Attributed to multiple brain mets, some with complication of bleeding, and surrounding vasogenic edema. No clinical or EEG evidence for active seizures. Treated with oral steroids and prophylactic anti-convulsant. BRAIN LESIONS – Not previously recognized. Likely metastatic disease from her known poorly differentiated CA of uncertain primary. Evidence for hemorrhage into lesions per CT. Per our oncology team no further theraputic or palliative chemo/radiation can be offered that would be of benefit to the patient. HEMIPLEGIA, LEFT – likely ___ to acute bleed into brain mets(consistent with right thalamic lesion and hemmorage seen on CT). Repeat Head CT without significant change. CARCINOMA – metastatic poorly differentiated, unclear etiology. Per oncology team no plans for further chemotherapy. RIGHT LEG SWELLING – recent orthopedic surgery ORIF. No further interventions with Orthopedic service. No evidence for DVT by ___. Goals of care: meeting was held with patient's family, ICU and Oncology team, per patient's dire condition and family's wishes decision to transition to comfort focused care. Patient was followed by palliative care and is now dicharged to out patient hospice. DISPOSITION -- returned home with hospice services. Discharge Medications: 1. methadone in 0.9 % sod. chlor 1 mg/mL (1 mL) Syringe Sig: 0.6 mg per hour Intravenous continuous via CADD pump: + Bolus 0.2mg every 20 minutes PRN breakthrough pain . Disp:*10 100ml vials* Refills:*0* 2. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Fourteen (14) units Subcutaneous at bedtime. Disp:*30 ml * Refills:*0* 3. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous four times a day. Disp:*1 kit* Refills:*0* 4. Dilaudid concentrate (20mg/ml) Sig: ___ mL Sublingual q2hr as needed for pain/respiratory distress: Please use 0.5-1mL (___) q2 hours sublinguially PRN for pain or respiratory distress. Disp:*60 mL* Refills:*0* 5. Ativan liquid (2mg/ml) Sig: 0.5 ml Sublingual every six (6) hours: Please use 1mg (0.5ml) sublingually q6hrs. ___ hold for sedation. Disp:*30 mL* Refills:*0* 6. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day: ___ hold for loose stools. Disp:*30 suppositories* Refills:*0* 7. acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every six (6) hours as needed for fever or pain. Disp:*30 suppositories* Refills:*2* 8. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1) liter Intravenous q nightly: Please run 1 Liter nightly at 100ml/hr over 10 hours. Disp:*7 liters* Refills:*2* 9. dexamethasone oral solution (10mg/ml) Sig: One (1) ml Sublingual every eight (8) hours: Please place 1ml sublingual q8 hours. Disp:*60 ml* Refills:*0* 10. supplies Please supply with One Touch Ultra testing strips. Dispense 100 strips, no refills 11. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous every six (6) hours. Disp:*100 lancets* Refills:*0* 12. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection five times a day as needed for IV flush: 10cc flush to IV site PRN. Disp:*30 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: metastatic brain cancer Secondary: endometrial cancer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted because you were found unresponsive and with trouble moving the left side of your body. You had a head CT scan here that showed multiple areas of cancer in the brain. You were initially intubated to support your breathing but the breathing tube was quickly removed and you have been breathing well on your own. With the help of your family, we have arranged for you to be able to go home and be comfortable. Please take the following medications: 1. Please use a methadone pump at 0.6 mg per hour Intravenous continuous infusion via CADD pump: + Bolus 0.2mg every 20 minutes as needed for breakthrough pain 2. Please check blood sugars daily and give glargine 14 units for blood sugars >200. Please do not give if sugars are <200. 3. Please use Dilaudid for breakthrough pain control. Use ___ ml under the tongue as needed for pain every 2 hours. 4. Please use ativan to prevent seizures. Place 0.5ml under the tongue every 6 hours. This may be held if Ms. ___ is too sedated and sleepy. 5. Please use bisacodyl 10 mg Suppository daily. This should be held for loose stools. 6. Use acetaminophen 650 mg Suppository every 6 hours as needed for fever or pain. 7. Take dexamethasone 1mL under the tongue every 8 hours. 8. Please take 1 liter of fluid (normal saline) nightly, to be run at 100cc/hr for 10 hours. Followup Instructions: ___

10033085-DS-11

DS

2160-10-22 00:00:00

2160-10-23 12:33:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R foot Osteomyelitis Major Surgical or Invasive Procedure: ___: R ___ MPJ debridement; abx spacer History of Present Illness: ___ male patient presenting to the ED with concern for a right toe infection. Patient with PMH of DM with history of prior foot infections. He gets his care in ___. He states that he has a 5 week history of a R foot/hallux infection. He had been on IV abx converted to orals and then started on daptomycin/ertapenem by Infectious Disease in ___. He relates that his foot has continued to be erythematous and swollen for the past few weeks despite abx course. He was seen today by his podiatrist and had xrays take which revealed bony destruction. He was then told to present to ___ for further workup and treatment. Denies any recent fevers or chills. No recent nausea, vomiting, chest pain, or SOB. The foot is not painful but he has neuropathy. Past Medical History: DM - does not recall last HgbA1C HTN cataracts - surgery in the past Social History: ___ Family History: n/c Physical Exam: Admission Phyisical Exam: PE: Vitals: 98.1 98 189/108 17 99% RA GEN: NAD, Aox3 RESP: CTA, breathing comfortably on room air CV: RRR ABD: soft, nontender, ___ FOCUSED EXAM: Dp/Pt pulses palpable b/l. crt<3sec to the digits. normal proximal to distal cooling. Edema to the R forefoot and ___ MPJ area. Small ulceration to the plantar aspect of the R hallux which probes deep. Mild erythema surrounding the R ___ MPJ. No pain with palpation. NEURO: CNII-XII intact. light touch sensation diminished to the ___ b/l. Discharge Physical Exam: PE: Vitals: GEN: NAD, Aox3 RESP: CTA, breathing comfortably on room air CV: RRR ABD: soft, nontender, ___ FOCUSED EXAM: crt<3sec to the digits. Dry surgical dressing intact Pertinent Results: ___ 10:10PM BLOOD WBC-7.6 RBC-4.18* Hgb-11.7* Hct-37.5* MCV-90 MCH-28.0 MCHC-31.2* RDW-15.0 RDWSD-48.4* Plt ___ ___ 10:10PM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-4* Eos-2 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-6.46* AbsLymp-0.53* AbsMono-0.30 AbsEos-0.15 AbsBaso-0.00* ___ 10:10PM BLOOD ___ PTT-34.8 ___ ___ 10:10PM BLOOD Glucose-69* UreaN-19 Creat-1.0 Na-141 K-4.7 Cl-102 HCO3-23 AnGap-16 ___ 07:28AM BLOOD %HbA1c-9.5* eAG-226* ___ 06:34AM BLOOD CRP-11.2* ___ 10:27PM BLOOD Lactate-1.8 ___ 1:45 pm TISSUE PROXIMAL PHALYNIX 5. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 1:38 pm TISSUE IST METATARSAL. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): GRAM POSITIVE COCCUS(COCCI). RARE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ED on ___ for a R foot infection. On admission, he was started on broad spectrum antibiotics. He was taking to the OR for Right foot debridement on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with oral antibiotics. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient was subsequently discharged to home on POD3 with IV antibiotics. 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. Carvedilol 25 mg PO BID 2. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H 3. amLODIPine 10 mg PO DAILY 4. SITagliptin 100 mg oral DAILY 5. Other 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Daptomycin 600 mg IV Q24H Duration: 6 Weeks RX *daptomycin 500 mg 600 mg IV q24h Disp #*51 Vial Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Ertapenem Sodium 1 g IV Q24H Duration: 6 Weeks RX *ertapenem [Invanz] 1 gram 1 gram IV q24h Disp #*42 Vial Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #*20 Tablet Refills:*0 6. Other 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Carvedilol 25 mg PO BID 10. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H 11. SITagliptin 100 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R foot Osteomyelitis 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: Mr. ___, It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service after your right foot surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain non weight bearing to your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___

10033106-DS-8

DS

2166-03-29 00:00:00

2166-03-29 15:30:00

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: none History of Present Illness: This is a ___ yo M with a PMHx of alcoholic pancreatitis who p/w abominal pain following a recent episode of drinking. . The patient reports that he has had several episodes of pancreatitis in the past, most recently ___ years ago. He started drinking after his wife died but denies problems with alcholism. The most recent episode started ___ with epigastric and suprapubic ___ pain that caused the patient to assume the fetal position. The patient thinks that this may be similar to prior episodes of pancreatitis. The above episode was preceeded by the patient consuming 2- 12 oz drinks of rum and coke that contained 3 oz of alcohol each. She denies radiation of the pain to her back or other portions of her abdomen. The pain was relieved by tylenol 3 and made worse with po intake at home. The patient had worsening pain on the day of admission and came to the ED. . In the ED, the patients VS were stable, was found to have a lipase of 379, she was given IVF and sent to the floor. . The patient currently has ___ pain in the epigastric portion of his abdomen. Denies n/v, f/c and says that he moved his bowels in the last 24 hours that was NB. He endorses decreased ability to sleep and decreased po intake ___ to his pain. . 12 point ros is otherwise negative Past Medical History: -HCV infection, genotype 1-had been seen by Dr. ___ never got active treatment -PTSD likely from military action -HTN -ED -h/o alcoholic pancreatitis Social History: ___ Family History: multiple reported cancers in mother, father, both died in ___;s of cancer Physical Exam: Admission VS: 97.9 178/88 56 18 100 RA Gen: AAOX3, NAD HEENT: OP clear, MMM Endo/Lymph: no obvious thryoid masses, no lad CV:RRR, no RMG Lungs:CTAB, no wrr Abdomen: mildly TTP in epigastrum, no rebound, active BS X4 Extremities: WWP, no edema, pulses 2+ and equal Skin: no rashes Neuro: MS and CN wnl, strength and sensation wnl Psyc: mood and affect wnl Pertinent Results: CXR ___ -preliminary read by me-no pleural effusions, no CM, no focal infiltrates ___ 08:58PM LIPASE-379* Brief Hospital Course: This is a ___ yo with a PMHx of alcoholic pancreatitis who p/w epigastric abdominal pain following alcohol consumption and a lipase of 379 and a leukocytosis with eosinophillia . #Acute pancreatitis: suspected alcohol related due to recent alcohol intake and the fact that he is s/p cholecystectomy and has unremarkable LFTs making stone related pancreatitis less likely. He received supportive care while on bowel rest with IVF and IV morphine PRN on admission Though his exam his abdomen is soft and he appears quite comfortable he rated his pain ___ on ___. His pain resolved as ___ and he was tolerating PO fluids and toast/crackers with plans to advance his diet. He had no abdominal pain on exam and his vitals remained stable. At discharge he was avised to abstain from alcohol and continue to advance his diet. For loose stool a cdiff test was sent and was negative in addition to O+P sent for ___. #Significant Eosinophillia with absolute eosinophil count of 7400. Hematology has been consulted to review smear and discuss appropriate workup. Differential remains broad but the magnitude of his eosinophillia is quite high. Hematology evaluated the patient and reviewed his peripheral smear which did show a high number of eo's but no other abnormalities. For now they recommend troponin, CK-MB and EKG which were all normal to exclude end organ damage with eosinophilic cardiac infiltration. Heme recommended beginning an outpatient workup with the following tests: B12 (normal), SPEP (normal), stool O+P (pending), HIV serology, PFTs, TTE, tryptase, strongy ab. *The following tests need to be ordered as an outpatient HIV, strongylodes antibody, PFTs, TTE, tryptase [] *monitor CBC with diff as outpatient *New medications should be minimized, though no allergic medication exposures are known at this time. *If he has persistent eosinophilia he will require more in depth workup as 6 months is required in order to make a diagnosis of hypereosinophillic syndrome. ## HTN: Resume lisinopril but held HCTZ on admission due to limited PO intake. He will resume lisinopril and HCTZ on discharge ##Alcohol abuse: We have advised cessation and have started thiamine and folate. No signs of active withdrawal ## HCV: chronic. Has not received interferon based therapy in the past due to diagnosis of PTSD Medications on Admission: trazadone 150 QHS lisinopril/HCTZ-unsure of dose protonix prn Discharge Medications: 1. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every ___ hours as needed for pain for 3 days. Disp:*20 Tablet(s)* Refills:*0* 2. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed for Insomnia. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day as needed for indigestion. Discharge Disposition: Home Discharge Diagnosis: Acute Pancreatitis Eosinophilia Hypertension Chronic HCV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized for treatment of pancreatitis (inflammation of pancreas). This may have been a result of alcohol use and you are advised to avoid further alcohol use to minimize the chance of this happening again. You underwent a gallbladder operation so it is less likely that this is related to gallstones. Your blood work showed an abnormally high level of white blood cells called, eosinophils. There are many possible reasons for this and your doctors ___ need to do additional tests as well as to monitor this blood cell level. Medication changes: NEW: oxycodone (pain medicine), take as needed for next 3 days continue home blood pressure medications Followup Instructions: ___

10033106-DS-9

DS

2169-06-11 00:00:00

2169-06-11 16:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right groin pain Major Surgical or Invasive Procedure: Aspiration of R seminal vesicle abscess History of Present Illness: ___ yo M with a history of HCV, HTN who presents with right groin pain since ___. He also noticed swelling in his right groin as well associated with tenderness to palpation. He thought it was related to when he lifted a heavy object. The pain persisted and got worse so he presented to the ED for further evaluation. He denies any fevers or chills. He denies any new sexual partners and denies having unprotected sex. He denies any burning with urination, dysuria, or hematuria. He denies a history of STI. He has had a poor PO appetite since the pain started and urinating less frequently during this time. He has continued to take all his home medications. In the ED, initial vitals were: ___ 111/68 16 100% ra - Labs were significant for WBC 14.0 without bands, BUN/Cr ___ (baseline ___, urinalysis with positive leukocytes, positive nitrites, large blood and many WBC and moderate bacteria - CT ab/p revealed a ring-enhancing mass in the area of the right seminal vesicle and bladder wall thickening. - He was seen in the ED who recommended broad spectrum antibiotics with vanc and zosyn and admission to medicine because of medical co-morbidities. - The patient was given 5mg IV morphine x 2, 4.5 g pip-tazo, 1gm vancomycin, and 3L IVF. Vitals prior to transfer were: 98.7 70 117/58 18 100% RA. Upon arrival to the floor, he reports that his pain has significantly improved. Social History: ___ Family History: multiple reported cancers in mother, father, both died in ___;s of cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 ___ 20 98%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, tender 4cm x 4cm area of induration on right groin GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. left EJ Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: Brief Hospital Course: ___ is a ___ year old man with a past medical history of untreated hepatitis C and hypertension who presented with 6 days of right groin pain and swelling found to have a seminal vesicle abscess on CT and subsequently found to have a UTI be bacteremic. He had no fever, chills, dysuria, hematuria, or flank pain. He was afebrile with normal vitals throughout his hospitalization. The seminal vesicle abscess was aspirated, resulting in significant relief of his pain and he was started on IV Zosyn. He was initially treated with IV Zosyn but switched to PO ciprofloxacin based on culture data and ID recommendations. Cultures from the abscess, urine, and blood all grew pan-sensitive E. coli so, per ID recommendations, he was switched to PO ciprofoxacin 500 mg BID and discharged on this regimen to complete a 14 day course from the first negative blood culture. He developed diarrhea on the day before discharge. Urology was consulted and recommended tamsulosin for 3 months post-discharge due to concern for urinary retention. He had 3 PVRs not indicative of urinary retention post-aspiration. He was instructed to f/u with urology 2 weeks after discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. lisinopril-hydrochlorothiazide ___ mg oral DAILY 2. sildenafil 100 mg oral as directed 3. TraZODone 150 mg PO QHS 4. Cyanocobalamin 1000 mcg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Cyanocobalamin 1000 mcg PO DAILY 2. TraZODone 150 mg PO QHS 3. Vitamin D 1000 UNIT PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Ciprofloxacin HCl 500 mg PO Q12H bacteremia RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*26 Tablet Refills:*0 6. Tamsulosin 0.4 mg PO DAILY urinary retention RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*90 Capsule Refills:*0 7. lisinopril-hydrochlorothiazide ___ mg oral DAILY 8. Sildenafil 100 mg ORAL AS DIRECTED Discharge Disposition: Home Discharge Diagnosis: Seminal vesicle abscess Ecoli Bacteremia (blood stream infection) Ecoli Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized at ___ from ___ because you had an abscess (a collection of bacteria and pus) in your groin, an infection in your urine, and an infection in your blood. The abscess in your groin was drained and you were treated with antibiotics. Initially you were given antibiotics by IV, but then you were switched to oral antibiotics. It is important that you continue to take the oral antibiotics (ciprofloxacin 500 mg twice a day) through ___ to ensure that you complete eliminate the infection from your blood. You developed diarrhea the day before discharge. We think this was due to the stool softeners you were taking. If you continue to have diarrhea, please follow up with your PCP. You should also follow up with urology in 2 weeks and with your primary care provider ___ ___ days. It was a pleasure taking care of you. Sincerely, Your ___ Team Followup Instructions: ___

10033290-DS-7

DS

2163-07-08 00:00:00

2163-07-11 16:13:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUE pain/weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with afib on apixaban, CHF, and LBBB who presents from clinic for evaluation of left hand pain and right arm pain. History was obtained with help from a ___ in Yesterday, he developed acute onset numbness and pain in his right hand. Started at 2pm when he was on the bus going home after working for a day. Did not do anything out of the ordinary at work, did not lift heavy boxes. Pain (numbness, some tingling with needle-like sensation) was most severe in his right thumb, and it went up his right arm gradually. Felt like his arm was not there, and he would have to use his left hand to move his right arm around. At ___, sensation was returning, and he started being able to move his arm again. He took eliquis at 8pm, then another at 10pm, and another at midnight. He felt like this helped his weakness. He went to work today and noticed that he was unable to do things as quickly with his right hand. He was also having some trouble with fine motor movements such as buttoning his pants. Still has pain in her right thumb and thenar eminence, sometimes his fingertips as well. Pain is worse with certain positions. Of note, he has been taking 2 tablets of eliquis at midnight since ___ started rather than BID. Past Medical History: afib, CHF, LBBB, varicose veins Social History: ___ Family History: mother with CAD, father with liver cancer, brother died of cancer Physical Exam: ADMISSION PHYSICAL EXAMINATION Vitals: T: 96.8F HR: 60 BP: 141/85 RR: 16 SaO2: 98% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: irregularly irregular Pulmonary: breathing comfortably on RA Abdomen: Soft, NT, ND Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, 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 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [Delt] [Bic] [Tri] [ECR] [FEx][IO] [IP] [Quad] [Ham] [TA] [Gas] L 5 5 5 5 5 4+ 5 5 5 5 5 R 5 5 5 5 5 4+ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 1+ 1+ 1+ 1+ 0 R 1+ 1+ 1+ 1+ 0 Plantar response flexor bilaterally - Sensory: decreased sensation to pin over right thenar eminence, thumb/index/middle/ring fingers, and just below the pinky finger. Dorsum of hand is normal as is the pinky finger. Decreased sensation to LT over similar areas. Intact elsewhere. Increased pain with wrist flexion and extension on the right. - Coordination: No dysmetria with finger to nose testing bilaterally. Able to tap each finger to thumb easily on L hand, more difficult on R hand though pt says this is pain limited. Also slower with rapid alternating movements in R hand. - Gait: deferred DISCHARGE EXAM MS ___, attentive, fluent CN PERRLA, no droop, Motor: ___ throughout, sensory intact to light tough. Able to ambulate with good balance. Reports pain with manipulation of the first carpo-metacarpal joint Pertinent Results: ___ 01:50PM BLOOD WBC-6.8 RBC-4.66 Hgb-14.4 Hct-41.0 MCV-88 MCH-30.9 MCHC-35.1 RDW-12.2 RDWSD-39.2 Plt ___ ___ 07:35PM BLOOD WBC-7.1 RBC-4.67 Hgb-14.4 Hct-41.5 MCV-89 MCH-30.8 MCHC-34.7 RDW-12.2 RDWSD-39.5 Plt ___ ___ 07:35PM BLOOD Neuts-51.1 ___ Monos-8.1 Eos-4.5 Baso-0.3 Im ___ AbsNeut-3.64 AbsLymp-2.54 AbsMono-0.58 AbsEos-0.32 AbsBaso-0.02 ___ 01:50PM BLOOD ___ PTT-33.2 ___ ___ 07:35PM BLOOD ___ PTT-32.9 ___ ___ 01:50PM BLOOD Glucose-126* UreaN-17 Creat-0.8 Na-137 K-4.5 Cl-100 HCO3-26 AnGap-16 ___ 07:35PM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 ___ 07:35PM BLOOD ALT-15 AST-16 AlkPhos-51 TotBili-0.7 ___ 01:50PM BLOOD CK-MB-5 cTropnT-<0.01 ___ 07:35PM BLOOD Albumin-4.4 Calcium-9.4 Phos-4.0 Mg-1.9 Cholest-158 ___ 07:35PM BLOOD %HbA1c-6.3* eAG-134* ___ 07:35PM BLOOD Triglyc-95 HDL-39 CHOL/HD-4.1 LDLcalc-100 ___ 07:35PM BLOOD TSH-1.4 HAND (PA,LAT AND OBLIQUE) RIGHT Severe osteoarthritis of the first CMC and triscaphe joint and probable mild degenerative changes of the radio scaphoid joint. Minimal degenerative change involving the DIP joints. No fracture, dislocation, bone erosion, suspicious lytic or sclerotic lesion, soft tissue calcification or radiopaque foreign body identified. IMPRESSION: Osteoarthritis including severe osteoarthritis of the first CMC and triscaphe joints. No fracture or bone erosion. Brief Hospital Course: ___ man with afib on AC (but not taking it correctly at the moment) presents with R hand pain with a report of weakness after sleeping on the arm. He has had weakness of the arm in the past after sleeping on it in a peculiar way. He main complaint that brought him into the hospital is pain in the joints of the hand. Xray confirmed severe arthritis in the first CMC and triscaphe joint. He was prescribed ibuprofen for pain and given a prescription for a wrist splint to stabilize his hand while sleeping. He was also instructed to take his Eliquis BID in order to best prevent future strokes. He should follow up with his PCP in one week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Furosemide 20 mg PO DAILY:PRN edema 3. Lisinopril 5 mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Simvastatin 40 mg PO QPM Discharge Medications: 1. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Furosemide 20 mg PO DAILY:PRN edema 4. Lisinopril 5 mg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Simvastatin 40 mg PO QPM 7.Hand Splint Please provide splint to the right hand for stabilization during sleep Discharge Disposition: Home Discharge Diagnosis: Hand Arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted with symptoms of hand pain. We performed an xray of your hand which showed a fair amount of arthritis but no evidence of fracture or dislocation. We are providing you with a prescription for ibuprofen to help with the pain as well as a hand splint to stabilize the area while you sleep. It was a pleasure taking care of you. ___ Neurology Followup Instructions: ___

10033409-DS-6

DS

2111-12-09 00:00:00

2111-12-13 17:57:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx uncontrolled DM2 c/b small vessel CVA ___, vascular dementia, recent L5 nerve root injection, frequent UTI p/w one week AMS and nonfocal weakness, superimposed on months of chronic behavior changes. History obtained from daughter (long term care ___), as patient unable to remember recent history. At baseline pt gives conflicting answers and has very poor short term memory; however over the last week she is more confused talking to herself and seems to be hallucinating, crying inappropriately. Hard time mobilizing to car (?weakness). Crying in a wheelchair -- "lost her hope she couldn't walk at all". She usually only uses a wheelchair for longer trips outside the house and uses the rolling walker in the house. ___ night she could not hold herself at all, not even to transfer from wheelchair to bed. Since ___ she hasn't been able to go to day care, not able to bathe in tub. Patient was treated ___ with Cipro for UTI, however abx stopped after the cultures were negative. Has had months of intermittent urinary incontinence. Daughter has not noted any new breathing symptoms (has a chronic dry cough). No sputum production. Has chronic intermittent constipation. Intermittent enemas at home. No fevers. No chills. No clear sweats - maybe that one day it was very hot. No N/V/D. H/o small vessel CVA ___, vascular dementia. At baseline attends Adult Day Care 4x/week, uses rolling walker for ambulation, Mini-mental ___. Behavior changes noted in outpt notes ___. Pt has had at least 3 falls since ___. Fall ___ with head trauma and presented to BID ED, where ___ showed "No acute intracranial process. Chronic small vessel disease and old lacunar infarcts, unchanged from prior." In the ED, initial vitals: 97.1, 76, 123/67, 18, 98% RA Labs were significant for: Plt 141, Alb 2.9 CXR ED ___: "volumes are low with bibasal opacities most suggestive of atelectasis, though difficult to exclude a component of pneumonia in the correct clinical setting." EKG ED: In the ED, pt received: IV Ceftriaxone 1g, IV Azithromycin 500mg Vitals prior to transfer: , 83, 109/97, 16, 99% RA Currently, patient is laying comfortably in bed, afebrile ROS: No photophobia. No fevers/chills/HA/changes in vision/abd pain/burning on urination/dyspnea. Past Medical History: - Vascular dementia without behavioral disturbance ___ - Stroke, small vessel ___: "Around ___ she was noted to have problems with speaking, forgetfulness, and mild right sided weakness. She was seen at ___ for an MRI scan on ___ which showed diffuse periventricular white matter disease. There was also a subacute hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule. MR angiography of the ___ ___ and neck were normal" - Lumbar Radiculitis (sx include low back and R leg pain since ___ MRI lumbar spine ___ showed severe L4-L5 circumferential disc bulge with right neural foraminal stenosis) s/p R L5 lumbar transforaminal selective nerve root injection (2.0 cc of kenalog (40 mg/ml) and 1 cc of 1% of lidocaine) on ___ - DM (diabetes mellitus), type 2, uncontrolled w/neurologic complication (CVA, retinopathy) - Mild nonproliferative diabetic retinopathy ___ - Nephrotic syndrome ___ - CKD stage G2/A3, GFR ___ and albumin creatinine ratio >300 mg/g ___ - Minimal change disease ___ - Hypothyroidism ___: "atrophic thyroid on us ___- prob ___'s" - Hypertension, essential ___ - Hypercholesterolemia ___: "LDL Goal < 70" Social History: ___ Family History: Mother had DM2, lived to ___ No family hx of dementia Physical Exam: ======================= ADMISSION PHYSICAL ======================= VS: 97.6, 164 / 89, 101, 18, 97 RA GEN: Alert, lying in bed, no acute distress. Unable to sit up without assistance, apparently due to truncal weakness HEENT: Moist MM, anicteric sclerae, no conjunctival pallor. NECK: Supple PULM: Bibasilar crackles, no wheezes COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, no lower abdominal TTP EXTREM: Warm, well-perfused, no edema, 2+ DP b/l NEURO: A&Ox2. Symmetric smile, grimace, shoulder shrug, head turn. Mild L ptosis. Neg pronator drift b/l. ___ strength RUE (limited by R shoulder pain), 4+/5 strength LUE, ___ strength b/l ___. ======================= DISCHARGE PHYSICAL ======================= Vitals: 98.7, 153 / 78, 73, 18, 98 Ra General: alert, laying in bed, no acute distress HEENT: MMM, anicteric sclera Lungs: clear to auscultation bilaterally, no wheezes CV: regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-distended Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: Does not cooperate fully with neuro exam. Oriented to self and "hospital", does not know year. Mild L ptosis. B/l stiffness on passive plantarflexion and dorsiflexion. Stiff (?Cogwheeling) at wrists b/l. Pertinent Results: ========================= ADMISSION LABS ========================= ___ 05:53PM BLOOD WBC-7.7 RBC-3.86* Hgb-12.6 Hct-36.8 MCV-95 MCH-32.6* MCHC-34.2 RDW-12.6 RDWSD-43.9 Plt ___ ___ 05:53PM BLOOD Neuts-64.0 ___ Monos-8.8 Eos-2.0 Baso-0.5 Im ___ AbsNeut-4.92 AbsLymp-1.87 AbsMono-0.68 AbsEos-0.15 AbsBaso-0.04 ___ 05:53PM BLOOD Glucose-227* UreaN-17 Creat-0.8 Na-133 K-3.4 Cl-100 HCO3-26 AnGap-10 ___ 05:53PM BLOOD ALT-22 AST-19 AlkPhos-51 TotBili-0.3 ___ 06:20AM BLOOD CK(CPK)-68 ___ 05:53PM BLOOD cTropnT-<0.01 ___ 07:20AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 05:53PM BLOOD Albumin-2.9* Calcium-9.2 ___ 07:20AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7 ___ 06:20AM BLOOD TSH-13* ___ 06:20AM BLOOD Free T4-1.1 ___ 12:24AM BLOOD Lactate-1.3 ___ 05:53PM BLOOD Lipase-32 ========================= DISCHARGE LABS ========================= ___ 06:20AM BLOOD WBC-8.8 RBC-4.26 Hgb-14.0 Hct-40.3 MCV-95 MCH-32.9* MCHC-34.7 RDW-12.8 RDWSD-44.1 Plt ___ ___ 06:20AM BLOOD Neuts-63.4 ___ Monos-8.9 Eos-2.0 Baso-0.7 Im ___ AbsNeut-5.59 AbsLymp-2.18 AbsMono-0.79 AbsEos-0.18 AbsBaso-0.06 ___ 06:20AM BLOOD Glucose-182* UreaN-22* Creat-0.7 Na-138 K-3.5 Cl-103 HCO3-24 AnGap-15 ___ 06:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9 ========================= MICRO ========================= ___ 12:10 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:08 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:53 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ========================= IMAGING SUMMARIES ========================= ___ Imaging MRI CERVICAL, THORACIC, LUMBAR 1. Lumbar spondylosis, similar from examination of ___ with degenerative grade 1 anterolisthesis of L4 on L5 and L5 on S1, severe L4-L5 spinal canal narrowing crowding the cauda equina, severe L4-L5 right and moderate to severe neural foraminal narrowing and bilateral L5-S1 moderate to severe bilateral neural foraminal narrowing. 2. Cervical spondylosis results in bilateral moderate neural foraminal narrowing at multiple levels without high-grade spinal canal narrowing. 3. No significant spinal canal or neural foraminal narrowing at the thoracic spine. 4. No cord signal abnormality. 5. Additional findings as described above. ___ Imaging MR HEAD W/O CONTRAST 1. No acute infarct. 2. Confluent moderate to severe subcortical and periventricular T2/FLAIR white matter hyperintensities are nonspecific, but compatible with chronic microangiopathy in a patient of this age. 3. Moderate cerebral volume loss. 4. Additional findings as described above. ___ Imaging CT HEAD W/O CONTRAST No intracranial hemorrhage. Stable chronic lacunar infarct left basal ganglia, internal capsule. Severe chronic small vessel ischemic changes. ___ Imaging CHEST (PA & LAT) AP upright and lateral views of the chest provided. Lung volumes are low with bibasal opacities most suggestive of atelectasis, though difficult to exclude a component of pneumonia in the correct clinical setting. No large effusion, pneumothorax. No signs of congestion or edema. Cardiomediastinal silhouette is unchanged. Bony structures appear intact. ___BD & PELVIS WITH CO No acute findings to account for abdominal pain. Incidental findings as detailed above. Brief Hospital Course: Ms ___ is a ___ with poorly controlled DM2 c/b small vessel CVA ___ and vascular dementia who presents with one week of worse-than-usual confusion, increased frequency of urinary incontinence, and nonfocal weakness, superimposed on months of chronic behavior changes, likely progression of vascular dementia. She was noted to have intermittent urinary retention while admitted. ==================== ACUTE ISSUES ==================== # Altered Mental Status Believed to be progression of vascular dementia. ICH/ischemic stroke ruled out by NCHCT and MRI. Patient is afebrile, no leukocytosis, neg UCx from ___, CXR shows most likely atelectasis and no SOB/change in chronic dry cough. No current medications or electrolyte abnormalities that could cause toxic/metabolic AMS. NPH unlikely given imaging. Neuro consulted, recommended contrast MRI of brain, and C, T, L-spine. These spine MRIs showed no interval changes compared to prior in ___ (stable lumbar and cervical spondylosis with spinal canal narrowing and neural foramen narrowing). MRI brain shows no acute infarct, just confluent subcortical ___ changes c/w chronic microangiopathy. Ortho Spine does not think surgery is indicated in this pt because her neuro deficits do not correlate with MRI findings, so surgery not likely to improve her function. Per Neuro Movement Disorders, pt has Parkinsonism from either vascular dementia vs actual ___ dz. Plan is to trial Carbidopa-Levodopa (___) 0.5 TAB PO TID until follow up with Dr. ___ in ___ months. # Urinary incontinence Subacute vs chronic. Could be related to progression vascular dementia. Bladder scans this admission c/f retention, decided on straight cath BID with titration of frequency as needed. ==================== CHRONIC ISSUES ==================== # Nephrotic syndrome: high protein diet (Ensure). Chronic (last albumin also 2.9 in outpatient setting in ___ - monitor albumin - urine protein and albumin # HTN: continue home losartan 100mg PO QD and hydrochlorothiazide25mg PO QD # DM2: managed with lifestyle interventions at home. Started ISS ___ because ___ # Hypothyroidism: continue home levothyroxine 125 mcg PO QD # Hypercholesterolemia: continue home simvastatin 40 mg tablet PO QPM ===================== TRANSITIONAL ISSUES ===================== - re-check TSH in 2 weeks as outpt (was ___ here with normal free T4) - family education on physical assist, straight cathing (some of daughters are ___) - BID straight catherization, tirate frequency as needed - submitted requet for electric bed. Will also need ___ lift and ramp at home before returning home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. losartan-hydrochlorothiazide 100-25 mg oral DAILY 3. Simvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Artificial Tears 1 DROP BOTH EYES TID 6. melatonin 1 mg oral QPM:PRN 7. Aspirin 81 mg PO DAILY 8. Acetaminophen 650 mg PO BID:PRN Pain - Mild 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Carbidopa-Levodopa (___) 0.5 TAB PO TID 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Senna 8.6 mg PO BID:PRN constipation 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Artificial Tears 1 DROP BOTH EYES TID 6. Aspirin 81 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. losartan-hydrochlorothiazide 100-25 mg oral DAILY 11. melatonin 1 mg oral QPM:PRN 12. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Weakness - Acute on chronic encephalopathy or dementia - Urinary incontinence and urinary retention 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 ___ and family, WHY WAS I ADMITTED TO THE HOSPITAL? - you have been more confused over the past week - you have been having weakness as well WHAT WAS DONE FOR ME IN THE HOSPITAL? - we ruled out other causes of your confusion and believe it is due to progression of your vascular dementia - A head CT and brain MRI were performed - our Neurologist and Movement Disorder Specialists evaluated you for your weakness and rigidity and started you on Sinemet for ___ stiffness - we worked with case management to apply for more equipment at home for after rehab WHAT SHOULD I DO WHEN I GO BACK TO HOME? - review your medication list and take as prescribed - follow up with the neurology movement disorder clinic as recommended below - work with your rehab doctors - please work with physical therapy - Straight cath twice a day and record the values of how much urine comes out in a log to show your doctor. It was a pleasure to take part in your care. Sincerely, Your ___ team Followup Instructions: ___

10033552-DS-6

DS

2132-07-02 00:00:00

2132-07-02 21:16:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Atenolol / Amlodipine / Tekturna / felodipine Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Lap appendectomy History of Present Illness: Mrs. ___ is a ___ yo F with a past medical history of GERD, hypertension, and chronic kidney disease. She is presenting with sudden onset RLQ abdominal pain that began at 9 am this morning. She reports that the pain began in the periumbilical area and localized to the RLQ. She has experienced nausea this morning but no emesis, she reports being slightly hungry. She did have some chills earlier but no subjective fevers. She denies any urinary symptoms, as well as any back or flank pain. WBC 11.3 in the ED, CT abdomen highly suspicious for acute appendicitis. Past Medical History: PMH: GERD, HL, HTN, CKD PSH: Hysteroscopy w/ dilation and curretage (___), Tonsillectomy ___ for cyst), resection bilateral wrist cysts Social History: ___ Family History: FH: HTN in mother, CVA and prostate cancer in father Physical ___: On admission: PE: 99.7 92 140/71 16 95% RA NAD, AAO RRR CTA b/l soft, nondistended abdomen, tender to palpation in RLQ with voluntary guarding no peripheral edema or cyanosis On discharge: 97.8, 83, 104/75, 18, 94% RA Gen: NAD, AAOx3 CV: RRR no m/r/g Pulm: CTAB no w/r/r Abd: Soft, appropriately TTP about incisions, ND, +BS. Incisions with dermabond, c/d/i. Ext: WWP no c/c/e Pertinent Results: ___ 02:40PM BLOOD WBC-11.3*# RBC-5.12 Hgb-14.8 Hct-47.4 MCV-93 MCH-28.8 MCHC-31.1 RDW-12.6 Plt ___ ___ 02:40PM BLOOD Neuts-79.6* Lymphs-15.7* Monos-3.3 Eos-1.1 Baso-0.2 Imaging: CT A/P ___ - wet read): 1. Dilated appendix measuring up to 1.8-cm with surrounding inflammatory changes concerning for acute appendicitis. There is a focus of gas within the tip of the lumen. No abscess is identified, however there is a small amount of pelvic free fluid. 2. Heterogeneous, enlarged uterus is concerning for fibroids. Brief Hospital Course: Ms. ___ was admited to the ___ service with HPI as stated above and went to the OR for an uncomplicated lap appy, which procedure she tolerated well. For full details please see the dictated operative report. She was extubated and went to the PACU in good condition. In the PACU she rapidly improved and was quickly ambulating, voiding, tolerating a regular diet, and saturating well, and she stated desire to be discharged. She was evaluated by surgery resident in the PACU and exam was non-concerning (see above). She is discharged to home on ___ with appropriate information, warnings, prescriptions, and plans to follow up. Medications on Admission: Simvastatin 40 mg PO DAILY Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Simvastatin 40 mg PO DAILY 2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Acetaminophen ___ mg PO Q6H:PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain No driving nor operating other machinery while using narcotics RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 6. Docusate Sodium 100 mg PO BID Take twice daily while still using narcotic pain meds RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute appendicitis 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 acute appendicitis. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home with the following instructions: Please follow up at the appointment in clinic listed below. We also generally recommend that patients follow up with their primary care provider after having surgery. We have scheduled an appointment for you listed below. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. Don't lift more than ___ lbs for ___ weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: You may feel weak or "washed out" a couple weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You could have a poor appetite for a couple days. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Tomorrow you may shower and remove the gauzes over your incisions. Under these dressings you have small plastic bandages called steristrips. 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. Your incisions may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: Constipation is a common side effect of narcotic pain medicaitons. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Do not drink alcohol or drive while taking narcotic pain medication. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the 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. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: ___

10033661-DS-20

DS

2162-07-01 00:00:00

2162-07-01 12:05:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Celebrex / codeine / Demerol / epinephrine / epinephrine / Penicillins / scallops / shellfish derived Attending: ___. Chief Complaint: LC1 pelvis fracture Major Surgical or Invasive Procedure: None History of Present Illness: ___ female history arthritis, COPD, osteoporosis, skin cancer, glaucoma who presents with right groin pain status post fall from bed. She states that she was trying get out of bed when she fell directly onto the ground onto her right side. She was unable to ambulate after then due to the pain. She was evaluated outside hospital where there was concern for possible periprosthetic fracture as well as subarachnoid hemorrhage, so she was transferred here for further evaluation. On repeat imaging, no periprosthetic fracture or subarachnoid hemorrhage, and no other injuries identified by trauma surgery. She is complaining of severe groin pain and inability to move the leg. No numbness or tingling. Endorses head strike, but denies loss of consciousness. Past Medical History: COPD, glaucoma, arthritis, osteoporosis, skin cancer Social History: ___ Family History: See OMR Physical Exam: Vitals: ___ 0720 Temp: 98.1 PO BP: 114/61 HR: 72 RR: 17 O2 sat: 94% O2 delivery: Ra General: Well-appearing, breathing comfortably MSK: - Pelvis stable - TTP in R groin - Grossly motor intact bilateral lower extremities - SILT bilateral lower extremities Pertinent Results: See OMR 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 LC1 minimally displaced pelvic fracture and was admitted to the orthopedic surgery service for pain control and placement. The patient was given anticoagulation with enoxaparin per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, and the patient was voiding/moving bowels spontaneously. The patient is weight-bearing as tolerated in the right lower extremity, and will be discharged on enoxaparin 40mg SC daily for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: Omeprazole Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 200 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain Please take with Tylenol, wean ASAP RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as needed Disp #*20 Tablet Refills:*0 5. Senna 17.2 mg PO BID 6. Gabapentin 100 mg PO TID 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R LC1 pelvis 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: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for monitoring after your pelvis fracture. This injury is treated non-operatively, and you may continue to work on walking and building your strength back at the rehab facility. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated, no ROM restrictions 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 ___ tablet every 4 hours as needed x 1 day, then ___ tablet every 6 hours as needed x 1 day, then ___ tablet every 8 hours as needed x 2 days, then ___ tablet every 12 hours as needed x 1 day, then ___ 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 enoxaparin 40mg daily for 4 weeks 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 - 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 <30 DAYS OF REHAB Physical Therapy: WBAT bilateral lower extremities No braces needed Crutches or Walker PRN per physical therapy Treatments Frequency: No surgical incisions - non-operative treatment Followup Instructions: ___

10033710-DS-2

DS

2168-11-29 00:00:00

2168-11-29 12:43:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: codeine Attending: ___. Chief Complaint: Right intertrochanteric femur fracture Major Surgical or Invasive Procedure: ___: Right trochanteric femoral nail History of Present Illness: This is a ___ female who presents to the emergency department at ___ in transfer from ___ with right intertrochanteric hip fracture, right fifth metacarpal neck fracture, and T/L-spine compression fractures status post an unwitnessed ground level fall. Patient is oriented only to self and so much of the history is obtained from discussion with members of the emergency department staff and review of the medical records from the outside facilities. Ms. ___ does endorse pain to her right hip and right hand. She denies pain elsewhere. She states she has no numbness or tingling of her right lower extremity. She denies head strike. She denies loss of consciousness. Per review of outside facility records the patient was brought into ___ by ambulance from ___ where the patient resides in the memory care unit. She reportedly was found down approximately 30 minutes prior to arrival at that hospital. She initially complained only of right hip pain. Evaluation at ___ demonstrated a right intertrochanteric hip fracture, right fifth metacarpal neck fracture, question of acute versus chronic right olecranon fracture, and T/L-spine vertebral compression fx. She was also found to have an abrasion over the posterior aspect of the elbow. Past Medical History: Atrial fibrillation not on anticoagulation dementia Depression History of clavicle fracture Glaucoma Hearing loss Orthostatic hypotension Osteoporosis Vertigo Open reduction internal fixation closed left hip fracture, ___ Cataract extraction, ___ Social History: ___ Family History: NC Pertinent Results: see OMR Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopaedic surgery team. The patient was found to have right intertrochanteric femur fracture and was admitted to the orthopaedic surgery service. The patient was taken to the operating room on ___ for right trochanteric femoral nail, 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 rehab 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 weightbearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Brinzolamide 1% Ophth (*NF* ) 1 drop Other TID 4. Digoxin 0.0625 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Aspirin 325 mg PO DAILY 8. Sertraline 50 mg PO DAILY 9. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Right hip fracture Discharge Condition: Mental Status: Confused - sometimes. 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: -Weightbearing as tolerated right lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add low-dose 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: 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. - 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 greater than 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 FOLLOW UP: Please call ___ to schedule a follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: Your incision is closed with Monocryl sutures that will be assessed at your 2-week postoperative visit. If the dressing falls off on its own three days after surgery, no need to replace the dressing unless actively draining. Followup Instructions: ___

10034049-DS-15

DS

2156-11-10 00:00:00

2156-11-10 14:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: abdominal pain, AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ PMHx chronic pain on methadone, chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS and abdominal pain. History is predominant obtained from son and ___ sign-out as patient is limited by her mental status. Patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream. 2 days ago, she reportedly developed new urinary incontinence and symptoms of dysuria as well as malorous urine c/w prior UTI. She also has been having 2 days of suprapubic abdominal pain. Since yesterday, she also developed new intermittent confusion and disorientation. In the ___, initial VS 97.1, 83, 178/96, 18, 97% on RA. Initial labs were notable for Na 137, K 3.1, Cr 0.8, WBC 6.3, Hgb 10.8 (baseline Hgb ~12), Plt 182. Lactate 2.1. UA grossly positive with mod leuks, sm bld, positive nitrites, 69 WBC, and few bacteria. She was given ceftriaxone prior to transfer to the floor. Given agitation, she required olanzapine x 1 in the ___ prior to transfer. Upon arrival to the floor, the patient states that her son is transitioning her care from ___ to ___. The patient reports significant suprapubic discomfort and states that she has to urinate. She states that she self-catheterizes herself at home intermittently, but cannot explain to me what her underlying urologic issue is and if she has seen urology in the past. She does not know if her BLE edema is stable. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HTN hypothyroidism chronic venous stasis ulcers recurrent UTIs chronic pain back injury NOS asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: NC Physical Exam: Admission Physical Exam Vitals- 98.3 159 / 88 84 20 96 RA GENERAL: well-appearing elderly female lying in bed in NAD HEENT: MMM, NCAT, EOMI, anicteric sclera CARDIAC: RRR, nml S1 and S2, no m/r/g LUNGS: Clear to auscultation bilaterally, unlabored respirations ABDOMEN: soft, obese, somewhat distended EXTREMITIES: wwp, chronic venous stasis changes bilaterally with scattered healing wounds SKIN: chronic venous stasis changes as above NEUROLOGIC: AOx2 (able to state month, states she is in a "hospital", and to self), grossly nonfocal Discharge Physical Exam: Vital Signs: 98.2 PO 137 / 73 74 18 94 RA GENERAL: elderly woman sitting up in bed. HEENT: MMM, anicteric sclera CARDIAC: RRR LUNGS: CTAB, no accessory muscle use ABDOMEN: soft, obese, non-tender, non distended. EXTREMITIES: wwp, chronic venous stasis changes bilaterally with scattered healing wounds, dressing that is C/D/I. SKIN: chronic venous stasis changes as above NEUROLOGIC: alert, oriented to hospital and to self, moving all extremities Pertinent Results: ___ 08:54PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08:54PM URINE BLOOD-SM NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD ___ 08:54PM URINE RBC-4* WBC-69* BACTERIA-FEW YEAST-NONE EPI-1 ___ 08:54PM URINE MUCOUS-OCC ___ 07:57PM LACTATE-2.1* ___ 07:48PM GLUCOSE-201* UREA N-7 CREAT-0.8 SODIUM-137 POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-30 ANION GAP-16 ___ 07:48PM WBC-6.3 RBC-3.74* HGB-10.8* HCT-31.6* MCV-85 MCH-28.9 MCHC-34.2 RDW-14.1 RDWSD-43.6 ___ 07:48PM NEUTS-75.0* LYMPHS-16.1* MONOS-6.6 EOS-1.3 BASOS-0.5 IM ___ AbsNeut-4.75 AbsLymp-1.02* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.03 ___ 07:48PM PLT COUNT-182 Micro: ___ BCx x 2 pending ___ UCx pending Imaging/Studies: none Micro: ___ 8:54 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: STAPH AUREUS COAG +. >100,000 CFU/mL. 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 _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Blood Cultures: Negative TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No echocardiographic evidence of endocarditis or pathologic flow. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Elevated PCWP suggested. MRI: IMPRESSION: 1. Incomplete examination with acquisition of localizer and sagittal T2 images only. 2. Provided images demonstrate levoscoliosis with moderate to severe L3-L4 and severe L4-L5 spinal canal stenosis with moderate to severe multilevel neural foraminal narrowing, as detailed above. Recommend repeat examination when the patient is able to better tolerate the entire exam. 3. Suboptimal evaluation for epidural fluid collection on this study although there is no obvious evidence. Discharge Labs: ___ 06:57AM BLOOD WBC-4.7 RBC-3.84* Hgb-10.7* Hct-32.2* MCV-84 MCH-27.9 MCHC-33.2 RDW-14.0 RDWSD-42.3 Plt ___ ___ 06:57AM BLOOD Glucose-208* UreaN-13 Creat-0.8 Na-136 K-4.4 Cl-95* HCO3-30 AnGap-15 Brief Hospital Course: Ms. ___ is a ___ PMHx chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS and UTI. # abdominal pain likely ___ # complicated MRSA UTI. # urinary retention Patient with history of recurrent UTIs (6 within past ___ years per son); she is likely at risk for UTIs in the setting of urinary stasis. It is unclear why the patient requires intermittent self-catheterization. She has been referred to uro-gyn by her ___ PCP but unclear if she actually attended any visits. Per son, she has history of a "lady cancer" with episodes of recurrence necessitating chemo/randiation, last was ~ ___ years ago. CT scan without clear etiology for pain. Urine culture with MRSA in urine. No growth in blood cultures. MRI as suboptimal study but without clear epidural collection. In the setting of MRSA bactermia up to 27% of patients with have bacteruria but in studies of patients with MRSA bacteruria only 1 in 30 patients has MRSA bactermia. MRI L-spine incomplete study but no definitive abscess and patient would like to not complete pain at baseline level. TTE suboptimal study but no frank vegetations and negative blood cultures make risk of TEE higher than benefit. She was treated with IV vancomycin and then transitioned to doxycycline (given sulfa allergy will not use Bactrim) for complicated UTI for 10 day course when her blood culture finalized as negative. # Encephalopathy Likely induced in the setting of acute infection as described above. Patient without other evidence of metabolic derangements at this time. Home methadone and pain regimen initially held and then restarted slowly as mental status improved. She returned to her baseline mental status. # Concern for elder abuse: Patient reported verbal abuse from her son with whom she lives with. No evidence of physical abuse on my exam. Mental status is improved and long discussion with PCP and SW. I spoke for some time about the situation with her son. She reports that he is not physically abusive but is verbally and is nervous about him. When we discussed she reports that she does not want to move forward with a police filing or a restraining order because of what it would do to her family. I was also able to speak with her PCP for about ___ minutes who reports that they have had similar concerns but that she has declined reporting in the past due to the same concerns. Her PCP reports that she can be difficult to engage in follow up be reported that at her baseline (which she is at) she has been found to have capacity to make her own decisions.as well. Social work was involoved and relayed information to the open elder services case. # Hypothyroidism TSH is very abnormal though notably with normal free T4. Home levothyroxine continued. # Chronic pain # Rheumatoid arthritis Home prednisone continued. Home methadone continued. Home oxycodone restarted. # HTN: Continued home losartan, amlodipine, triamterene-HCTZ # HLD: Continued home statin # Depression. Continued home sertraline # GERD. Continued home omeprazole # T2DM: Home metformin held and patient managed with ISS. Restarted at discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 2. amLODIPine 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Gabapentin 300 mg PO QID 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 8. Methadone 10 mg PO QHS 9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 10. Aspirin 81 mg PO DAILY 11. Methotrexate 2.5 mg PO Frequency is Unknown 12. Nabumetone 500 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Sertraline 100 mg PO DAILY 15. PredniSONE 5 mg PO DAILY 16. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*14 Capsule Refills:*0 3. Senna 8.6 mg PO BID:PRN constipation 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours Disp #*10 Tablet Refills:*0 5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 50 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 13. Methadone 10 mg PO QHS RX *methadone 10 mg 10 mg by mouth at bedtime Disp #*3 Tablet Refills:*0 14. Methotrexate 10 mg PO QSUN 15. Multivitamins 1 TAB PO DAILY 16. Nabumetone 500 mg PO BID 17. Omeprazole 20 mg PO DAILY 18. PredniSONE 5 mg PO DAILY 19. Sertraline 100 mg PO DAILY 20. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 21. HELD- Gabapentin 300 mg PO QID This medication was held. Do not restart Gabapentin until follow up with PCP. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: urinary tract infection encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for confusion and concern for urinary tract infection. You were treated with IV antibiotics and found to have a MRSA UTI. You were investigated for a bloodstream source ant it was negative. Both TTE and MRI did not show any focus of infection. Please take your medications as directed and follow up with your PCP once discharge. Followup Instructions: ___

10034049-DS-18

DS

2157-11-23 00:00:00

2157-11-23 10:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, DM2, asthma, depression, anxiety who presents with AMS. The patient's son is not present, but the patient tells me that he brought her to the ED. She says "he's an ex ___, he thinks he knows everything but knows nothing. I think he jumped the gun bringing me here, overreading into things". She was noted to be reportedly lethargic in the ED. The patient is oriented to ___, ___, and can recite the days of the weeks backwards. She says she has had 2 days of malaise and feeling overall unwell. No myalgias, subjective fever, nausea, vomiting, dysuria, hematuria. However she does have suprapubic discomfort the past 2 days. She denies flank or back pain. No dyspnea or chest pain. Of note she was admitted/discharged ___ for AMS due to UTI and found to have enterococcus. ___ as outpatient she had urine culture for urinary urgency/dysuria by PCP and that showed GBS. She completed a 5 day course of Macrobid for that. ED: ___. Got IV Tylenol, IV vanc, IV CTX for presumed UTI. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy ___ ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: sitting up in chair EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, mildly TTP across upper abdomen. Bowel sounds present. MSK: Neck supple, moves all extremities NEUROLOGIC: Oriented to person, place, and situation Pertinent Results: ___ 05:06AM BLOOD TSH-20* CT ABD 1. Bladder appears mildly inflamed, correlate for cystitis. No signs of pyelonephritis. 2. Marked degenerated disease at L4-5, similar to prior, better assessed on prior CT and MRI. Please correlate clinically. 3. Renal hypodensities, possibly cysts, several too small to characterize. ___ 7:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Ms. ___ is a ___ female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, NIDDM2, asthma, depression, anxiety who presents with AMS and fever, found to have a UTI. #UTI #Metabolic encephalopathy: The patient presented with increased frequency of urination, foul-smelling urine, and disorientation. Pt's UCx grew Ecoli that was sensitive to CTX and cipro. Pt improved after IV ceftriaxone and was transitioned to PO cipro, to complete a 7d course (last day = ___ for complicated UTI. Pt was then discharged to ___ Rehab. When discussing a discharge plan with the patient, she reported that she would like to stay in the hospital a little longer. When asked why this was the case, she alluded to issues at home and with her son with whom she lives. She explained that her son is a former ___ and has anger management issues. She reported theft of her personal property and suggested verbal abuse. Before providing more details, however, the patient became very nervous and shut down, expressing regret that she said anything at all, fearful of suffering retaliation. Based on patient's reports in the morning, an online EPS report was filed. #Slow-transit constipation: Exacerbated by chronic opioid use. Employing docusate, senna, polyethylene glycol, and bisacodyl suppositories titrated to have daily bowel movements. #Rheumatoid arthritis: Pt's home 5mg pred was continued. Of note, on presentation due to concerns for sepsis, pt received one dose of stress dose steroids, 100mg hydrorcortisone IV x1, which were then discontinued when pt was stable upon arrival to the floor. #NIDDM2 - SSI while inpatient, held home oral agents. Resume at discharge #HTN - Continued home losartan, amlodipine, HCTZ-triamterene #HLD - Continued home statin #Anxiety - Continued home zoloft #Hypothyroidism - Continued home synthroid (takes weekly ___ mcg/kg x7)) to help with compliance. TSH was elevated at 20, and the patient's son reported she has not been taking at home. #TRANSITIONAL: [ ] On CT A/P: Marked degenerated disease at L4-5, similar to prior, better assessed on prior CT and MRI. Nothing on exam to suggest myelopathy at this time; for outpatient follow up. [ ] Complete ciprofloxacin 500 mg q12 hr on ___ Ms. ___ was seen and examined on the day of discharge is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Losartan Potassium 50 mg PO DAILY 7. Methadone 10 mg PO Q8H:PRN severe back pain 8. Nabumetone 500 mg PO BID 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Omeprazole 20 mg PO DAILY 11. PredniSONE 5 mg PO DAILY 12. Senna 8.6 mg PO BID:PRN constipation 13. Sertraline 200 mg PO DAILY 14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 17. Gabapentin 600 mg PO QID 18. Levothyroxine Sodium 1000 mcg PO EVERY ___ 19. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 22. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS Discharge Medications: 1. Bisacodyl 10 mg PR ONCE Duration: 1 Dose 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Polyethylene Glycol 17 g PO BID 4. Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime 5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 600 mg PO QID 12. Levothyroxine Sodium 1000 mcg PO EVERY ___ 13. Losartan Potassium 50 mg PO DAILY 14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 15. Methadone 10 mg PO Q8H:PRN severe back pain 16. Multivitamins 1 TAB PO DAILY 17. Nabumetone 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Omeprazole 20 mg PO DAILY 20. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 21. PredniSONE 5 mg PO DAILY 22. Senna 8.6 mg PO BID:PRN constipation 23. Sertraline 200 mg PO DAILY 24. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 25. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 26. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: UTI 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 hospitalized for a very severe infection. Now that you are stable, you are able to leave and be discharged to ___ Rehab. Please be sure to follow-up with your appointments listed below. We wish you the best with your health. Warm regards, ___ Health Followup Instructions: ___

10034049-DS-19

DS

2158-03-02 00:00:00

2158-03-02 18:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F w/ severe RA w/ leukocytoclastic vasculitis, venous insufficiency, hypothyroid, DM, presenting with abdominal pain and AMS. Per EMS, found seated hunched over on portable commode in bedroom of residence, alert and oriented x4 with warm, dry skin. Pt complained of constipation x2 days with associated abdominal pain. Family member reports pt had two bowel movements today but pt reports still feeling "urgent need to go." Pt reports that she is "very blocked up." On our assessment, patient intermittently reports abdominal pain. Also mentions a fall, unsure when. Reports some mid back pain. Unable to obtain other significant history. Recent ___ admission for fall, thought to be due to deconditioned/meds, also hypothyroid, restarted on levothyroxine. D/c to SAR. Noted to have difficulty with med compliance. EMS physical: L sided tenderness in LUQ on palpation. No distention, rigidity or masses felt. Pt had multiple large bruises all over her body which family member and pt report are from repeated falls in residence. Pt denied chest pain, shortness of breath, nausea, vomiting, fever or chills. Pt was extricated via stair chair, secured to stretcher and transported to BID with no further change in condition. In the ED: On EMS arrival, the patient endorsed LUQ tenderness. Notably, the patient recently had a ___ admission for a fall due to suspected deconditioning. The patient was noted to have difficulty with med compliance. The patient reports bilateral ___ pain. Denies fever, chills, dyspnea, chest pain, or n/v. Initial vital signs were notable for: 97.7 83 130/69 18 98% RA Exam notable for: Patient AAOx2, trying to get out of bed. PERLA, EOMI, no obvious head trauma No C spine tenderness, mild T spine tenderness Flinches with abdominal palpation, especially on the left side. But is soft and not notably distended LEs with bilaterally venous stasis changes and multiple open wounds that do not appear actively infected Labs were notable for: 141 95 12 ---------------< 147 3.6 28 1.0 8.3 > 10.7/33.6 < 207 UA: Large leuks, 30 protein, 40 WBCs Studies performed include: CT head: No acute intracranial process. Diffuse hypodensities in the white matter again seen, similar in extent to CT head dated ___ and ___ which could be related to prior therapy or due to extensive small vessel disease. CT C-Spine 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes including mild anterolisthesis of C2 on C3, intervertebral disc space narrowing, and osteophytosis worse at C4-C5. CT Abd/Pelvis with contrast: 1. Ground-glass opacification in the posterior segment of the right upper lobe that may represent infection. 2. No intrathoracic or intra-abdominal sequela of trauma. 3. Irregularity and lucency at the superior endplate of L5 and inferior endplate of L4 are slightly progressed when compared to prior dated ___ and infection cannot be excluded. 4. Nonspecific, unchanged prominent pelvic lymph nodes. 5. Prominent bilateral external iliac lymph node are again seen measuring up to 0.9 cm in short axis, nonspecific. 6. Mild stranding adjacent to the left adrenal may represent possible adrenal injury. 7. Unchanged, indeterminate renal lesion in the interpolar region of the right kidney seen since ___. Non emergent follow-up renal ultrasound is recommended if no prior characterization has been performed. Pt was given: Olanzapine for agitation Tylenol Cefpodoxime 200mg Ceftriaxone 1g Azithro IVF sitter for agitation Consults: None Vitals on transfer: T102.7, BP 171/92, HR90, RR20, 94% RA Upon arrival to the floor, pt was somnolent and stated she had L-sided pain of her torso. Her attention waxed/waned and she responded somewhat appropriately when prodded. Vital signs were significant for hypertension and febrile to 102.7 reduced to 100 with IV Tylenol. Her HCP, her son, was called for assessment of her baseline which he says is AOx4 and occasionally combative. She has a history of recurrent UTIs which present with similar delirium. Has mild baseline dementia with forgetfulness of certain memories but functional and independent otherwise. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy ___ ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Intermittent urinary retention Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient previously stated her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T102.7, BP171/92, HR90, RR20, 94%RA GENERAL: Somnolent, responds appropriately intermittently. In mild distress ___ abd pain. HEENT: NCAT. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: Unable to evaluate for CVA tenderness ___ pt refusal. ABDOMEN: Soft, non distended, tender to palpation in left quadrants (LUQ worse than LLQ). Healed surgical scar on R. EXTREMITIES: B/L ___ erythema with multiple bruises and scars in various stages of healing with overlying blanching well-demarcated erythema. Warm to touch. L leg erythema outlined on ___. Pulses DP/Radial 2+ bilaterally. SKIN: See Ext above. Warm. NEUROLOGIC: Sensation intact in ___. DISCHARGE PHYSICAL EXAM: ============================ VITALS: 98.5 PO 99 / 58 71 16 95 RA GEN: Lying in bed on her left side, eyes closed CV: Normal rate, regular rhythm, no m/r/g Pulm: CTAB Abdomen: Deferred due to abdominal pain Ext: B/L ___ with erythema with bruising and skin breakdown c/w venous stasis changes Neuro: EOMI, R facial droop, R upper extremity can elevate without resistance, can move R toes and ankle, improved from prior, grossly normal on the Left side Pertinent Results: ADMISSION LABS: ================= ___ 03:31AM BLOOD WBC-8.3 RBC-3.80* Hgb-10.7* Hct-33.6* MCV-88 MCH-28.2 MCHC-31.8* RDW-15.5 RDWSD-49.9* Plt ___ ___ 03:31AM BLOOD Neuts-87.3* Lymphs-6.8* Monos-4.6* Eos-0.4* Baso-0.4 Im ___ AbsNeut-7.36* AbsLymp-0.57* AbsMono-0.39 AbsEos-0.03* AbsBaso-0.03 ___ 03:25AM BLOOD Glucose-147* UreaN-12 Creat-1.0 Na-141 K-3.6 Cl-95* HCO3-28 AnGap-18 ___ 03:25AM BLOOD ALT-9 AST-10 AlkPhos-113* TotBili-0.7 ___ 03:25AM BLOOD Lipase-10 ___ 10:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.4* ___ 03:25AM BLOOD Albumin-4.3 ___ 02:29AM BLOOD Glucose-112* Lactate-2.3* Na-139 K-3.4 Cl-98 calHCO3-26 INTERVAL LABS: =============== ___ 07:25AM BLOOD ___ PTT-28.5 ___ ___ 07:25AM BLOOD Ret Aut-2.3* Abs Ret-0.08 ___ 03:30AM BLOOD Lipase-79* ___ 03:00PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7 Cholest-118 ___ 07:25AM BLOOD calTIBC-229* VitB12-731 Ferritn-186* TRF-176* ___ 03:00PM BLOOD %HbA1c-6.1* eAG-128* ___ 03:00PM BLOOD Triglyc-181* HDL-40* CHOL/HD-3.0 LDLcalc-42 ___ 10:45AM BLOOD TSH-43* ___ 10:45AM BLOOD Free T4-0.7* ___ 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ================= ___ 06:43AM BLOOD WBC-4.9 RBC-3.51* Hgb-10.1* Hct-30.3* MCV-86 MCH-28.8 MCHC-33.3 RDW-15.1 RDWSD-47.8* Plt ___ ___ 06:43AM BLOOD Glucose-157* UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-98 HCO3-26 AnGap-16 ___ 06:30AM BLOOD Glucose-137* UreaN-26* Creat-0.9 Na-139 K-3.8 Cl-98 HCO3-26 AnGap-15 ___ 06:43AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 MICROBIOLOGY: =============== ___ AND ___ URINE CULTURES: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ URINE CULTURE: NO GROWTH. ___ 4:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. ___ BLOOD CULTURE: NO GROWTH ___ BLOOD CULTURE X2: NGTD ___ BLOOD CULTURE: NGTD IMAGING: =========== CT C-SPINE W/O CONTRAST Study Date of ___ 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes including mild anterolisthesis of C2 on C3, intervertebral disc space narrowing, and osteophytosis worse at C4-C5. 3. Multilevel posterior osteophytosis and calcified disc bulge result in moderate spinal canal narrowing most severe at C3-C4. 4. Multilevel uncovertebral facet joint hypertrophy resulting mild neural foraminal stenosis worse than right C3-C4 facet joint. CT HEAD W/O CONTRAST Study Date of ___ No acute intracranial process. Diffuse hypodensities in the white matter again seen, similar in extent to CT head dated ___ and ___ which could be related to prior therapy or due to extensive small vessel disease. CT CHEST a/p W/CONTRAST Study Date of ___ 1. Nodular, ground-glass opacification in the posterior right upper lobe concerning for pneumonia. In the setting of trauma, underlying pulmonary contusion is not excluded. 2. Mild stranding between the left adrenal gland and kidney is nonspecific, but may relate to acute injury or ascending GU infection. 3. Irregularity and lucency at the superior endplate of L5 and inferior endplate of L4 are slightly progressed when compared to prior dated ___ and infection cannot be excluded. 4. Nonspecific, unchanged prominent pelvic lymph nodes. CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1. No etiology identified for severe abdominal pain. Specifically, no intra-abdominal abscess or small bowel obstruction. 2. The bladder wall appears mildly thickened, which may be related to nondistention, however, cystitis should be considered and correlation with urinalysis is recommended. 3. Redemonstration of the irregularity and lucency at the superior endplate of L5 in the inferior endplate of L4, which is unchanged compared to ___ but slightly progressed compared to ___. Findings may represent progressive neuropathic degenerative changes however underlying infection cannot be excluded. 4. Unchanged, nonspecific prominent/enlarged pelvic/inguinal lymph nodes. MR HEAD W/O CONTRAST Study Date of ___ 1. Late acute to subacute in the left corona radiata. No intracranial hemorrhage. 2. Atrophy and stable extensive white matter signal abnormality, possibly related to prior therapy or chronic small vessel ischemic disease. 3. Additional findings described above. CTA HEAD AND CTA NECK Study Date of ___ 1. Redemonstration of a focus of late acute to subacute infarct in the left corona radiata. No intracranial hemorrhage. 2. Atrophy and stable extensive white matter disease, possibly related to prior therapy or chronic small vessel ischemic disease. 3. No severe vascular stenosis, occlusion or aneurysm. Mild atherosclerotic disease is noted in the posterior cerebral arteries and cavernous internal carotid arteries. 4. Improved nodular and ground-glass opacities in the posterior right upper lobe, consistent with resolving infection or contusion. 5. Additional findings as described above. TTE Study Date of ___ IMPRESSION: Mild symmetric left ventricular hypertophy with normal cavity sizes, and regional/global systolic function. No definite structural cardiac source of embolism identified. Compared with the prior TTE (images not available for review) of ___, the findings are similar. Brief Hospital Course: Ms. ___ is a ___ year old lady with history of rheumatoid arthritis on chronic prednisone, leukocytoclastic vasculitis, hypothyroidism, diabetes, and question of recent stroke with residual R sided weakness, who presents with toxic metabolic encephalopathy in setting of pyelonephritis, with MRI confirming subacute left corona radiata CVA. # Pyelonephritis # Abdominal pain Patient presented with fever to 102.7F and diffuse abdominal pain, with pyuria on U/A as well as CTA/P remarkable for stranding surrounding bladder and near L adrenal/kidney, which was repeated later in hospital course for ongoing abdominal pain and distension, unrevealing for a new source of pain. Other sources of fever considered included possible PNA, given ground glass changes in RUL seen on CT chest, however patient without cough or hypoxia. She completed 7 day course of antibiotics with vancomycin + ceftriaxone ending ___, given history of MRSA UTI (at that time with indwelling foley cathether), with resolution of fever. Urine cultures returned as mixed bacterial flora, and blood cultures notable for only 1 bottle in one set positive for coag negative staph after >48 hours, thought to be a contaminant. Given clinical stability patient did not receive stress dose steroids. # Toxic metabolic encephalopathy # Delirium In ED patient was very agitated, refusing care, requiring multiple doses of IM zyprexa, then on medical floor was initially somnolent, with negative CTH. By hospital day 2 was AO x 3 after treatment of infection as above. Throughout hospital course mental status waxed and waned, likely with component of delirium, but improved back to her baseline by discharge (oriented and able to perform ___ backwards) as her antibiotics course was ending. ___ oxycodone, methadone, gabapentin were held in setting of altered mental status, restarted methadone partway through hospital course, held others, to be restarted at rehab if needed. # Right hemiparesis # Subacute L corona radiata stroke On HD1, patient noted to have R sided hemiparesis. This was previously documented in PCP note from ___, and upon further investigation, appeared that patient had presented to ___ ___ in ___ with complaint of right sided weakness. Per their discharge summary, "patient was not a candidate for intravenous alteplase, MRI/MRA of brain was ordered but patient was not cooperative. We spoke again with her and family members and patient is insisting in refusing brain MRI." She was discharged with aspirin 324 mg and Lipitor 80 mg daily. Their exam documents "AOx2 strength ___ in LUE, ___ ___ in L leg and ___ in R leg. Sensation in L arm dull when compared to right". There was also report of patient saying "this is not the first time she is having this right sided weakness and usually recovers". After prolonged discussion, MRI ___ was obtained showing late acute to subacute infarct in the left corona radiata, no intracranial hemorrhage. Note was also made of extensive white matter signal abnormality likely related to chronic small vessel ischemic disease. CTA head and neck revealed no severe vascular stenosis, occlusion or aneurysm. TTE with no definite structural cardiac source of embolism identified. Patient was initially maintained on telemetry without any report of atrial fibrillation but ultimately declined to continue monitoring. Long-term event monitoring could be discussed as an outpatient. Regarding other stroke risk factors, LDL was 42, TSH 43/fT4 0.7, A1c 6.1. She was placed on aspirin 81 mg, atorvastatin 80 mg. ___ and OT evaluated patient and recommended rehab, and she was agreeable. # +BCx for coag negative staph: Aerobic bottle from ___ positive for coag negative staph ___ bottles) after >48 hours of growth, likely contaminant. However, patient did receive vancomycin x 7 days given history of MRSA UTI. # Hypothyroidism: Note patient with TSH 43, fT4 0.7, was evaluated by endocrine at ___ and also seen for this at ___, attributed to medication noncompliance, started 125 mcg daily weight based in ___ which was continued this stay. She will need repeat TSH within 6 weeks. # Hypertension: Continued ___ amlodipine. Initially held ___ triamterene-HCTZ and losartan I/s/o normotension, held on discharge for mild ___. # ___: Noted to have elevated Creatinine 1.2 from 0.9 and BUN 26 from 12 one day prior to discharge I/s/o receiving multiple contrast loads. Held ___ antihypertensives as above. # Chronic back and ___ pain: Continued ___ methadone 10 mg TID:PRN (confirmed with ___ that patient takes methadone 10 mg TID:PRN + oxycodone 5 mg TID). ___ oxycodone and gabapentin held as above. Please note that per last pain clinic note ___, there may be an element of opioid induced hyperalgesia as well as opioid tolerance. There was recommendation for continued gradual taper 10% reduction starting with breakthrough oxycodone over ___ intervals then methadone. Her narcotics contract from ___ was reviewed (Dr. ___, with documentation of plan for taper by 10% every 4 weeks- does not appear that this had been done. ___ benefit from new pain clinic referral. CHRONIC ISSUES: ================= # Diabetes: Continued on SSI while in house, resumed ___ metformin on discharge. # Rheumatoid arthritis with leukocytoclastic vasculitis: Continued ___ prednisone 5mg daily # Urinary retention: # Recurrent UTIs: Patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream. Previously referred to uro-gyn by her ___ PCP, unclear if followed up. Required intermittent straight cath during hospitalization. # Normocytic anemia: Mixed iron deficiency and anemia of chronic inflammation # Chronic venous stasis ulcerations: ___ care RN previously recommended waffle boots, ace wraps to b/l LEs. TRANSITIONAL ISSUES: ==================== [] Neurology follow up for CVA [] Started aspirin 81 mg, atorvastatin 80 mg daily [] Resumed Levothyroxine 125 mg daily [] Held gabapentin and oxycodone for altered mental status, consider pain clinic followup to taper off methadone [] Held ___ triamterene-HCTZ and losartan for mild ___, please restart in 1 week if needed for BP control [] Consider re-referral to uro-gyn for ongoing urinary retention [] Monitor BMs and uptitrate bowel regimen as needed [] Continue to address long term event monitor as outpatient to workup stroke [] Social work in contact with ___ to increase patient's ___ services, which she adamantly refused, would continue to readdress at rehab [] Please recheck TSH ___ (TSH 43, Free T4 0.7 on ___ [] Noted on CT A/P incidentally: fusion of the L3-L4 vertebral bodies with irregularity and lucency of the superior endplate L5 and the inferior endplate L4, which is similar compared to prior but mildly progressed compared to ___, Unchanged, nonspecific prominent/enlarged pelvic/inguinal lymph nodes. Further followup if clinically warranted. #CODE: DNR/DNI (MOLST in chart, ___ #CONTACT: ___ (HCP, noted in chart, Son): ___ Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) 5 mg PO Q12H 2. Methadone 10 mg PO Q8H:PRN moderate pain 3. Gabapentin 600 mg PO QID 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 6. Sertraline 100 mg PO BID 7. PredniSONE 5 mg PO DAILY 8. Nabumetone 500 mg PO BID 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Levothyroxine Sodium 1000 mcg PO 1X/WEEK (___) 12. amLODIPine 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Atorvastatin 20 mg PO QPM 15. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY 4. Simethicone 80 mg PO QID dyspepsia, gas 5. Atorvastatin 80 mg PO QPM 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Methadone 10 mg PO TID:PRN moderate-severe pain RX *methadone 10 mg 1 tab by mouth three times per day Disp #*9 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. amLODIPine 10 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Sertraline 200 mg PO DAILY 15. HELD- Gabapentin 600 mg PO QID This medication was held. Do not restart Gabapentin until there is need for it 16. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until your kidneys recover and your blood pressure is higher 17. HELD- Nabumetone 500 mg PO BID This medication was held. Do not restart Nabumetone until you have more pain 18. HELD- OxyCODONE (Immediate Release) 5 mg PO Q12H This medication was held. Do not restart OxyCODONE (Immediate Release) until your kidneys recover and your blood pressure is higher 19. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This medication was held. Do not restart Triamterene-HCTZ (37.5/25) until your kidneys recover and your blood pressure is higher Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Toxic metabolic encephalopathy Sepsis Urinary tract infection/pyelonephritis Right-sided weakness Late acute to subacute stroke in the left corona radiata Abdominal pain Constipation Secondary: Hypertension Hypothyroidism Type 2 diabetes Rheumatoid arthritis with a history of leukocytoclastic vasculitis Venous insufficiency 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 caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? You came to the hospital because of confusion and belly pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - You got antibiotics for a urinary tract infection that went to your kidneys (pyelonephritis) - You had pictures of your brain that confirmed you had a stroke, which is the cause of the weakness on your right side. - You had pictures taken of your belly which did not show why you were having so much pain, but restarting your ___ methadone was helpful for your pain. - You were evaluated by our physical therapists, who recommended that you go to rehab to get stronger before you go ___. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - It is very important to participate in the rehab program so you can get as much of your strength back as possible before you go ___. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10034345-DS-3

DS

2184-10-09 00:00:00

2184-10-14 19:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ glyburide Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of CAD s/p multiple stents and CABG presents with acute onset back pain. Pt was in his usual state of health and had eating breakfast this morning as usual when he later had acute onset of pain affecting his entire back while walking through kitchen. Pain radiated around rib cage, not into arms or up neck. Describes it as sharp, extreme pain, ___ in severity. Pain grew worse despite sitting and despite applying heating pad. It was accompanied by shortness of breath and diaphoresis, "sweating buckets." No nausea/vomiting or palpitations. He also reports severe shaking all over; denies loss of consciousness or mental status change. Pain lasted about 8:30 to 9:30 am and was improved by receiving NTG spray x3 by EMS, along with pain killer (300mics fentanyl) and fluids. Also received ASA 325mg. En route to hospital, ECG by EMS reportedly showed ST elevations in inferior leads, though initial ECG in ED was without ischemic changes. In the ED, initial vitals were 98 64 155/58 18 98% 3L. Labs showed WBC 7.5, Hgb 14.5, Hct 41.1, Plt 121. Initial trop <0.01. BUN 23, Cr 1.0. PTT 134.6 as pt had already been started on heparin drip. On arrival to floor, VS 97.5 162/70 65 16 98% RA. He has had no recurrence of pain since the initial episode which has resolved. Of note, he has had no prior pain like today's back pain. His prior anginal pain resulting in stent placement manifested as left arm pain. He reports mowing his own lawn two days before without pain or other problems, and he does not usually get musculoskeletal pain while doing labor. On review of systems, he denies nasal congestion, sore throat, cough, abdominal pain. +Diarrhea x 2 days, light brown. No hematochezia. MSK ROS + occasional cramps. No dysuria/hematuria. No rash, no LAD, no abnormal bruising/bleeding. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes type II, (+) Dyslipidemia (goal LDL<70), (+) essential HTN/white coat hypertension (home blood pressure readings all well controlled except to readings just over 140 per progress note ___ 2. CARDIAC HISTORY: - CABG: In ___ - PERCUTANEOUS CORONARY INTERVENTIONS: ___: Adjunctive ReoPro of 99% stenosis mid-RCA (also 40-60% ___ RCA); 70% ___ LAD; 50% ___. RCA stenting c/b dissection, requiring five stents to maintain patent vessel. Cardiac cath ___: normal LMCA with minimal distal narrowing. ___ LAD 60-70%, distal LAD ___. 60% ___ stenosis in obtuse marginal, 50% stenosis true circumflex. Cardiac cath ___: 50% LMCA, 95% mid LAD, 90% D1, 70-80% OM1; he was then referred for CABG, which was done in ___ at ___. - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Diabetes mellitus type 2, c/b neuropathy, nephropathy. HgbA1c 5.1 on ___ CKD stage 3 Hiatal hernia, GERD Adenomatous colon polyp Basal cell cancer Actinic keratosis Social History: ___ Family History: Father died at ___ with heart problem. Mother has heart problem at age ___. Physical Exam: ADMISSION VS: VS 97.5 162/70 65 16 98% RA General: WDWN male, comfortable appearing, laying in bed. HEENT: No scleral icterus. EOMI. PERRL. MMM. Scant dried blood on left upper lip, attributed to shaving. CV: RRR, no m/g/r. Lungs: CTA b/l. No wheezes/rhonchi/crackles. Abdomen: +BS, soft, nontender, nondistended. Ext: No clubbing/cyanosis/edema. Feet without any sores. Neuro: CN ___ intact. MOTOR: ___ b/l elbow flexion/extension, ___ b/l ankle plantar/dorsiflexion. SENSORY: intact light touch sensation distal UEs/LEs. Skin: Moist, warm skin on back while laying in bed. PULSES: 2+ DP pulses b/l. DISCHARGE VS: 98.0 (max 98.4) 157/57 (140s-150s/50s-60s) 57 (48-50s) 16 98% RA Weight 60.8kg Blood sugar ___ 148 116 Gen: No apparent distress HEENT: EOMI, anicteric CV: RRR, no m/g/r Pulm: No rales, no wheezes Abd: +BS, soft, nontender Ext: Warm, no edema Neuro: Alert, nonfocal Psych: Calm, appropriate Pertinent Results: ADMISSION LABS ___ 11:45AM ___ PTT-134.6* ___ ___ 11:45AM PLT COUNT-121* ___ 11:45AM NEUTS-75.6* LYMPHS-13.4* MONOS-5.7 EOS-4.7* BASOS-0.5 ___ 11:45AM WBC-7.5 RBC-4.53* HGB-14.5 HCT-41.1 MCV-91 MCH-32.0 MCHC-35.3* RDW-13.0 ___ 11:45AM CALCIUM-9.2 PHOSPHATE-1.9* MAGNESIUM-1.9 ___ 11:45AM cTropnT-<0.01 ___ 11:45AM GLUCOSE-174* UREA N-23* CREAT-1.0 SODIUM-141 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 ___ 09:00PM CK-MB-9 cTropnT-<0.01 ___ 09:00PM CK(CPK)-171 DISCHARGE LABS ___ 06:50AM BLOOD WBC-7.3 RBC-4.74 Hgb-14.8 Hct-43.7 MCV-92 MCH-31.2 MCHC-33.8 RDW-12.6 Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD Glucose-106* UreaN-28* Creat-0.9 Na-141 K-4.1 Cl-102 HCO3-25 AnGap-18 ___ 06:50AM BLOOD Calcium-10.0 Phos-4.2 Mg-1.8 IMAGING / STUDIES CTA chest ___ is no axillary, mediastinal or hilar lymphadenopathy. The thyroid is normal. The airways are patent to the subsegmental level. The esophagus is normal. There is no filling defect in the pulmonary arteries to the subsegmental level. The aorta is normal in caliber. Mild atherosclerotic calcifications. No evidence of dissection. There are coronary artery calcifications. No pericardial effusion. Heart size is normal. There is no pleural effusion, focal consolidation, or pneumothorax. There is no acute bony abnormality. Patient is status post sternotomy. IMPRESSION: 1. No evidence of aortic dissection. No pulmonary embolism. 2. Coronary artery calcifications. Brief Hospital Course: ___ with h/o CAD s/p CABG, HTN, HLD, DMII, CKD stage 3, presents with acute onset back pain, SOB and diaphoresis, thought likely to be aborted STEMI. ACTIVE DIAGNOSES # Back pain: Pt presented with acute onset severe diffuse back pain radiating around ribs to anterior torso. Sx resolved with EMS administration of ASA and SL nitro x3. One tracing from EMS reportedly showed ST elevations in inferior leads (see below) but this was not seen on EKG at OSH on arrival nor on EKG at ___. Troponins negative x 2 at ___ and x 1 per report from OSH. Initially concern was for anginal equivalent, though pt's presentation was atypical for ACS. He was started on heparin drip, which was discontinued the morning following admission. At that point, CTA chest was checked due to concern for aortic dissection, and it was negative for aortic abnormality. Back pain resolved and did not recur in hospital. Ultimately the episode of acute back pain was thought to be likely aborted STEMI; treatment of aborted STEMI/coronary artery disease is described below. # Aborted STEMI: ECG without ischemic changes here, although by report the ECG by EMS showed inferior STE. Trop negative x 2 here. He was initially treated with heparin drip, though this was discontinued the morning following admission. Obtained a copy of ECG by EMS via OSH, though due to incomplete labeling with incorrect patient age, it was unclear whether the ECG truly belonged to patient. (Direct discussion with EMS personnel who transported patient also corroborated STE in inferior leads verbally over the phone.) Based on the description of the event and available information about ST elevation by EMS, the episode is concerning for an aborted STEMI, with spontaneous lysis of the clot. Pain did not recur in the hospital. Aspirin 325mg daily and beta-blockade with home dose atenolol 50mg PO daily were continued. Home simvastatin was replaced by high-dose atorvastatin. Plavix was added to home medication list prior to discharge. He was advised to seek immediate medical attention for any recurrence of symptoms. CHRONIC DIAGNOSES # DMII: Well controlled, HgbA1c 5.1 on ___. DCed glipizide while in hospital and replaced with low-dose sliding scale insulin. # History of CKD stage III: Cr 0.9-1.1 this admission. Avoided nephrotoxins and monitored daily Cr. # HTN: Continued home atenolol 50mg daily, lisinopril 20mg daily, amlodipine 10mg daily, and HCTZ 25mg daily. # Chronic pain: No acute exacerbation of chronic disease. Continued home gabapentin. # GERD: No acute exacerbation of chronic disease. Continued omeprazole. TRANSITIONAL ISSUES - Follow up with primary care doctor within one week. Obtain a referral to a cardiologist as an outpatient. - Advise ETT MIBI to assess for coronary artery disease/bypass graft disease as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. GlipiZIDE XL 2.5 mg PO QAM 5. Simvastatin 20 mg PO QHS 6. Atenolol 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Gabapentin 200 mg PO QAM 9. Gabapentin 200 mg PO QPM:PRN pain 10. Gabapentin 300 mg PO HS 11. Multivitamins 1 TAB PO DAILY 12. Aspirin (Buffered) 325 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Gabapentin 200 mg PO QAM 8. Gabapentin 200 mg PO QPM:PRN pain 9. Gabapentin 300 mg PO HS 10. GlipiZIDE XL 2.5 mg PO QAM 11. Aspirin (Buffered) 325 mg PO DAILY 12. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 13. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Aborted STEMI Secondary diagnoses: Coronary artery disease s/p CABG, hypertension, hyperlipidemia, diabetes type II 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 ___ ___. As you know, you went to the hospital due to acute back pain. You were transferred to ___ for further management. The lab values and rhythm tracings here did not suggest damage to the heart muscle, though the description of the event and the description of the rhythm tracing in the ambulance are concerning for a blockage in a vessel supplying blood to the heart. Your pain resolved, indicating that the clot broke up on its own. You had a CT scan of the chest which did not show a problem of the aorta. If you have any recurrence of symptoms, please seek immediate medical attention. Please see the attached sheets for changes to your home medication regimen. Plavix has been added, which is a drug to help prevent blood clots from forming in the heart vessels. Simvastatin is replaced by atorvastatin. Followup Instructions: ___

10034354-DS-21

DS

2159-05-14 00:00:00

2159-05-16 09:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right hand clumsiness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year-old man with hx of controlled HTN and hpl, presented here as a transfer from OSH as a code stroke around ___, code stroke was called at ___, he was seen around ___. I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. He said tonight he and his wife decided to go out for dinner, around 1745 when they started to have their dinner, he noticed that his right hand is clumsy and funny: lighter and slower than before and he dropped the fork multiple times before he could grab it and use it, his wife also noticed that but the did not pay attention and had their dinner, when they wanted to go home, he wanted to clean the car windshield with the sponge, but he could not hold it in his hand and dropped it multiple times. At this time his wife told him that they need to go to the hospital, they went to ___ and as the CT machine was not working there, he was transferred here after initial evaluation and blood work, his BP was around 120-130s. He said after 45 min his hand clumsiness improved but still not normal. It was not weak, it was not numb, but he could not control it. He denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the 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: Controlled HTN for ___ years, controlled HPL, GERD He has hx of bilateral shoulder surgery Social History: ___ Family History: Father had 4 MI and stroke before ___. There is no history of seizures, developmental disability, learning disorders, migraine headaches, strokes less than 50, neuromuscular disorders, or movement disorders. Physical Exam: 98.4 102 136/84 18 98% RA 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. Full range of motion OR decreased neck rotation and flexion/extension. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Calves SNT bilaterally. Skin: no rashes or lesions noted. Neurological examination: ___ Stroke Scale score was 0 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 - Mental Status: ORIENTATION - Alert, oriented x 3 The pt. had good knowledge of current events. SPEECH Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. NAMING Pt. was able to name both high and low frequency objects. READING - Able to read without difficulty ATTENTION - Attentive, able to name ___ backward without difficulty. REGISTRATION and RECALL Pt. was able to register 3 objects and recall ___ at 5 minutes. COMPREHENSION Able to follow both midline and appendicular commands There was no evidence of apraxia or neglect - Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Blinks to threat bilaterally. Funduscopic exam reveals no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal pursuits and saccades. V: Facial sensation intact to light touch. Good power in muscles of mastication. VII: No facial weakness, 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 with normal velocity movements. - Motor: Normal bulk, tone throughout.Although because of his shoulder surgery he has int rotation in his arm, but he has a mild pronator drift in the right hand, finger tap is slower than the left. No adventitious movements, such as tremor, noted. No asterixis noted. SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___ L 5 5 ___ ___ 5 5 5 5 5 5 5 R 5 5 ___ ___ 5 5 5 5 5 5 5 - Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout in UE and ___. No extinction to DSS. - DTRs: BJ SJ TJ KJ AJ L ___ 2 1 R ___ 2 1 There was no evidence of clonus. ___ negative. Pectoral reflexes absent. Plantar response was flexor bilaterally. - Coordination: No intention tremor, normal finger tapping. No dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. - Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. *************** Discharge neuro exam: normal Pertinent Results: ___ 09:15PM CREAT-1.1 ___ 09:15PM CREAT-1.1 ___ 09:14PM GLUCOSE-106* NA+-144 K+-3.7 CL--99 TCO2-31* ___ 09:13PM UREA N-22* ___ 09:13PM WBC-8.2 RBC-5.78 HGB-16.0 HCT-47.0 MCV-81* MCH-27.7 MCHC-34.0 RDW-13.9 ___ 09:13PM PLT COUNT-192 ___ 09:13PM ___ PTT-35.0 ___ CT head with CTP and CTA ___: Normal CT head. Normal CT perfusion head. Normal CT angiography of the head and neck. MR head ___: No evidence for acute ischemia. ECHO ___: Likely patent foramen ovale with early appearance of microbubbles in the left heart after intravenous injection at rest. Otherwise normal study with normal biventricular cavity sizes with preserved regional and global biventricular systolic function and normal valvular pathology and absence of pathologic flow. Brief Hospital Course: ___ year-old right-handed man with HTN and HLD who p/w an one-hour episode of right hand clumsiness. MRI negative for ischemic infarct. Given risk factors, concerning for TIA. He was continued on ASA 81 and simvastatin. Risk factors assessment revealed: LDL (110) and HbA1c (5.9). Etiology likely small vessel disease from HTN and HLD although TTE with bubbled did show potential PFO. He is referred for outapatient lower extremity doppler to rule out DVT and paradoxical embolus. # Transitional issues - f/u lower extremity doppler - f/u in stroke clinic AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes [performed and documented by admitting resident] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented (required for all patients)? () Yes (LDL = 110) - () No 5. Intensive statin therapy administered? (x) Yes - () No [if LDL >100, reason not given: ____ ] (intensive statin therapy = simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) 6. Smoking cessation counseling given? () Yes - (x) No [if no, reason: (x) non-smoker - () unable to participate] 7. Stroke education given (written form in the discharge worksheet)? (x) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No [if no, reason not assessed: ____ ] 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100 or on a statin prior to hospitalization, reason not discharged on statin: ____ ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No [if no, reason not discharge on anticoagulation: ____ ] - (x) N/A Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Cialis (tadalafil) 5 mg oral daily 2. Hydrochlorothiazide 25 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Potassium Chloride 20 mEq PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Co Q-10 (coenzyme Q10;<br>coenzyme Q10-vitamin E) 60 mg oral daily 8. Glucosamine (glucosamine sulfate) 500 mg oral daily Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. Simvastatin 40 mg PO DAILY RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 3. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*3 4. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 5. Cialis (tadalafil) 5 mg oral daily 6. Co Q-10 (coenzyme Q10;<br>coenzyme Q10-vitamin E) 60 mg oral daily 7. Glucosamine (glucosamine sulfate) 500 mg oral daily 8. Hydrochlorothiazide 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Potassium Chloride 20 mEq PO DAILY Discharge Disposition: Home Discharge Diagnosis: TRANSIENT ISCHEMIC ATTACK (TIA) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam: Normal Discharge Instructions: Dear Mr ___, You were hospitalized due to symptoms of right hand clumsiness resulting from an TRANSIENT ISCHEMIC ATTACK (TIA), a condition where a blood vessel providing oxygen and nutrients to the brain is transiently blocked by a clot. TIA can have many different causes, so we assessed you for medical conditions that might raise your risk of having TIA or stroke. In order to prevent future TIA or strokes, we plan to modify those risk factors. Your risk factors are: Hypertension High cholesterol We are changing your medications as follows: - we added aspirin 81mg daily to decrease your stroke risk - we increased your simvastatin to 40mg daily to better control your high cholesterol - please take Bactrim twice a day for one week to treat your urinary tract infection. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: ___

10034742-DS-18

DS

2152-06-14 00:00:00

2152-06-14 10:52:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: gait instability Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: HPI: ___ is a ___ F with a history of chronic back pain s/p multiple lumar surgeries and hypothyroidism who is transferred from ___ where she presented with 4 days of maliase, unsteady gait and slurring of speech which started after a brief episode of fever to 101 and a transient headache. The headache was bifrontal and pressure like and pounding in quality, more severe than any headache she has had in the past. It came on gradually and lasted for roughly 24hours before abating. It has not returned. The slurring of speech has occurred intermittently and usually lasts on the order of hours when present. There is no difficulty with language. She does not have any word finding difficulty and has not made any errors in her speech. Her husband describes the difficulty walking and speaking as appearing as if she is drunk. The unsteadiness on the feet has been gradually worsening since onset and has been continuously present. She has not had any exacerbation in her She has not fallen. She does report awaking with an episode of vertigo a few days before the current symptoms, which was similar to episodes of BPPV she has had in the past. Currently she denies any changes in vision. There is no new weakness or numbness. No problems swallowing. She has chronic urinary incontinence related to her chronic back problems, but this has not worsened. She denies any problems with her bowels. She does endorse some light headedness upon standing. ___ obtained at ___ showed dilatation of the ventricals concerning for a communicating hyrocephalus. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysphagia, vertigo, tinnitus or hearing difficulty. 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 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: chronic back pain s/p multiple lumar surgeries Urinary incontinence Radicular BLE pain hypothyroidism Social History: ___ Family History: non contributory Physical Exam: 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. Speech was not dysarthric. Able to follow both midline and appendicular commands. Good knowledge of current events. No evidence of apraxia or neglect. CN: II: PERRLA 3 to 2mm and brisk. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI, no nystagmus. Normal saccades. V: Sensation intact to LT. VII: Facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 4+ 5- 5 5 R ___ ___ ___ 4+ 5- 5 5 Sensory: No deficits to light touch, pinprick, vibratory sense. Mild impairment in proprioception at toes, R>L. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Toes downgoing bilaterally Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Wide based, unsteady. Falls backward on Romberg testing Pertinent Results: ___ 04:22AM CEREBROSPINAL FLUID (CSF) PROTEIN-25 GLUCOSE-65 ___ 04:22AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-4* POLYS-0 ___ ___ 01:10PM PLT COUNT-363 ___ 01:10PM WBC-8.4 RBC-4.33 HGB-12.6 HCT-38.6 MCV-89 MCH-29.1 MCHC-32.6 RDW-13.0 ___ 01:10PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.2 ___ 01:10PM GLUCOSE-126* UREA N-14 CREAT-0.6 SODIUM-144 POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-31 ANION GAP-14 Brief Hospital Course: #Neuro: Mrs. ___ was found to have mild gait instability on exam upon admission. She had no other focal neurological findings. We believed her instability to be secondary to dehydration. We gave her aggressive IV fluid rehydration overnight and on day 2 of admission she had significant improvement in her gait. She was evaluated by physical therapy who had initially recommended outpatient physical therapy but on reevaluation on day 2, felt that she had no physical therapy needs. Her csf studies were unremarkable so she was discharged home on ___ with the plan to follow up with Dr. ___ in the neurology clinic in ___ weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 112 mcg PO DAILY 2. Oxybutynin 10 mg PO DAILY 3. Pregabalin 100 mg PO TID 4. TraMADOL (Ultram) 50 mg PO TID 5. Diazepam 10 mg PO Q6H:PRN pain 6. Gabapentin 300 mg PO TID 7. Imipramine 25 mg PO Frequency is Unknown 8. Diclofenac Sodium ___ ___ is Unknown PO Frequency is Unknown 9. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN respiratory distress Discharge Medications: 1. Diclofenac Sodium ___ 75 mg PO TID 2. Gabapentin 300 mg PO TID 3. Gabapentin 300 mg PO HS 4. Imipramine 25 mg PO HS 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Oxybutynin 5 mg PO BID 7. Pregabalin 100 mg PO TID 8. TraMADOL (Ultram) 50 mg PO TID:PRN pain 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN respiratory distress 10. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 11. Diazepam 10 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: DEHYDRATION GAIT INSTABILITY Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were admitted to the ___ Service after presenting with gait instability due to DEHYDRATION. ___ had a head CT that showed age-related changes that was unremarkable. ___ had a lumbar puncture that did not show signs of increased pressure or infection. We gave ___ aggressive IV fluid hydration and your symptoms improved overnight. There were no changes made to your medications. Followup Instructions: ___

10034933-DS-22

DS

2111-12-18 00:00:00

2111-12-18 13:11:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue, New Effusion Major Surgical or Invasive Procedure: Bone marrow biopsy ___ History of Present Illness: ___ PMH Bipolar Disorder, HTN, Metastatic HCC (on nivolumab, s/p recent XRT to skull bony mets), CVA, MCA Aneurysm, presented to ED with fatigue and new pleural effusion As per call in, patient initially presented to OSH with increasing confusion, CTH with stable skull mets, but further workup revealed neutropenia, and CXR with new loculated pleural effusion. Accordingly, he was given vanc/cefepime, and was transferred to ___ for thoracic evaluation. Patient's wife is unavailable at time of admission to the oncology floor however patient was alert and oriented and able to provide adequate history. He noted that he was not confused but instead was fatigued for 2 days and that was the reason that his wife brought him to the outside hospital. He noted that he was without fever, chills, cough, sore throat, nausea, vomiting, diarrhea, abdominal pain, dysuria, rash, sick contacts. He noted that his oral intake has been less than optimal. He noted that he has been voiding/stooling without issue. He denied any respiratory issues, shortness of breath or labored breathing. In the ED, initial vitals: 98.0 78 148/78 16 100% RA. WBC 1.0, (8% PMN, 8% bands), Hgb 8.0, plt 58, INR 1.2, ALT 73 AST 118, TBili 3.5, AP 368, Alb 2.3, Phos 2.2, Na 129, Lactate 0.8, UA + Glc /Prot/Bili but no e/o infection. CT Chest revealed: 1. New, lobulated, right greater than left, small pleural effusions. 2. No evidence of new or growing pulmonary nodules. 3. Cirrhotic liver, with multiple hepatic masses measuring up to 8.1 cm, compatible with known multifocal hepatocellular carcinoma, not fully assessed on this study. 4. New, wedge-shaped hypodensity within the spleen, which could be due to contrast bolus timing, although a splenic infarct could have a similar appearance. 5. Stable bilateral adrenal metastases. 6. No significant change in osseous metastatic disease of the ribs and vertebral bodies. 7. Other findings, as described above. Thoracic surgery consulted, noted that they will followup CT results. Patient was given normal saline and admitted for further care. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per last clinic note by Dr ___: - ___: Presented with back pain thought to be due to epidural abscess, a complication of his recent spinal surgery, found to have multiple spinal mets. - ___: Imaging shows multiple liver lesions and enlarged abdominal lymph nodes, metastases of the spine, skull, L adrenal gland, C2/3 paraspinal mass with cord impingement. - ___: Radiation therapy to C1-5 and associated paraspinal mass (20 Gy in 5 fx). - ___: plan port placement - ___: C1D1 FOLFOX - ___: C2D1 FOLFOX ___ bolus d/c for mouth sores) - ___: C3D1 held for hypokalemia - ___: C3D1 FOLFOX ___ bolus d/c), Zometa - ___: C4D1 FOLFOX ___ bolus d/c). D15 ___ CI ___ 20% for mucositis. (Zometa held for hypoPhos) - ___: C5D1 FOLFOX ___ bolus d/c, ___ CI ___ 20% for mucositis) - ___: C5D15 FOLFOX held for thrombocytopenia - ___: C6D1 FOLFOX ___ bolus d/c, CI ___ 20%, oxali ___ 20% for thrombocytopenia) - ___: Zometa only (Phos improved) - ___: C1 nivolumab PAST MEDICAL HISTORY: Bipolar Disorder Hypertension Pre-diabetes GERD Patient-reported Hemochromatosis (s/p phlebotomy, last done ___ years ago) s/p L3-S1 lumbar decompression with duraplasty in ___ s/p right hip replacement in ___ Chronic neoplasm related pain MCA Aneurysm CVA Social History: ___ Family History: Aunt with hemochromatosis Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: ___ 0118 Temp: 98.3 PO BP: 125/58 HR: 77 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: Chronically ill-appearing man, Laying in bed, appears comfortable, no acute distress, cachectic EYES: Pupils equally round and reactive to light, anicteric sclera HEENT: Oropharynx clear, dry mucous membranes NECK: Supple, normal range of motion LUNGS: Clear to auscultation bilaterally without any wheezes rales or rhonchi, no increased respiratory rate, speaks in full sentences CV: Regular rate and rhythm, normal distal perfusion, no edema ABD: Soft nontender nondistended, normoactive bowel sounds GENITOURINARY: No Foley or suprapubic tenderness EXT: Cachectic extremities, decreased muscle bulk, normal muscle tone SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech, able to describe his medical history in detail ACCESS: Port in right chest, dressing clean/dry/intact DISCHARGE PHYSICAL EXAM: ___ 0815 Temp: 98.3 PO BP: 147/81 HR: 66 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: Very pleasant but cachectic man sitting up in bedside chair in no distress. HEENT: Anicteric slcera, PERLL, OP clear, dry MM. Large 3cm circumscribed bony mass over left brow CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, crackles at bases bilaterally with good air movement. Speaking in full sentences. ABD: Soft, non-tender, moderately distended and dull to percussion, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema, decreased muscle bulk. NEURO: A&Ox3, good attention and linear thought. Strength full throughout. Sensation to light touch intact. No asterixis. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. Pertinent Results: ADMISSION LABS: =============== ___ 04:45PM BLOOD WBC-1.0* RBC-2.65* Hgb-8.0* Hct-23.7* MCV-89 MCH-30.2 MCHC-33.8 RDW-19.0* RDWSD-62.8* Plt Ct-58* ___ 04:45PM BLOOD Neuts-8* Bands-8* Lymphs-63* Monos-19* Eos-0* ___ Metas-2* AbsNeut-0.16* AbsLymp-0.63* AbsMono-0.19* AbsEos-0.00* AbsBaso-0.00* ___ 04:45PM BLOOD ___ PTT-34.1 ___ ___ 04:45PM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-129* K-4.0 Cl-101 HCO3-18* AnGap-10 ___ 04:45PM BLOOD ALT-73* AST-118* AlkPhos-368* TotBili-3.5* ___ 04:45PM BLOOD Albumin-2.3* Calcium-7.3* Phos-2.2* Mg-1.6 ___ 04:55PM BLOOD Lactate-0.8 DISCHARGE LABS: =============== ___ 05:12AM BLOOD WBC-6.6 RBC-2.92* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-18.5* RDWSD-57.7* Plt Ct-48* ___ 05:16AM BLOOD Neuts-66 Bands-18* Lymphs-14* Monos-2* Eos-0* Baso-0 AbsNeut-4.70 AbsLymp-0.78* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00* ___ 05:12AM BLOOD Ret Aut-0.4 Abs Ret-0.01* ___ 05:12AM BLOOD Glucose-150* UreaN-15 Creat-0.6 Na-131* K-4.6 Cl-98 HCO3-27 AnGap-6* ___ 05:16AM BLOOD ALT-70* AST-92* LD(LDH)-175 AlkPhos-388* TotBili-2.3* ___ 05:12AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7 MICROBIOLOGY: ___ Blood Culture x 2 - Pending ___ Urine Culture - No Growth BONE MARROW BX ___: Core Biopsy - PND Flow Cytometry - PND Cytogenetics - PND IMAGING: ___HEST W/CONTRAST 1. New, lobulated, right greater than left, small pleural effusions. 2. No evidence of new or growing pulmonary nodules. 3. Cirrhotic liver, with multiple hepatic masses measuring up to 8.1 cm, compatible with known multifocal hepatocellular carcinoma, not fully assessed on this study. 4. New, wedge-shaped hypodensity within the spleen, which could be due to contrast bolus timing, although a splenic infarct could have a similar appearance. 5. Stable bilateral adrenal metastases. 6. No significant change in osseous metastatic disease of the ribs and vertebrae. ___ Imaging LIVER OR GALLBLADDER US 1. Cirrhotic liver with redemonstration of a large, heterogeneous left hepatic mass. Additional masses are better appreciated on prior CT. 2. Sequela of portal hypertension including mild splenomegaly and small to moderate volume ascites. 3. Persistent moderate intrahepatic biliary ductal dilatation, primarily in the left hepatic lobe, similar to prior. Noevidence of common bile duct dilatation. 4. Focal, wedge shaped area of hypoechogenicity along the lateral margin of the spleen may represent a splenic infarct. ___ Imaging MRCP (MR ABD ___ 1. Probable progression of multifocal HCC compared to ___ with increased number and size of multiple lesions, although comparison is suboptimal due to differences in modality. 2. Worsening tumor thrombus in left portal venous branches. 3. Mild/moderate intrahepatic biliary dilation in segments II/III, worse compared to ___. No evidence of cholangitis or hepatic microabscess. 4. Bilateral adrenal and multiple osseous metastases. 5. Small bilateral pleural effusions, appearing slightly loculated on the right. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: Mr. ___ is a ___ male with history of bipolar disorder, hypertension, CVA, MCA aneurysm, and metastatic HCC on nivolumab who presents with fatigue, falls, and new pleural effusion. # Neutropenia (resolved) # Pure red cell aplasia: # Thrombocytopenia: He was found to have a hypoproliferative pancytopenia/neutropenia for which he started neupogen on ___. Etiology was thought potentially immune mediated reaction to nivolumab, and he underwent BM biopsy on ___ with initiation of prednisone. His WBC count improved, but he continued to have a pure red cell aplasia (per prelim BM bx results) and his retic count remained low. He received two tranfusions of pRBC and we increased his steroids to 60mg bid. Should be monitored closely on follow up. With extended prednisone taper. We did start Bactrim for PJP ppx, but DC'd on discharge given possible marrow suppressive side effects. # Hyperbilirubinemia: Patient with stable AST/ALT but elevated TBili that rose on admission. RUQUS and MRCP showed stable persistent moderate intrahepatic biliary ductal dilatation and no obvious intervenable lesion. Now improved upon discharge. We discontinued his statin. # Fatigue: # Fall: # Ascites: Fatigue likely to dehydration/malnutrition, anemia, medication effect. No clear source of infection and neuro exam was normal. Generally improved and he was cleared for DC home with home ___. We stopped his lisinopril and lorazepam. # Pleural Effusion: New small lobulated right pleural effusion on imaging. Likely due to metastatic disease. Less likely infection given no symptoms. Per Thoracic surgery very small effusion and given asymptomatic do not recommended drainage, would need CT-guidance if wish to drain. We deferred. # Concern for Splenic Infarct # PVT : CT was suggestive of infarct, but could also have been ___ contrast timing. No role for A/C for now given thrombocytopenia. # Metastatic HCC: # Secondary Neoplasm of Adrenal: # Secondary Neoplasm of Bone: Rising AFP and new effusion concern for disease progression despite initial treatment with FOLFOX and single dose of nivolumab. Unfortunately unlikely he will be able to resume nivolumab. Will need to discuss further plans with his outpatient oncologist. # Hyponatremia: Stable. Likely secondary to poor PO intake at baseline as well as poor renal perfusion with ascites. # Cancer-Related Pain: Continued home oxycontin and oxycodone. I refilled his RX on discharge. Continued bowel regimen # Hypophosphatemia - Repleted prn with oral repletion # Moderate Protein-Calorie Malnutrition - Nutrition consulted - Sent supplements # History of CVA - Held ASA given thrombocytopenia - Held Lipitor given transaminitis - Cont home atenolol # Hypertension - Continue home atenolol - Held home lisinorpil and monitor BPs # Bipolar Disorder - Continued home lamictal # Hypothyroidism - Continued home levothyroxine # Billing: >30 minutes spent coordinating this discharge plan TRANSITIONAL ISSUES: - Started Prednisone 60mg bid - Consider non-marrow suppressive PJP ppx - Stopped atorvastatin, lisinopril, and lorazepam - Holding ASA due to thrombocytopenia - Please check CBC with reticu count on follow up - Consider outpatient paracentesis pending PLT/WBC stability - Will need prolonged steroid taper - ___ final bone marrow biopsy results Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H 2. Atenolol 100 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. LamoTRIgine 200 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Senna 8.6 mg PO BID 10. Aspirin 81 mg PO DAILY 11. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate 12. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 13. Levothyroxine Sodium 25 mcg PO DAILY 14. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia 15. Potassium Chloride 20 mEq PO BID 16. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 17. Calcium Carbonate 600 mg PO BID 18. Vitamin D ___ UNIT PO DAILY 19. Magnesium Oxide 280 mg PO DAILY 20. Lidocaine Viscous 2% 15 mL PO Q3H:PRN throat pain 21. Phosphorus 250 mg PO DAILY 22. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth/throain pain 23. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 24. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. PredniSONE 60 mg PO BID RX *prednisone 20 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 3. Atenolol 100 mg PO DAILY 4. Calcium Carbonate 600 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. LamoTRIgine 200 mg PO BID 7. Levothyroxine Sodium 25 mcg PO DAILY 8. Magnesium Oxide 280 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 12. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 20 mg 1 tablet(s) by mouth q4 hours Disp #*120 Tablet Refills:*0 13. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H RX *oxycodone 60 mg 2 tablet(s) by mouth q8 hours Disp #*180 Tablet Refills:*0 14. Phosphorus 250 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Potassium Chloride 20 mEq PO BID 17. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 18. Senna 8.6 mg PO BID 19. Vitamin D ___ UNIT PO DAILY 20. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until your platelet counts are better Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Immune mediated pan-cytopenia # Hepatocellular cancer # Ascites # Pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for weakness. We found you had very low blood counts, along with increasing fluid in your abdomen and a small amount around your lungs. We believe you have had an immune reaction to your recent nivolumab immunotherapy, causing damage to your bone marrow. We gave you injections to help increase your white blood cell count, started you on steroids, and performed a bone marrow biopsy. You also received two blood tranfusions. We elected against interventions on the fluid in your belly or lung, as you began to feel better. You will need to follow up with Dr. ___ closely to evaluate for recovery in your bone marrow and future treatment planning for your liver cancer. Sincerely, Your ___ Care Team Followup Instructions: ___

10035631-DS-13

DS

2115-12-08 00:00:00

2115-12-08 18:55:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers, chills and fatigue; concern for acute leukemia Major Surgical or Invasive Procedure: ___ placement ___ Bone Marrow Biopsy ___ History of Present Illness: Mr. ___ is a ___ y/o male with a history of stage IIA breast cancer ___- s/p left mastectomy and currently on tamoxifen, also with a history of intermediate risk AML s/p reduced intensity allogeneic stem cell transplant ___, MRD sister) currently in remission who presented with myalgias, night sweats, fatigue and leukocytosis. Patient was in his usual stated of health until 4 days prior to admission when he received the influenza vaccine. Following vaccination he developed severe left arm pain. The patient subsequently developed upper body pain, back spasms, headaches, drenching night sweats and rigors. He also complained of severe fatigue and myalgias. He was afebrile. He has been taking ibuprofen 400 mg q3h for symptom control. Patient also reports having had a tick bite approximately ___ weeks ago. Denies bleeding, bruising, gingival hyperplasia, rashes, cough. Today the patient presented to ___ Urgent Care at which point a CBC showed a WBC 33, Hb 15, PLT 30. Patient was referred to ___ for further evaluation. Upon arrival to the ED, T 98.7, HR 100, BP 109/65, RR 18, 91% RA (rechecked and was 96% RA). Labs were notable for a white count of 32.7 (80% others, 7% neutrophils, 11% lymphocytes), Hb 14.6, Hct 41.4, platelet 24. K 4.1, Cr 1.1, lactate 2.9, Ca 9.2, Mg 2.0, Phos 2.4, LDH 682, UA 5.3, haptoglobin 143, INR 1.2. Upon arrival to the floor, the patient was complaining of back pain and headache. Review of Systems: A full 10 point review of systems was performed and negative unless stated above. Past Medical History: AML, Intermediate risk (normal cytogenetics, FLT3/NPM1 neg, diagnosed in ___. Enrolled in ECOG 2906, received indection with 7+3 with ___, consolidation with midAC x 1. MRD AlloSCT with reduced intensity flu/bu on ECOG 2906, d0 ___. Received 4.62 x 10^6 CD34+/kg cells. Male Breast Cancer s/p Mastectomy (___) Aspergillosis (___) Prostatitis (___) Seizure vs. Syncope (___) - Holter/MRI/MRA/EEG all negative Lyme Disease (___) Social History: ___ Family History: Mr. ___ has one brother with history of stroke. His father died of lung cancer at age ___. His mother died at age ___. Physical Exam: ADMISSION: ========== Vitals: Tc 98.2, BP 126/78, HR 85, RR 20, 96% RA Gen: A+Ox3, NAD, well nourished male HEENT: No conjunctival pallor. No icterus. MMM. OP clear. No petechiae. NECK: supple, no JVD LYMPH: No cervical, axillary, supraclav, inguinal LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No hepatosplenomegaly. EXT: WWP. No ___ edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. LINES: right PIV DISCHARGE: ========== VS: ___ 97.6 PO 116 / 64 79 18 100 RA Weight: 78.2 kg (77.11 on ___ I/O ytd: ___ BMx1 soft Gen: A+Ox3, Sitting in bed in no acute distress HEENT: EOMI, PERRL. MMM. No petechiae NECK: supple, JVP not elevated LYMPH: No significant cervical or supraclavicular LAD CHEST: Non-tender to palpation CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. No w/r/r. ABD: Normoactive bowel sounds. No tenderness to palpation. EXT: WWP. No ___ edema. SKIN: TEDS off this AM. Petechiae on bilateral shins. NEURO: A&Ox3, CN II-XII grossly intact. Sensation and strength grossly intact. LINES: R PICC is c/d/i Pertinent Results: ADMISSION: ========== ___ 01:00PM BLOOD WBC-32.7*# RBC-4.25* Hgb-14.6 Hct-41.4 MCV-97 MCH-34.4* MCHC-35.3 RDW-13.0 RDWSD-45.8 Plt Ct-24*# ___ 01:00PM BLOOD Neuts-7* Bands-0 Lymphs-11* Monos-0 Eos-2 Baso-0 ___ Myelos-0 Blasts-80* Other-0 AbsNeut-2.29 AbsLymp-3.60 AbsMono-0.00* AbsEos-0.65* AbsBaso-0.00* ___ 01:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Tear Dr-OCCASIONAL ___ 01:00PM BLOOD ___ PTT-25.4 ___ ___ 01:00PM BLOOD Ret Aut-0.3* Abs Ret-0.01* ___ 01:00PM BLOOD Glucose-193* UreaN-16 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-25 AnGap-19 ___ 01:00PM BLOOD ALT-50* AST-35 LD(LDH)-682* AlkPhos-69 TotBili-0.3 ___ 01:00PM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.4* Mg-2.0 UricAcd-5.3 ___ 01:00PM BLOOD Hapto-143 ___ 01:00PM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative ___ 01:00PM BLOOD HCV Ab-Negative ___ 01:06PM BLOOD Lactate-2.9* ___ 07:37PM BLOOD Lactate-1.8 ___ 07:26AM BLOOD Lactate-2.4* ___ 02:29AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 02:29AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 02:29AM URINE Color-Yellow Appear-Clear Sp ___ ___ 1:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. NADIR: ===== ___ 12:00AM BLOOD Neuts-17* Bands-3 ___ Monos-0 Eos-1 Baso-0 ___ Myelos-0 Blasts-57* AbsNeut-1.92 AbsLymp-2.11 AbsMono-0.00* AbsEos-0.10 AbsBaso-0.00* ___ 12:04AM BLOOD WBC-0.3* RBC-3.12* Hgb-10.4* Hct-29.8* MCV-96 MCH-33.3* MCHC-34.9 RDW-12.2 RDWSD-42.5 Plt Ct-9* ___ 12:00AM BLOOD WBC-0.4* RBC-3.09* Hgb-10.3* Hct-28.4* MCV-92 MCH-33.3* MCHC-36.3 RDW-11.9 RDWSD-39.8 Plt Ct-9* ___ 12:00AM BLOOD WBC-0.4* RBC-2.69* Hgb-8.9* Hct-25.2* MCV-94 MCH-33.1* MCHC-35.3 RDW-11.7 RDWSD-39.8 Plt Ct-33* ___ 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-99* Monos-0 Eos-0 Baso-0 ___ Myelos-0 Blasts-1* AbsNeut-0.00* AbsLymp-0.40* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Neuts-1* Bands-0 Lymphs-98* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.00* AbsLymp-0.29* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 12:01AM BLOOD WBC-0.4* RBC-2.31* Hgb-7.7* Hct-21.3* MCV-92 MCH-33.3* MCHC-36.2 RDW-11.5 RDWSD-38.4 Plt Ct-15* MICRO: ====== ___ 2:29 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 1:30 pm Blood (LYME) **FINAL REPORT ___ Lyme IgG (Final ___: POSITIVE BY EIA. (Reference Range-Negative). EIA RESULT NOT CONFIRMED BY WESTERN BLOT. NEGATIVE BY WESTERN BLOT. Refer to outside lab system for complete Western Blot results. Lyme IgM (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. ___ 9:34 pm STOOL CONSISTENCY: WATERY **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING: ======== ___ 8:13 ___ CT HEAD W/O CONTRAST IMPRESSION: No evidence of acute intracranial hemorrhage. ___ 10:___HEST W/CONTRAST IMPRESSION: 1. New ground-glass opacities with septal thickening and dependent small pleural effusions, most suggestive of hydrostatic edema. Differential agnosis includes atypical infection and less likely leukemic nfiltration. 2. Pre-existing lung nodules are difficult to compare to the prior CT due to technical limitations of today's exam. Consider a ___ month followup CT to allow more precise comparison of a potentially growing left upper lobe nodule in order to exclude the possibility of a slowly growing lesion within the lung adenocarcinoma spectrum. ___ 10:___BD & PELVIS WITH CONTRAST IMPRESSION: 1. No intra-abdominal infection or hemorrhage is identified. 2. Splenomegaly (similar to ___ CT) PATHOLOGY: ========== ___ FLOW CYTOMETRY REPORT Cell marker analysis demonstrates that a major subset of the cells isolated from this peripheral blood are in the CD45 dim/low side scatter “blast" region. They express CD38, immature antigens CD34, ___, nTdT (dim subset ~39%), myeloid associated antigens cytoplasmic MPO, CD117 and CD33. They co-express CD56. They lack B-cell associated antigens (CD19, cCD22, cCD79a), T cells (cCD3) associated antigens and are negative for CD13, CD14, CD64, CD11b. Blast cells comprise 88% of total analyzed events. INTERPRETATION Immunophenotypic findings consistent with involvement by acute myeloid leukemia. Correlation with clinical, morphologic (see separate pathology report ___ cytogenetic findings is recommended. ___ HEMATOPATHOLOGY REPORT - Final DIAGNOSIS: RELAPSED ACUTE MYELOID LEUKEMIA, SEE NOTE. NOTE: By flow cytometry, blasts comprise >90% of total analyzed events and have a myeloid immunophenotype expressing CD38, CD34, HLADR, nTdT (subset), CD117, CD33, cyMPO, along with CD56. Please correlate with cytogenetics (___-1550) findings. Findings discussed at interdepartmental ___ conference on ___. ASPIRATE SMEAR: The aspirate material is adequate for evaluation and consists of multiple cellular spicules. The cellularity is almost entirely comprised of blasts with cytomorphologic features similar to those described above. Residual hematopoiesis is extremely scant. DISCHARGE: ========== ___ 12:00AM BLOOD WBC-1.4* RBC-2.64* Hgb-8.2* Hct-24.3* MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 RDWSD-39.9 Plt Ct-88* ___ 12:00AM BLOOD Neuts-20.1* ___ Monos-28.1* Eos-0.0* Baso-0.0 NRBC-2.9* Im ___ AbsNeut-0.28* AbsLymp-0.71* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ 12:00AM BLOOD ___ PTT-27.1 ___ ___ 12:00AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-137 K-4.4 Cl-102 HCO3-27 AnGap-12 ___ 12:00AM BLOOD ALT-18 AST-17 LD(LDH)-180 AlkPhos-106 TotBili-0.2 ___ 12:00AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.1 Mg-2.3 Brief Hospital Course: Mr. ___ is a ___ y/o male with a history of stage IIA breast cancer ___- s/p left mastectomy and currently on tamoxifen, also with a history of intermediate risk AML s/p reduced intensity allogeneic stem cell transplant ___, MRD sister) currently in remission who presented with myalgias, night sweats, fatigue and leukocytosis concerning for acute leukemia. ACTIVE ISSUES: ============== # Relapsed acute leukemia: BM Bx ___ consistent with relapse. Treated w/ MEC (D1 = ___, no blasts on D23 sustained. Sluggish count recovery. Given low counts, repeat BM deferred to outpatient setting (f/u apt scheduled ___. # Abx: After completing tx for febrile neutropenia (cefepime, doxy), maintained on PPX with ciprofloxacin, acyclovir, voriconazole. # Dizziness/ Orthostatic symptoms: Differential includes autonomic neuropathy ___ chemo vs medication side effect (reported on voriconazole PI but incidence not included). Endocrine and cardiac sources less likely based on normal ___ stim (___), normal TSH (___), and normal LVEF (___). The role of anemia has also been considered, however, the Hgb has been stable for several days. Switched fludrocort -> midodrine ___. Midodrine titrated with good effect. Discharged on midodrine 7.5mg QAM and at noon, and 10mg QPM given symtoms occur o/n or in early AM CHRONIC ISSUES: =============== # Stage IIA breast cancer s/p mastectomy: Continued tamoxifen daily # Atypical chest pain: Had point tenderness above mastectomy scar and in R axilla, at different points during hospitalization. Most likely MSK or neuropathic and resolved prior to discharge. However, given h/o breast CA, there was concern for recurrent breast cancer. If symptoms worsen, would obtain chest imaging (CT v. MRI) to evaluate for masses. RESOLVED ISSUES: ================ # Pulmonary Edema/Borderline O2 sats: Acute pulmonary edema in setting of fluids with medications and as treatment for acute leukemia ___, improved O2 sats ___ and ___ after diuresis. Repeat TTE showed normal EF. Responded to Lasix 20mg IV PRN # Tick exposure: tick bite ___ wks prior to presentation. Treated w/ doxycycline x2 weeks. Serologies returned negative. # Pain: Severe multifocal pain on admission, worst site low back spasms; significantly improved. Improvement coincident with chemotherapy suggests cancer-related pain most likely; differential includes infection and electrolyte shifts. Negative lyme serologies argue against infection. Not requiring pain management today. # Loose stools: Loose stools for several days without abdominal pain or tenderness. Differential is medication side effect, infection or GVHD. Given benign abdomen and no history of chronic GHVD, most likely medication effect. C diff negative ___ and ___. Resolved w/ discontinuation of cefepime___. TRANSITIONAL: ============= - ORTHOSTATIC HYPOTENSION: If persistent orthostatic sx, refer to ___ clinic - CHEST PAIN: Had intermittent chest pain near mastectomy site. If progresses while patient immunosuppressed, please consider the need for imaging/ recurrence -------------- Discharge CBC: 1.4 > 8.2 / ___.3 < 88, ___ 280 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 2. Tamoxifen Citrate 20 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes Discharge Medications: 1. Acyclovir 400 mg PO TID RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 3. Midodrine 10 mg PO QPM RX *midodrine 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. Midodrine 7.5 mg PO QAM RX *midodrine 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Midodrine 7.5 mg PO NOON RX *midodrine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Voriconazole 200 mg PO Q12H RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 7. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 9. Multivitamins 1 TAB PO DAILY 10. Tamoxifen Citrate 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Acute myelogenous leukemia, relapsed Orthostatic hypotension SECONDARY DIAGNOSES: ==================== Lyme disease prophylaxis Male breast cancer (ER+/PR+, HER2-) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to ___ because you had fevers, chills and pain. You were admitted because your blood counts were concerning for infection or leukemia. What was done while you were in the hospital? - You were diagnosed with relapsed leukemia - You were treated with medications for acute leukemia - You were received medications for pain and infections - You had lightheadedness, possibly as a side effect of these treatments. We treated this with a new medication called midodrine. - We monitored your blood counts daily What should you do now that you are leaving the hospital? - Attend your doctor appointments as scheduled - Take your medications as prescribed - If you develop fever, severe pain, or other concerning symptoms, go to an emergency room right away It was a pleasure participating in your care. Wishing you all the best! Sincerely, Your ___ Team Followup Instructions: ___

10035631-DS-7

DS

2112-10-17 00:00:00

2112-10-17 14:14:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male without significant past medical history who presented to his PCP with dyspnea on exertion. In ___ he had an episode of diarrhea as well as fatigue which was self limiting and resolved. Over the past few days he presented with new dyspnea on exertion and fatigue. At his PCP's office, a CBC with diff, TSH, and chem 10 were checked. His hematocrit was 25 and his platelets were 11. He has also noted a breast mass over the past week which is new. Vitals in the ED: 97.8 59 145/69 16 100% ra He was sent directly to ___ per the instructions of the heme/onc team for full evaluation. Past Medical History: Prostatitis in ___ Seizure vs. Syncope - ___, holter, MRI/MRA, EEG all negative Lyme Disease in ___ Social History: ___ Family History: Brother Alive ___ Father ___ at ___ Cancer; Diabetes - Unknown Type Mother ___ at ___ Physical Exam: ADMISSION PHYSICAL EXAM VITALS - T 97.8, HR 64, BP 158/80, RR 20, sat 100% General: NAD, NC/AT, healthy appearing middle aged male HEENT: MMM, OP clear, EOMI, anicteric sclera LYMPH: No LAD CHEST: 2cm ___ mass, NT to palpation on the left chest CV: Normal rate, reg rhythm RESP: CTAB, no wheezes, rales, rhonchi GI: Soft, NT, ND, NABS GU: No foley Ext: Warm, well profused, no edema Neuro: Oriented, appropriate, linear thought, no gross deficits DERM: No active rash DISCHARGE PHYSICAL EXAM VITALS - Tmax 98.9, Tcurr 98.3, BP 114/64, HR 73, RR 18, Sat 100% on RA General: NAD, healthy appearing middle aged male HEENT: NCAT, MMM, OP clear, no oral lesions or ulcers LYMPH: No LAD CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks RESP: CTAB, no wheezes, rales, rhonchi GI: Soft, NT, ND, NABS GU: No foley Ext: Warm, well profused, no edema Neuro: Oriented, appropriate, linear thought, no gross deficits DERM: No rash, petechiae, or ecchymosis Pertinent Results: ADMISSION LABS ___ 08:30PM BLOOD WBC-5.0 RBC-2.82* Hgb-9.7* Hct-27.7* MCV-98 MCH-34.4* MCHC-35.0 RDW-18.9* Plt Ct-12* ___ 08:30PM BLOOD Neuts-30* Bands-0 Lymphs-47* Monos-4 Eos-5* Baso-0 ___ Metas-1* Myelos-1* Promyel-7* Blasts-5* NRBC-13* Other-0 ___ 08:30PM BLOOD ___ PTT-28.2 ___ ___ 08:30PM BLOOD ___ 03:15AM BLOOD QG6PD-9.9 ___ 08:30PM BLOOD Ret Aut-3.8* ___ 08:30PM BLOOD Glucose-124* UreaN-18 Creat-1.1 Na-139 K-4.2 Cl-102 HCO3-26 AnGap-15 ___ 08:30PM BLOOD ALT-41* AST-48* LD(___)-558* AlkPhos-63 TotBili-1.3 ___ 08:30PM BLOOD Calcium-9.7 Phos-3.2 Mg-2.1 UricAcd-6.0 ___ 08:30PM BLOOD D-Dimer-535* ___ 08:30PM BLOOD Hapto-<5* ___ 08:30PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE ___ 08:30PM BLOOD HIV Ab-NEGATIVE ___ 08:30PM BLOOD ___ HOSPITAL COURSE ___ 03:15AM BLOOD WBC-4.7 RBC-2.79* Hgb-9.5* Hct-26.9* MCV-96 MCH-33.9* MCHC-35.2* RDW-18.9* Plt Ct-11* ___ 06:15AM BLOOD WBC-3.3* RBC-2.57* Hgb-8.7* Hct-24.8* MCV-97 MCH-33.8* MCHC-34.9 RDW-18.8* Plt Ct-8* ___ 07:30PM BLOOD WBC-2.9* RBC-2.09* Hgb-7.2* Hct-20.3* MCV-97 MCH-34.3* MCHC-35.3* RDW-19.0* Plt Ct-44*# ___ 04:23AM BLOOD WBC-3.0* RBC-2.55* Hgb-8.4* Hct-23.6* MCV-93 MCH-32.8* MCHC-35.4* RDW-18.8* Plt Ct-43* ___ 12:00AM BLOOD WBC-3.5* RBC-2.71* Hgb-8.8* Hct-26.0* MCV-96 MCH-32.4* MCHC-33.9 RDW-18.8* Plt Ct-42* ___ 10:59PM BLOOD WBC-1.7*# RBC-2.42* Hgb-8.4* Hct-22.9* MCV-95 MCH-34.7* MCHC-36.7* RDW-18.2* Plt Ct-28* ___ 12:31AM BLOOD WBC-0.6*# RBC-2.21* Hgb-7.2* Hct-20.7* MCV-94 MCH-32.4* MCHC-34.6 RDW-17.8* Plt Ct-17* ___ 12:00AM BLOOD WBC-0.4* RBC-2.36* Hgb-7.6* Hct-21.8* MCV-93 MCH-32.4* MCHC-35.0 RDW-17.6* Plt Ct-10* ___ 12:34AM BLOOD WBC-0.6* RBC-2.33* Hgb-7.4* Hct-21.6* MCV-93 MCH-31.7 MCHC-34.3 RDW-17.1* Plt Ct-31* ___ 12:00AM BLOOD WBC-0.6* RBC-2.07* Hgb-6.6* Hct-19.2* MCV-93 MCH-31.9 MCHC-34.4 RDW-16.7* Plt Ct-22* ___ 12:00AM BLOOD WBC-0.8* RBC-2.44* Hgb-7.7* Hct-22.3* MCV-92 MCH-31.5 MCHC-34.4 RDW-16.1* Plt Ct-21* ___ 12:00AM BLOOD WBC-0.9* RBC-2.34* Hgb-7.7* Hct-20.9* MCV-89 MCH-33.0* MCHC-37.0* RDW-15.4 Plt Ct-10*# ___ 12:16AM BLOOD WBC-0.5* RBC-2.43* Hgb-7.9* Hct-21.6* MCV-89 MCH-32.3* MCHC-36.4* RDW-14.7 Plt Ct-25* ___ 11:02PM BLOOD WBC-0.4* RBC-2.40* Hgb-7.9* Hct-21.4* MCV-89 MCH-32.9* MCHC-37.0* RDW-14.6 Plt Ct-17* ___ 11:30PM BLOOD WBC-0.5* RBC-2.50* Hgb-7.9* Hct-22.1* MCV-88 MCH-31.8 MCHC-35.9* RDW-14.4 Plt Ct-13* ___ 12:00AM BLOOD WBC-0.4* RBC-2.67* Hgb-8.6* Hct-23.4* MCV-88 MCH-32.3* MCHC-36.9* RDW-14.0 Plt Ct-8* ___ 12:00AM BLOOD WBC-0.4* RBC-2.55* Hgb-8.3* Hct-22.1* MCV-87 MCH-32.6* MCHC-37.6* RDW-13.9 Plt Ct-19* ___ 12:01AM BLOOD WBC-0.4* RBC-2.48* Hgb-7.8* Hct-21.7* MCV-87 MCH-31.3 MCHC-35.8* RDW-14.0 Plt Ct-12* ___ 12:00AM BLOOD WBC-0.4* RBC-2.53* Hgb-7.9* Hct-22.8* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.7 Plt Ct-10* ___ 12:00AM BLOOD WBC-0.1*# RBC-2.03* Hgb-6.3* Hct-17.7* MCV-87 MCH-31.0 MCHC-35.5* RDW-13.3 Plt Ct-25* ___ 12:58PM BLOOD Hct-23.8*# ___ 06:10AM BLOOD WBC-.1* RBC-2.76*# Hgb-8.2*# Hct-23.2* MCV-84 MCH-29.8 MCHC-35.4* RDW-15.7* Plt Ct-16* ___ 06:35AM BLOOD WBC-0.1* RBC-2.56* Hgb-7.7* Hct-21.9* MCV-85 MCH-30.2 MCHC-35.4* RDW-15.1 Plt Ct-16* ___ 08:00AM BLOOD WBC-0.2*# RBC-2.68* Hgb-8.0* Hct-22.6* MCV-85 MCH-29.9 MCHC-35.4* RDW-14.6 Plt Ct-30*# ___ 06:25AM BLOOD WBC-0.5*# RBC-2.97* Hgb-9.0* Hct-25.4* MCV-86 MCH-30.2 MCHC-35.3* RDW-14.6 Plt Ct-50*# ___ 06:55AM BLOOD WBC-1.3*# RBC-3.24* Hgb-9.8* Hct-28.1* MCV-87 MCH-30.2 MCHC-34.8 RDW-14.6 Plt ___ ___ 06:15AM BLOOD WBC-4.1# RBC-3.16* Hgb-9.5* Hct-27.6* MCV-87 MCH-30.2 MCHC-34.5 RDW-14.5 Plt ___ ___ 09:10AM BLOOD WBC-5.1 RBC-3.63* Hgb-10.7* Hct-31.8* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.8 Plt ___ ___ 06:45AM BLOOD WBC-3.4* RBC-3.21* Hgb-9.7* Hct-28.5* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.8 Plt ___ ___ 07:10AM BLOOD WBC-4.9 RBC-3.49* Hgb-10.3* Hct-29.9* MCV-86 MCH-29.5 MCHC-34.4 RDW-15.1 Plt ___ ___ 06:25AM BLOOD WBC-5.0 RBC-3.48* Hgb-10.2* Hct-30.4* MCV-87 MCH-29.3 MCHC-33.7 RDW-15.6* Plt ___ ___ 06:15AM BLOOD ___ PTT-27.4 ___ ___ 04:23AM BLOOD ___ PTT-29.2 ___ ___ 12:34AM BLOOD ___ PTT-24.9* ___ ___ 12:16AM BLOOD ___ PTT-25.3 ___ ___ 12:00AM BLOOD ___ PTT-30.2 ___ ___ 06:10AM BLOOD ___ PTT-31.0 ___ ___ 02:45PM BLOOD ___ ___ 06:35AM BLOOD ___ PTT-27.3 ___ ___ 08:00AM BLOOD ___ PTT-27.1 ___ ___ 06:25AM BLOOD ___ PTT-30.9 ___ ___ 06:15AM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-144 K-4.6 Cl-110* HCO3-28 AnGap-11 ___ 10:59PM BLOOD Glucose-158* UreaN-20 Creat-0.9 Na-138 K-3.8 Cl-108 HCO3-25 AnGap-9 ___ 12:00AM BLOOD Glucose-168* UreaN-22* Creat-0.8 Na-137 K-4.2 Cl-106 HCO3-25 AnGap-10 ___ 12:00AM BLOOD Glucose-137* UreaN-24* Creat-0.9 Na-136 K-3.6 Cl-105 HCO3-24 AnGap-11 ___ 12:00AM BLOOD Glucose-120* UreaN-19 Creat-0.9 Na-136 K-4.1 Cl-102 HCO3-26 AnGap-12 ___ 06:10AM BLOOD Glucose-155* UreaN-14 Creat-0.9 Na-135 K-3.7 Cl-102 HCO3-22 AnGap-15 ___ 08:00AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-134 K-3.5 Cl-101 HCO3-24 AnGap-13 ___ 06:55AM BLOOD Glucose-116* UreaN-8 Creat-0.7 Na-137 K-3.2* Cl-101 HCO3-26 AnGap-13 ___ 09:10AM BLOOD Glucose-171* UreaN-9 Creat-0.8 Na-135 K-4.0 Cl-99 HCO3-26 AnGap-14 ___ 07:10AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-137 K-4.3 Cl-102 HCO3-30 AnGap-9 ___ 06:25AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-136 K-4.7 Cl-100 HCO3-29 AnGap-12 ___ 06:15AM BLOOD ALT-28 AST-32 LD(LDH)-403* AlkPhos-48 TotBili-0.9 ___ 12:00AM BLOOD ALT-31 AST-34 LD(LDH)-453* AlkPhos-51 TotBili-1.1 ___ 12:31AM BLOOD ALT-43* AST-38 LD(___)-383* AlkPhos-48 TotBili-0.8 ___ 12:00AM BLOOD ALT-50* AST-31 LD(___)-290* AlkPhos-46 TotBili-0.8 ___ 12:00AM BLOOD ALT-46* AST-23 LD(___)-250 AlkPhos-43 TotBili-0.7 ___ 12:16AM BLOOD ALT-39 AST-20 LD(___)-224 AlkPhos-38* TotBili-0.8 ___ 11:02PM BLOOD ALT-38 AST-19 LD(___)-226 AlkPhos-46 TotBili-0.6 ___ 11:30PM BLOOD ALT-36 AST-17 LD(___)-218 AlkPhos-48 TotBili-0.6 ___ 12:00AM BLOOD ALT-38 AST-24 LD(LDH)-214 AlkPhos-63 TotBili-0.8 ___ 12:01AM BLOOD ALT-42* AST-23 LD(LDH)-203 AlkPhos-70 TotBili-0.7 ___ 12:00AM BLOOD ALT-44* AST-23 LD(___)-200 AlkPhos-86 TotBili-0.6 ___ 12:00AM BLOOD ALT-52* AST-30 LD(___)-191 AlkPhos-98 TotBili-0.9 ___ 06:10AM BLOOD ALT-51* AST-21 LD(___)-196 AlkPhos-109 TotBili-1.9* DirBili-0.9* IndBili-1.0 ___ 02:45PM BLOOD ALT-43* AST-13 AlkPhos-93 TotBili-1.4 DirBili-0.7* IndBili-0.7 ___ 08:00AM BLOOD ALT-28 AST-12 LD(___)-181 AlkPhos-101 TotBili-1.4 ___ 06:25AM BLOOD ALT-48* AST-34 LD(___)-206 AlkPhos-134* TotBili-1.1 ___ 06:55AM BLOOD ALT-67* AST-39 AlkPhos-163* TotBili-0.7 ___ 06:15AM BLOOD ALT-76* AST-39 LD(___)-280* AlkPhos-160* TotBili-0.6 ___ 09:10AM BLOOD ALT-101* AST-51* LD(___)-289* AlkPhos-174* TotBili-0.5 ___ 06:45AM BLOOD ALT-100* AST-50* LD(___)-239 AlkPhos-154* TotBili-0.4 ___ 07:10AM BLOOD ALT-114* AST-57* LD(___)-226 AlkPhos-145* TotBili-0.4 ___ 06:25AM BLOOD ALT-110* AST-49* LD(LDH)-216 AlkPhos-142* TotBili-0.4 ___ 06:15AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.3 ___ 04:26PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 UricAcd-3.4 ___ 12:31AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1 UricAcd-3.5 ___ 12:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3 UricAcd-3.2* ___ 12:34AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.2 UricAcd-2.8* ___ 12:00AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.2 UricAcd-2.6* ___:00AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.3 UricAcd-2.6* ___ 11:30PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1 ___ 12:01AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 ___ 12:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0 ___ 08:00AM BLOOD Calcium-8.2* Phos-1.2* Mg-2.1 ___ 06:15AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 ___ 06:45AM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.2 Mg-2.3 ___ 07:10AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.4 ___ 06:25AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4 ___ 06:10AM BLOOD Vanco-6.2* ___ 08:00AM BLOOD Vanco-10.4 ___ 06:55AM BLOOD Vanco-17.1 ___ 09:10AM BLOOD Vanco-18.1 ___ 06:25AM BLOOD Vanco-28.3* ___ 08:30PM BLOOD HIV Ab-NEGATIVE ___ 08:30PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE ___ 08:30PM BLOOD Hapto-<5* ___ 11:08AM BLOOD Hapto-<5* ___ 08:30PM BLOOD D-Dimer-535* DISCHARGE LABS ___ 06:35AM BLOOD WBC-4.5 RBC-3.51* Hgb-11.2* Hct-31.8* MCV-91 MCH-32.0 MCHC-35.4* RDW-16.1* Plt ___ ___ 06:35AM BLOOD Neuts-77* Bands-3 Lymphs-8* Monos-4 Eos-2 Baso-2 ___ Metas-1* Myelos-3* ___ 06:35AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-137 K-4.8 Cl-100 HCO3-30 AnGap-12 ___ 06:35AM BLOOD ALT-112* AST-51* LD(LDH)-211 AlkPhos-135* TotBili-0.4 ___ 06:35AM BLOOD Albumin-3.5 Calcium-9.3 Phos-3.4 Mg-2.4 MICRO ___ 3:30 pm BLOOD CULTURE Source: Line-TLCL. **FINAL REPORT ___ Blood Culture, Routine (Final ___: VIRIDANS STREPTOCOCCI. Isolated from only one set in the previous five days. SENSITIVITY REQUESTED BY ___. ___ ___. Sensitivity testing performed by Sensititre. CLINDAMYCIN <= 0.12 MCG/ML. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ VIRIDANS STREPTOCOCCI | CLINDAMYCIN----------- S ERYTHROMYCIN---------- =>8 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Chest CT without contrast ___: IMPRESSION: 1. Numerous small ground glass and semi-solid pulmonary nodules are randomly distributed throughout all lobes of both lungs and are new since the prior study. Although this finding is not concerning for malignant disease, their presence in a neutropenic patient could represent an inflammatory or infectious process such as viral pneumonia. No evidence of bacterial or fungal pneumonia. 2. Interval decrease in size of left breast nodule, in keeping with a hematoma as described on recent diagnostic mammogram from ___. 3. Numerous bilateral axillary and mediastinal lymph nodes are not pathologically enlarged. 4. Trace left pleural effusion (5:206). TTE ___ IMPRESSION: Preserved regional and global biventricular systolic function. Trace aortic regurgitation. CT chest/abdomen/pelvis ___. Left breast nodule as described that should be further correlated with tissue biopsy. 2. Right axillary lymph nodes, not pathologically enlarged but multiple. 3. Several pulmonary nodules that should be reassessed in three months for assessment of stability. 4. Mild splenomegaly. 5. Sigmoid diverticulosis but no diverticulitis. Bilateral Diagnostic Mammography ___ 1. There are two echogenic/hypoechoic masses lateral to the left nipple having the appearance of hematomas. 2. Bilateral moderate gynecomastia. BI-RADS 3 -- probably benign. Brief Hospital Course: BRIEF SUMMARY: Mr. ___ is a ___ year old male without significant past medical history originally presenting w/ DOE, fatigue, and diarrhea found to have anemia and thrombocytopenia. Bone marrow biopsy consistent with AML on ECOG 2906 and randomized to 7+3 (day ___ now C1D28 with course complicated by neutropenic fever likely secondary to strep viridans bacteremia. ACTIVE ISSUES: # AML: Patient presented with fatigue, diarrhea, and DOE, found to have anemia and thrombocytopenia. Prelim reading on smear shows multiple blasts concerning for AML. Bone marrow biopsy was performed and confirmed AML. The patient was started on a clinical trial and randomized to the 7+3 arm (Day ___. FISH negative. Karyotype normal. NPM negative, FLT3 negative consistent with intermediate Risk genotype. Hemoglobin electrophoresis with 100% Hgb A. Day 14 bone marrow is ablated, no blasts. A bone marrow donor screen was begun and the patient's sister is a confirmed donor match. The patient had a repeat bone marrow on Day ___, the day of discharge. # Neutropenic Fever: Patient spiked fever to 102.5 on ___ w/ exam significant for erythema around line site. CXR/UA were both negative. Pt. c/o headache and sinus pressure. Underwent Head-CT without any acute infectious process noted. Blood cultures positive for strep viridans 2 out of 4 bottles. Central line (originally placed ___ pulled for concern of line infection. Pt. was started on vancomycin and cefepime but continued to spike fevers for several days. Pt.'s ongoing fevers were thought to be related to subtherapeutic vanc level vs. fungal infection vs. endocarditis without source control vs. G-CSF as pt. was started on neupogen around time of first fever. TTE returned without evidence of endocarditis. Given continued fevers, pt. was started on empiric micafungin and a chest CT was done which showed possible early viral vs. fungal pneumonia. Pulm was consulted who indicated that this could be early fungal pneumonia but that BAL at this point would not be useful. Pt's neutropenia resolved. He had a B glucan, galactomannan, and DFA viral swab which all returned negative. ID recommended treating Strep bacteremia for 10 day course with nafcillin. Pt. without central line, therefore continued vanc for ___ompleted on day of discharge. # Headache: The patient experienced significant frontal headaches during his admission. He had a Head CT which was normal. At first, his headaches were thought to be due to anemia as they improved slightly with pRBC transfusions. His anemia resolved and his headaches continues. The patient underwent a Head MRI given the acute onset of a sharp headache that woke pt. from sleep in the early morning of ___. MRI revealed no evidence of acute intra-cranial process. The headaches improved dramatically when the patient was taken off of his neupogen. This was thought to be the cause. # Mild Transaminitis: Both hepatocellular and cholestatic hepatitis new as of ___. Mostly likely ___ to fluconazole. As such, fluconazole was discontinued. At time of discharge, pt.'s LFTs have plateaued and seem to be somewhat downtrending. # Diarrhea: The patient had several days of ongoing diarrhea during his hospitalization. C. diff PCR was negative. Diarrhea resolved. Transitional Issues: 1. CT Scan: Pt. had a CT scan which showed semi-solid nodules randomly distributed in lung fields possibly consistent with early viral pneumonia. A repeat chest CT without contrast was recommended. You have a CT scheduled on ___. 2. Infectious Disease Consult: Pt. requires outpatient infectious disease consult prior to transplant 3. Dental Clearance: Pt. has a dental appointment on ___. He will bring with him the transplant paperwork to be completed at his appointment. 4. Flu Shot: The decision was made not to give the flu vaccine given the pt's future chemotherapy and likely immunosuppressed state. 5. Transaminitis: Pt. had elevated LFTs likely ___ to fluconazole on ___ The fluconazole was d/c'ed at this time and his LFTs plateaued in the several days leading up to discharge. Please assess for resolution with repeat LFTs. If does not resolve, consider imaging for infectious source. Medications on Admission: None Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Capsule Refills:*0 2. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule,delayed ___ by mouth Daily Disp #*30 Capsule Refills:*0 3. Lorazepam 0.5 mg PO HS:PRN insomnia RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth at bedtime Disp #*30 Tablet Refills:*0 (Per pt., he had been on ativan at home prior to admission). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses 1. Acute Myelogenous Leukemia 2. Neutropenic fever secondary to strep viridans bacteremia 3. Anemia 4. Transaminitis secondary to fluconazole 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 the ___ ___. You presented with shortness of breath and fatigue and were found to have very low blood counts. A bone marrow biopsy was done that confirmed acute myelogenous leukemia (AML). You enrolled in a clinical trial and received 7+3 (cytarabine and danorubicin). You tolerated the chemotherapy very well. Your repeat day 14 bone marrow biopsy showed an ablated marrow without blasts (diseased cells). You spiked a fever and were started on broad spectrum antibiotics and your central line was removed. Urine culture and chest xray were clear but your blood cultures were positive for a bacteria known as strep viridans. Your antibiotics were narrowed to treat the bacteria and you no longer had any fevers. You also had significant headaches during your hospitalization. You had both a CT scan and MRI which showed no concerning process. Your headache was thought to be due to the neupogen (filgrastim) that you were receiving. We stopped the medication and your headaches resolved. You had a bone marrow biopsy on your day of discharge that you tolerated very well. All the best, Your ___ Team Followup Instructions: ___

10035780-DS-12

DS

2131-08-10 00:00:00

2131-08-12 15:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Interview conducted with assistance of telephone interpreter with patient's daughter. Mrs. ___ is a ___ y/o woman with a PMH of CKD V (recently started on ___ HD ___, T2DM, HTN, CAD, HBV/HCV, GERD, gout, and osteoporosis, recently discharged from ___, who was found to have C. difficile during the course of her admission and was discharged on a 10 day course of PO Flagyl (to be completed ___, who presented from rehab with persistent diarrhea. Per the patient's daughter, the diarrhea improved ___ days after discharge, but it has been worsening over the last two to three days. She had mixed watery and formed stools, with 3 this morning; she was unable to complete HD and was sent to the ED. In the ED, initial vitals were:T 98.5F P92 BP 149/63 RR 22 O2 99% RA Labs were notable for: Na 134, K 3.5, Cl 96, HCO3 27, BUN 21, Cr 2.2, Gluc 121. WBC of 11.0 (Neut of 59.7%, Lymph 22.9%), H/H of 9.4/28.8, Plts of 174. Patient was given: ___ 18:32 PO/NG Vancomycin Oral Liquid ___ mg Consults: nephrology, transplant surgery On the floor, the patient reported that the diarrhea was non-bloody, yellow in color, and originally started two weeks ago. Her daughter is uncertain if she has been taking the Flagyl upon discharge (reportedly, her younger sister ___ is in charge of her medications). Called younger sister, however the conversation was inhibited by limited ___ proficiency. She says that she will be in the hospital tomorrow to discuss with the assistance of an interpreter. The patient's primary complaint was that she was hungry. Denies fevers, chills, nausea, vomiting, constipation, hematochezia, dysuria, hematuria, headache, dizziness. She has also had a cough and runny nose for the past two weeks, but this does not appear to be bothering her; she denies any sputum production. Past Medical History: Her past medical history is also significant for Type II diabetes, hypertension, osteoarthritis(pain in both knees), osteoporosis, hyperlipidemia, asthma, anemia, Hepatitis B and hepatitis C, gout, GERD, s/p laparoscopic cholecystectomy in ___. 1) Hypertension. 2) Asthma. 3) Renal insufficiency. 4) Hepatitis B and hepatitis C 5) knee pain LUE AVG ___ Social History: ___ Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 98.2F BP 149/68 mmHg P 96 RR 18 O2 100% RA General: Alert, elderly woman, comfortable, NAD. HEENT: Sclera anicteric, MMM, OP clear, EOMs intact, PERRL. Neck: IJ tunnelled line with dressing c/d/i. Supple; no LAD. CV: RRR, no MRGs; normal S1/S2. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, mildly and diffusely tender to palpation. No organomegaly NABS. GU: No foley Ext: Warm and well-perfused. 2+ pulses; 2+ pitting edema. Neuro: A&Ox3; CNs II-XII grossly intact. Gait deferred. DISCHARGE PHYSICAL EXAM: VS - 97.7 85 18 132/57 100% sat on RA General: Alert, elderly woman, comfortable, NAD. HEENT: Sclera anicteric, MMM, OP clear, EOMs intact, PERRL. Neck: R IJ tunnelled line with dressing c/d/i. Supple, mild tenderness to palation; no LAD. CV: RRR, no MRGs; normal S1/S2. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, mildly/diffusely tender to palpation. No organomegaly NABS. GU: No foley Ext: Warm and well-perfused. 2+ pulses; 2+ pitting edema. Neuro: A&Ox3; CNs II-XII grossly intact. able to walk with cane AV Graft: Left arm, mild redness, indurated, areas of hardness distal to graft; graft is palpable thrill, bruit audible. Pertinent Results: ADMISSION LABS =============== ___ 05:20PM BLOOD WBC-11.0* RBC-2.98* Hgb-9.4* Hct-28.8* MCV-97 MCH-31.5 MCHC-32.6 RDW-15.7* RDWSD-54.8* Plt ___ ___ 05:20PM BLOOD Neuts-59.7 ___ Monos-12.0 Eos-3.1 Baso-1.1* Im ___ AbsNeut-6.54* AbsLymp-2.51 AbsMono-1.32* AbsEos-0.34 AbsBaso-0.12* ___ 05:20PM BLOOD Glucose-121* UreaN-21* Creat-2.2* Na-134 K-3.6 Cl-96 HCO3-27 AnGap-15 PERTINENT FINDINGS =================== CXR ___: There is a dialysis catheter overlying the right chest with the tip in the cavoatrial junction. Heart size is stable. The mediastinal and hilar contours are stable. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. C. Diff ___ **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). C. Diff ___: 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. ___ 1:12 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ___ 03:10PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 03:10PM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG ___ 03:10PM URINE RBC-15* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 ___ 03:10PM URINE WBC Clm-MANY DISCHARGE LABS =============== ___ 06:46AM BLOOD WBC-8.3 RBC-2.74* Hgb-8.6* Hct-26.3* MCV-96 MCH-31.4 MCHC-32.7 RDW-15.2 RDWSD-53.2* Plt ___ ___ 06:46AM BLOOD Glucose-114* UreaN-36* Creat-2.5* Na-132* K-3.4 Cl-92* HCO3-28 AnGap-15 ___ 06:46AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.6 Brief Hospital Course: This is a ___ year old female with past medical history of ESRD on HD (recently initiated ___, type 2 diabetes with complications, CAD, recent admission at ___ (___) for initiation of dialysis course complicated by poorly functioning AV graft requiring tunneled line placement and diarrhea attributed to cdiff colitis, discharged to rehab on flagyl, subsequently readmitted ___ w several days of worsening diarrhea, found to be cdiff negative x 2, but also reporting new dysuria, found to have a UTI, with urinary symptoms improving on empiric antibiotics, diarrhea resolving without additional intervention, discharged back to rehab. ACUTE ------- # Diarrhea: At her previous hospitalication, Ms. ___ was discharged with diagnosis of Clostridium Difficile Colitis, and started on a course of Flagyl 500mg PO TID for 10 days total (___). In rehab her diarrhea improved, but shortly returned. On ___ patient began to have worsening diarrhea forcing her to miss HD. She was brought to ___ for evaluation and concern for failure to treat. ___ found to be 12.8. She was started on PO Vancomycin 125mg Q6hr. Stool cultures and found to be negative. C. Diff toxin were sent off twice and found to be negative twice. While C. diff toxin PCR assays may often linger longer even if infection is cleared, the PCR assay is highly sensitive, and 2 negatives results is strongly suggestive that there is no C. Diff infection. It was determined that it was likely viral enteritis. Patient had no abdominal pain, 2 well formed but soft stools in 24 hrs with downtrending leukocytosis (8.7 by day of discharge). Patient was discharged with plan for no further antibiotics. If patient reports significantly worsening or persistent symptoms, she should represent for further evaluation. # UTI: Patient presented with history of blood in Urine. Urine cultures grew skin and fecal contimaint. Patient was not complaining of dysuria, but began to develop urinary frequency. A UA was ordered, found to be positive for infection and patient was started on Ciprofloxacin 250mg PO Qdaily for 3 day course (___). CHRONIC -------- #CKD V: Thought to be from diabetic nephropathy, the patient recieves dialysis ___. She missed dialysis ___ in the setting of diarrhea. She recieved one session of HD on ___ and ___. Her home regimen of neprhocaps was also maintained. #AV GRaft: Previous admission deemed immature and not ready for cannulation. Currently has tunneled right IJ in place. Graft was evaluated and deemed improved by transplant surgery. Graft was not used for HD, but will be evaluated further in AV care clinic in the future. #T2DM. Patient's oral hypoglycemics were discontinued on previous admission. She was maintained on humolog insulin sliding scale. #GERD: Asymptomatic. Continued home omeprazole 20 mg PO bid. #Asthma: Stable throughout hosital stay. Continue home albuterol q6h PRN, home fluticasone-salmeterol BID, home montelukast 10 mg daily. #Osteoporosis: Stable, continued alendronate 35 mg QWED and home calcium carbonate + vitamin D #Gout: Continue home allopurinol ___ mg every other day without symptoms. #CAD. No chest pain. Continued home aspirin 325 daily #HTN: Continue home metoprolol succinate 200 mg and nifedipine 90 mg PO daily. TRANSITIONAL ISSUES ==================== - On Ciprofloxacin 250mg PO Q24 3 day ___ - Will need AV graft care follow up to assess for maturation and readiness for use, and patient will receive HD through the IJ line in the interim. IJ will need to be removed when forearm graft able to be used Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Aspirin EC 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 5. Furosemide 80 mg PO BID 6. Losartan Potassium 100 mg PO 4X/WEEK (___) 7. NIFEdipine CR 90 mg PO DAILY 8. Omeprazole 20 mg PO BID 9. TraMADOL (Ultram) 50 mg PO BID:PRN pain 10. Vitamin D 1000 UNIT PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 14. Allopurinol ___ mg PO EVERY OTHER DAY 15. Nephrocaps 1 CAP PO DAILY 16. Alendronate Sodium 35 mg PO QWED 17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin EC 325 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. TraMADOL (Ultram) 50 mg PO BID:PRN pain 14. Vitamin D 1000 UNIT PO DAILY 15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Alendronate Sodium 35 mg PO QWED 19. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days Please give first dose ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary - UTI - Diarrhea, unclear etiology, likely Acute viral enteritis - CKD Secondary - T2DM - HISS - GERD. - Asthma. - Osteoporosis. - Gout - CAD - HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ for acute episodes of diarrhea, concerning for C. diff colitis recurrence. While in the hospital you underwent hemodialysis. The stool was evaluated and not found to have any sign of infection. It may have been caused by a virus. You were found to have a urinary tract infection and were given antibiotics. You were discharged back to your rehabilitation center with antibiotics for the UTI. It was a pleasure to take care of you at ___ and we wish you the best in the future. If you have any questions about the care you received, please do not hesitate to ask. Sincerely, Your ___ Care Team Followup Instructions: ___

10035780-DS-13

DS

2131-11-17 00:00:00

2131-11-17 17:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough and general malaise. History was obtained via review of records and via phone interpreter. Majority of history was obtained from daughter. Patient was recently treated for a UTI with PO antibiotics and she has been doing well until yesterday when she developed general malaise, fever, nausea and lightheadedness. Also has been complaining of shortness of breath which has improved with albuterol inhalers. This morning the patient had 2 episodes of emesis as well as a productive cough. Today during HD she was found to have a fever to 100.8 and leukocytosis and was transferred to ___ for further evaluation. In the ED, initial vitals: T 98.5, BP 147/54, HR 95, RR 18, 98% RA. Labs were significant for WBC 17 (85% PMN), Hb 8.9, PLT 268. Na 132, Cr 2.6 (on HD), gluc 190, AP 152, AST 85, ALT 47, BNP 7841. UA + WBC + epi. Flu was negative. BCx and UCx were drawn. CXR showed no acute cardiopulmonary process and no consolidation. Patient received ceftriaxone 1 g, levofloxacin 750 mg, vanco 1000 mg. Vitals prior to transfer: T 98.8, HR 83, BP 137/60, RR 17, 99% RA. Upon arrival to the floor Tc 87.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg. Patient was resting in bed and in no acute distress. Reported that her breathing was uncomfortable but improved with inhalers. Also reported a heavy sensation on her chest which has persisted throughout the day. States that she get dizzy when going from a sitting to a standing position. ROS: reports fever at HD today. No chills. + SOB as stated above. Chronic cough, no change. No sick contacts. No travel. + nausea, + vomiting. No diarrhea. + mild lower extremity edema. No rashes. No recent dysuria (however just finished treatment for a UTI and had dysuria at the beginning of that course). Otherwise, ___ ROS was negative unless stated above. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: Tc 97.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg GEN: Alert, lying flat in bed, no acute distress; oriented to self, but not place or time HEENT: sclera anicteric, oropharynx MMM, EOMI NECK: Supple without LAD, unable to visualize JVD PULM: bibasilar crackles R>L, no wheezing COR: RRR (+)S1/S2 no m/r/g ABD: Soft, ___, mildly distended, no fluid wave, normal bowel sounds EXTREM: Warm, ___, trace peripheral edema b/l; LUE fistula with palpable thrill NEURO: CN ___ grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM ======================== VS: Tc 97.9, Tm 99.0, BP ___, HR ___, RR 18, 98% RA, weight 57.6 kg, BMx5 (small soft stools), finger stick 130s GEN: Alert, sitting up in bed, no acute distress HEENT: sclera anicteric, oropharynx MMM, EOMI NECK: Supple, unable to visualize JVD PULM: CTAB, no wheezing COR: RRR normal S1 and S2, ___ systolic murmur heard throughout ABD: Soft, ___, mildly distended, no fluid wave, normal bowel sounds EXTREM: Warm, ___, trace peripheral edema b/l; LUE fistula NEURO: CN ___ grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS ================ ___ 09:40AM BLOOD ___ ___ Plt ___ ___ 09:40AM BLOOD ___ ___ ___ 09:40AM BLOOD ___ ___ 09:40AM BLOOD ___ ___ 09:40AM BLOOD cTropnT-<0.01 ___ 07:18PM BLOOD ___ cTropnT-<0.01 ___ 05:40AM BLOOD cTropnT-<0.01 ___ 09:40AM BLOOD ___ ___ 06:35AM BLOOD ___ ___ 09:08AM BLOOD ___ ___ ___ 09:08AM BLOOD HCV ___ DISCHARGE LABS ================ ___ 07:00AM BLOOD ___ ___ Plt ___ ___ 07:00AM BLOOD ___ ___ ___ 07:00AM BLOOD ___ IMAGING ================ ___ TTE The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild pulmonary artery systolic hypertension. Increased PCWP. ___ RUQ US 1. No evidence of focal hepatic lesions. 2. No ascites. 3. Dilatation of the common bile duct is similar to prior, and likely relates to ___ state. ___ CXR No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. MICRO ============== ___ 10:49 am URINE TAKEN FROM ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. ___ ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMIKACIN-------------- 4 S AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ 1 S ___ 11:55 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 ___. ___ 9:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:45 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: Ms. ___ is a ___ y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough and general malaise found to have E coli UTI. Hospital course was complicated by AF with RVR. Hospital course is outlined below by problem: # E coli UTI: Pt endorsed dysuria prior to presentation. She was started on vanc/cefepime empirically. UCx grew E coli sensitive to ceftriaxone and her antibiotics were transitioned to ceftriaxone. She received a 7 day course of antibiotics. Her last day of antibiotics was ___. # AF with RVR: patient was found to have new afib with RVR during this hospitalization. Her AF was controlled with AV nodal agents. TSH was wnl. TTE was performed and did not show valvular disease. We discussed anticoagulation with the patient and her daughter. We explained that there is a risk of stroke in the setting of AF however given that the patient is a high fall and bleeding risk we wanted to discuss the risks/benefits of anticoagulation with her outpatient provider. Her primary care doctor was called but was unreachable. Anticoagulation will be a transitional issue and should be discussed in the outpatient setting. She remained on aspirin 325 mg daily and metoprolol 200 mg XL daily. # Chest pain: patient had chest pain on admission with negative troponins and EKG. This was likely due to palpitations in the setting of AF with RVR. Her pain improved with better HR control. # Dyspnea: patient complained of dyspnea on admission. The patient had a difficult time explaining her symptoms but quickly resolved. CXR did not show an acute process. She remained on RA and received inhalers for asthma. # Transaminitis, alk phos elevation: patient has known HCV and HBV but no diagnosis of cirrhosis. AST/ALT 85/47 and ALK phos 152 TB 0.3 on admission. A RUQ US was performed and did not show evidence of cholangitis or hepatic lesions. LFTs were noted to downtrend. # Diarrhea: patient had diarrhea after receiving antibiotics. There was concern for C diff initially and she was started on empiric treatment with flagyl. Her C diff returned negative, however given that she had C diff in the past she received flagyl prophyalxis while on ceftriaxone. Her diarrhea was attributed to antibiotic associated diarrhea and received Imodium prn. # Hyponatremia: patient's sodium was noted to decrease to ___. This was attributed to low solute intake and she was encouraged to eat more during meals. CHRONIC ISSUES # Gout: continued allopurinol ___ mg QOD # DM: patient was placed on a sliding scale and required small amounts of Humalog during her hospitalization. It is unclear what she takes as an outpatient for her diabetes but possibly takes Januvia. This will need to be clarified. # HTN: continued ___, metoprolol, nifedipine # ESRD on HD: continued ___ dialysis. Patient will need to have HD on ___ and ___ the week of ___. Her regular HD schedule will resume the following week on ___. # GERD: continued home PPI TRANSITIONAL ISSUES ===================== - patient is considered to be a high fall risk and the risk of starting anticoagulation may outweigh the benefit in the setting of AF. A discussion was held with her family about this issue. The patient and family will need to discuss anticoagulation for Afib with outpatient PCP - discharged to rehab, will need f/u with outpatient PCP - ___ the week of ___, patient will need HD on ___ and ___. Her regular HD schedule will resume the following week on ___. - patient was kept on a SSI during this hospital stay with minimal insulin requirements. It is unclear what medication she takes at home for her diabetes (possibly Januvia). This will need to be clarified. # CODE STATUS: Full # CONTACT: daughter ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin EC 325 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. ___ Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. TraMADOL (Ultram) 50 mg PO BID:PRN pain 14. Vitamin D 1000 UNIT PO DAILY 15. Calcium 600 + D(3) (calcium ___ D3) 600 mg(1,500mg) -400 unit oral BID 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Alendronate Sodium 35 mg PO QWED Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin EC 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 5. ___ Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Omeprazole 20 mg PO BID 14. TraMADOL (Ultram) 50 mg PO BID:PRN pain 15. Vitamin D 1000 UNIT PO DAILY 16. Calcium 600 + D(3) (calcium ___ D3) 600 mg(1,500mg) -400 unit oral BID 17. Alendronate Sodium 35 mg PO QWED 18. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 19. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: urinary tract infection, atrial fibrillation Secondary diagnosis: ESRD, hypertension, DM, diarrhea 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 with a fever. While you were here you received antibiotics and your symptoms improved. You also received dialysis. You were found to have an abnormal heart rhythm call atrial fibrillation. We spoke to you about starting a blood thinner and you will need to continue having conversations with your primary care doctor. You are being discharged to a rehab facility to get stronger before you go home. We wish you the best, Your ___ Team Followup Instructions: ___

10035780-DS-14

DS

2132-05-19 00:00:00

2132-05-21 08:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Fever/Lethargy/Confusion Major Surgical or Invasive Procedure: Hemodialysis ___ History of Present Illness: This patient is a ___ yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following dialysis. The patient's daughter noted that she was not as interactive when she was receiving dialysis yesterday, and complaining of feeling hot. She brought her into the ED where she was febrile to 100.8, and found to have a WBC of 19.1, lactate of 2.6, and UA showing numerous WBCs (CT head negative). A trigger was called for unresponsiveness. She responded well to empiric coverage with vanc/cefepime/flagyl. The daughter mentioned that she has been getting UTIs frequently, and her last one in ___ was similar in presentation. On transfer to the floor, the patient was doing much better. This morning, she appeared 60% of her baseline (in terms of mental status) as per her daughter's report. Currently, she denies dysuria, f/c, abdominal pain, chest pain, or leg pain. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION ========= VITALS: 97.6 | 135/57 | 89 | 18 | 97 RA GENERAL: NAD, ___ only, alert, oriented x 2 (knew name, ___," and ___ but couldn't give date or year) HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD 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, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, fistula at R forearm w/ dressing PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength 4+/5 in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE ========== VITALS: 98.2 | 153/62 | 81 | 20 | 97RA GENERAL: NAD, ___ only, alert HEENT: anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, slight holosystolic murmur at the base LUNG: CTAB, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, slight peripheral edema in ___, fistula at L forearm PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact, mildly weak in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: CBC ==== ___ 06:19AM BLOOD WBC-8.5 RBC-3.37* Hgb-11.0* Hct-32.9* MCV-98 MCH-32.6* MCHC-33.4 RDW-14.6 RDWSD-51.3* Plt ___ ___ 08:20AM BLOOD WBC-8.8 RBC-3.46* Hgb-11.2 Hct-34.5 MCV-100* MCH-32.4* MCHC-32.5 RDW-14.8 RDWSD-53.1* Plt ___ ___ 07:30AM BLOOD WBC-7.9 RBC-3.34* Hgb-10.8* Hct-33.4* MCV-100* MCH-32.3* MCHC-32.3 RDW-14.8 RDWSD-53.7* Plt ___ ___ 06:22AM BLOOD WBC-10.6* RBC-3.48* Hgb-11.2 Hct-33.9* MCV-97 MCH-32.2* MCHC-33.0 RDW-14.4 RDWSD-51.1* Plt ___ ___ 08:11AM BLOOD WBC-10.9* RBC-3.60* Hgb-11.7 Hct-35.3 MCV-98 MCH-32.5* MCHC-33.1 RDW-14.7 RDWSD-53.0* Plt ___ ___ 03:37PM BLOOD WBC-19.1* RBC-4.37 Hgb-14.2# Hct-41.9 MCV-96 MCH-32.5* MCHC-33.9 RDW-14.7 RDWSD-51.5* Plt ___ BMP ==== ___ 06:19AM BLOOD Glucose-109* UreaN-76* Creat-3.6*# Na-133 K-4.3 Cl-93* HCO3-25 AnGap-19 ___ 08:20AM BLOOD Glucose-101* UreaN-55* Creat-3.2* Na-135 K-4.4 Cl-94* HCO3-27 AnGap-18 ___ 07:30AM BLOOD Glucose-107* UreaN-36* Creat-2.6* Na-136 K-4.2 Cl-97 HCO3-27 AnGap-16 ___ 06:22AM BLOOD Glucose-143* UreaN-69* Creat-3.6* Na-132* K-3.9 Cl-95* HCO3-22 AnGap-19 ___ 08:11AM BLOOD Glucose-114* UreaN-40* Creat-3.0* Na-132* K-3.9 Cl-96 HCO3-23 AnGap-17 ___ 03:37PM BLOOD Glucose-179* UreaN-24* Creat-2.2* Na-128* K-7.6* Cl-87* HCO3-26 AnGap-23* LFTs ==== ___ 07:30AM BLOOD ALT-80* AST-109* AlkPhos-119* TotBili-0.3 ___ 08:11AM BLOOD ALT-86* AST-104* AlkPhos-125* TotBili-0.4 ___ 03:37PM BLOOD ALT-101* AST-219* AlkPhos-142* TotBili-0.5 LACTATE ======= ___ 10:39AM BLOOD Lactate-1.0 ___ 03:58PM BLOOD Lactate-2.6* URINE ===== ___ 12:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:30PM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG ___ 12:30PM URINE RBC-3* WBC-47* Bacteri-FEW Yeast-NONE Epi-3 ___ 04:00PM URINE RBC-1 WBC-143* Bacteri-MANY Yeast-NONE Epi-<1 MICRO ====== ___ 12:49 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). Time Taken Not Noted Log-In Date/Time: ___ 9:59 pm URINE Site: NOT SPECIFIED CHEM S# ___ UCU ADDED 05.18. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R CT HEAD- ___ ============ IMPRESSION: No acute intracranial process. Lacunar infarct in the right pons. Additional chronic changes. MRI is more sensitive in detecting acute ischemia. RUQ US= ___ ============ IMPRESSION: Prominent extra hepatic bile duct measuring up to 10 mm without intrahepatic dilatation. This finding is stable since prior exam however if LFTs suggest biliary obstruction further evaluation with MRCP could be obtained. Brief Hospital Course: Ms. ___ is a ___ yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following dialysis. The patient's daughter noted that she was not as interactive when she was receiving dialysis on ___, and complaining of feeling hot. She brought her into the ED where she was febrile to 100.8, and found to have a WBC of 19.1, lactate of 2.6, and UA showing numerous WBCs (CT head negative). A trigger was called for unresponsiveness in the ED. She responded well to empiric coverage with vanc/cefepime/flagyl before transfer to the floor. Of note, the daughter mentioned that she has been getting UTIs frequently, and that her last one in ___ was similar in presentation. # Urinary tract infection: Ms. ___ was treated with IV ceftriaxone until her UCx speciation returned positive for multidrug resistant E. coli. Her WBC continued to downtrend from the initial level of 19 on admission. She was switched to IV ceftazadime once her sensitivities returned, and completed her treatment course on ___. Given her history of multiple UTIs recently, it was suggested that her PCP consider imaging/urogynocological evaluation or prophylactic abx moving forward. # Transaminitis: Patient has a history of HCV/HBV coinfection, however, it was thought that her initial transaminitis on admission (ALT 101 AST 219) was due to septic pathology (possibly insufficient hepatic perfusion from hypotension during volume shifts during dialysis). There was no evidence of cirrhosis or synthetic dysfunction (RUQ US with no change). Her LFTs continued to downtrend throughout the admission. # Elevated lactate- she initially presented with an elevated lactate of 2.5, likely caused by urosepsis vs. hypotension in the setting of volume shifts during dialysis. The lactate downtrended to 1 by the first day of admission. # Acute Encephalopathy: Ms. ___ presented with altered mental status on admission likely secondary to toxic metabolic effects, and had a negative head CT in the ED. Her mental status steadily improved with IV antibiotics and was close to baseline at the time of discharge. # Dialysis- Ms. ___ received dialysis on her usual MWF schedule while admitted. Last dialysis session was ___. # Chronic- Ms. ___ received her home medications for DM, HTN, osteoporosis, asthma, and gout while admitted. TRANSITIONAL ISSUES: ==================== [] F/u with PCP within one week to discuss urogyn evaluation, further imaging, or prophylactic antibiotics to prevent future UTIs (based on her prior speciation/sensitivities, however, there may not be a good oral antibiotic for prophylaxis in her case) [] Discuss possible need for anticoagulation with PCP given diagnosis of atrial fibrillation with RVR (diagnosed during ___ admission, never in afib during current admission) [] Discuss possible need to uptitrate antihypertensive medications (systolic BPs in the 140s-160s while admitted) [] F/u ___ blood cultures to final result [] consider checking LFTs at PCP appointment on ___ [] NEW MEDICATIONS: Loperamide 2mg every 2 hrs as needed for diarrhea [] CHANGED MEDICATIONS: none [] STOPPED MEDICATIONS: none [] APPOINTMENTS: PCP appointment on ___ at 11am [] follow 2gm low salt diet, 2g potassium CODE STATUS: FULL CODE HCP/CONTACT: daughter, ___ To ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO BID 2. Aspirin EC 325 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Furosemide 80 mg PO BID 6. Losartan Potassium 100 mg PO 4X/WEEK (___) 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Montelukast 10 mg PO DAILY 9. NIFEdipine CR 90 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Omeprazole 20 mg PO BID 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Alendronate Sodium 35 mg PO QWED 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 15. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 16. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 17. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 18. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol ___ mg PO BID 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 10. Losartan Potassium 100 mg PO 4X/WEEK (___) 11. Metoprolol Succinate XL 200 mg PO DAILY 12. NIFEdipine CR 90 mg PO DAILY 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 14. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 15. Montelukast 10 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Omeprazole 20 mg PO BID 18. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 19. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 20. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by mouth four times a day Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Urinary Tract Infection - Transaminitis Secondary Diagnoses: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - Osteoporosis - HLD - Asthma - Anemia - HBV /HCV - Gout - GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to ___ on ___ because of lethargy, confusion, and fever after your dialysis session. When you came to the hospital, we found out that you had a urinary tract infection, similar to ones you have had in the past. This is likely what caused your symptoms. After treating you with IV antibiotics, your confusion and fever improved. You finished your last dose of antibiotics on ___ ___, and won't require any antibiotics on discharge. While here, you also had some diarrhea. This can often happen when on antibiotics. We determined that it was not caused by a separate intestinal infection. It should resolve over the next several days. To prevent urinary tract infections, it is important to practice good hygiene. The most common source of bacteria is stool, so ensuring that you clean well after stooling is important. You should discuss with your PCP whether or not long term antibiotics to prevent infection is an option for you. Please continue to take all your medications as prescribed. See below for a list of follow up appointments. Thank you for allowing us to participate in your care. Sincerely, Your ___ Medicine team Followup Instructions: ___

10035780-DS-16

DS

2132-12-14 00:00:00

2132-12-14 18:15:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___ Chief Complaint: Head Injury, s/p Fall Major Surgical or Invasive Procedure: EUS with biopsy ___ Mediastinoscopy with biopsy ___ History of Present Illness: Ms. ___ is a ___ yo woman with PMH of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection presenting after a fall. History obtained via son and daughter at bedside as patient speaks only ___. The patient reports that she got up to use commode ___ bedroom today then slipped off of it. She denies LOC, lightheadedness, or weakness and states it was purely due to slipping. She struck the bed and was reportedly down for 30 minutes with moderate blood loss from a head wound. The family put tobacco into the wound to try to stop the bleeding. She denies fevers though she reports feeling "cold" this AM. She denies dysuria or changes ___ urination aside from mildly reduced UOP. She has been eating and drinking normally. She denies feeling confused. She reports constipation over the last several hours, but denies focal numbness/tingling/weakness. She denies cough/SOB/rhinorrhea. She does note rare night sweats and ___ lb weight loss over 2 months. She had some blood ___ stool several days ago which self-resolved without further issues. She denies neck pain or any other pain elsewhere. ___ ED, initial vitals 97.4 88 150/66 20 100% RA. Imaging notable for CT Torso with LAD c/f lymphoma and segmental colitis; CT head without fracture or ICH; minimal anterolisthesis of C4 on C5 and C7 on T1 likely degenerative. Labs notable for WBC 16.7 with 74%PMN, Hgb 9.7 (most recent baseline ~11); trop negative x1; UA with >182 WBC and many bacteria, pos nit; lactate 2.1; Na 131 (recent baseline 127-132), Cr 3.3 (baseline around ___, Bicarb 17 with AG 20 (similar to recent values ___. Seen by spine, who note minimal anterolisthesis of C4-C5, likely degenerative and recommend keeping ___ hard C-collar spine as well as nonemergent MRI which can be performed inpt as pt is stable w/ a normal neuro exam. Received CTX 1g, TDaP x1. Skin staples placed to close head wound. Vitals on transfer 82 138/64 16 100% RA. On arrival to floor, patient denies complaints but requests water and to sit up ___ bed if possible. ROS: Positive as per HPI, all other systems reviewed and negative. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy ___ ___ - h/o C diff Social History: ___ Family History: She is widowed and has 7 children, all ___ apparently good health. No notable family hx. Physical Exam: ADMISSION VS: 97.8 174 / 82 97 16 95 RA General: Well appearing elderly woman lying ___ bed ___ NAD, hard C-collar ___ place Eyes: PERLL, EOMI, sclera anicteric HENT: Semicircular wound on right anterior scalp with closed with staples, c/d/i without notable erythema, no bleeding. MMM, oropharynx clear without exudate or lesions. Respiratory: CTAB without crackles, wheeze, rhonchi on anterior exam, limited by positioning with C-collar Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, nondistended, +BS, no masses or HSM, mild suprapubic tenderness to palpation Extremities: Warm and well perfused, no peripheral edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert and oriented x2-3 (knows name, at ___, year ___ but unsure of date), CN2-12 intact, ___ strength ___ UE and ___ bilaterally, follows commands appropriately Discharge exam: Vitals: 98.1 PO 178/71 88 18 97 RA Gen - tired appearing, initially sleeping on entry into the room, seated upright ___ bed, breathing comfortably HEENT - head laceration is well healed, staples are removed, EOMI, poor dentition with multiple fillings/artificial teeth Heart - RR, ___ systolic murmur over R/LUSB, no r/g Lungs - clear to auscultation bilaterally, no wheezing or rhonchi noted today Abd - soft nontender, normoactive bowel sounds Ext - no edema, WWP Neuro - awake, alert, conversant ___ ___, moving all extremities purposefully with normal strength, no tremor or focal deficits appreciated Skin - there is some bruising at the clavicles at site of mediastinoscopy which is stable and some scattered bruising on her arms at phlebotomy sites Pertinent Results: LABS ========================== ADMISSION LABS ___ 09:00AM BLOOD WBC-16.7*# RBC-2.89* Hgb-9.7* Hct-30.6* MCV-106* MCH-33.6* MCHC-31.7* RDW-14.3 RDWSD-55.7* Plt ___ ___ 09:00AM BLOOD Glucose-173* UreaN-28* Creat-3.3* Na-131* K-4.3 Cl-94* HCO3-17* AnGap-24* DISCHARGE LABS: ___ 07:56AM BLOOD WBC-8.5 RBC-2.57* Hgb-8.3* Hct-24.7* MCV-96 MCH-32.3* MCHC-33.6 RDW-18.6* RDWSD-66.0* Plt ___ ___ 07:56AM BLOOD Glucose-108* UreaN-41* Creat-3.0*# Na-131* K-3.4 Cl-96 HCO3-23 AnGap-15 ___ 07:56AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.5* MICRIOBIOLOGY ========================== ___ 4:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ blood culture x 2 NGTD ___ 2:11 am SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending ___ 5:53 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): MTB Direct Amplification (Preliminary): M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. . NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method has not been approved by FDA for clinical diagnostic purposes. However, ___ ___ (___) has established assay performance by ___ validation ___ accordance with ___ standards. . PERFORMED AT THE ___, ___. . RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON RECEIPT OF WRITTEN REPORT. ___ 11:06 am SPUTUM Site: INDUCED Source: Induced. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending ___ 10:08 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 and/or Influenza PCR (results listed under "OTHER" tab) for further information.. ___ Influenza A and B negative ___ RPR negative ___ cryptococcal antigen negative ___ 5:59 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ blood culture x 2 no growth final ___ 12:55 pm URINE CATHETER. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R IMAGING: ========================== ___ CXR FINDINGS: Trace pleural effusions. Mild left basilar opacity, likely atelectasis ___ the setting of shallow inspiration. ___ CXR IMPRESSION: ___ comparison with the scout radiograph from the CT of ___, there is little overall change. Prominence of these hilar and mediastinal regions are concerning for underlying malignancy. Following mediastinoscopy, there is no evidence of pneumothorax or pneumomediastinum. ___ MRI C-spine w/o con (wetread) Again seen is minimal anterolisthesis of C4 on C5 and C7 on T1, likely degenerative. There is no prevertebral edema or evidence of ligamentous injury. There is no evidence of acute fracture. Cord signal is within normal limits. Again seen is moderate right neural foraminal stenosis due to a facet osteophyte. Small posterior intervertebral osteophytes at multiple levels, but no high-grade spinal canal stenosis. ___ CT Torso w/con 1. No evidence of traumatic injury within the chest, abdomen or pelvis. 2. Numerous enlarged mediastinal lymph nodes, with gastrohepatic and portacaval lymph node conglomerate measuring up to 3.5 x 2.0 cm with cystic components, suspicious for malignancy, although a definite primary is not visualized on this examination. Lymphoma is a consideration. 3. Focal segment of proximal transverse colon demonstrating wall thickening and surrounding fat stranding, which likely represents segmental colitis. No nodularity to suggest an underlying primary malignancy. 4. Grade 1 anterolisthesis of L4 on L5, unchanged. ___ CT C spine without contrast 1. Minimal anterolisthesis of C4 on C5 and C7 on T1, likely degenerative ___ nature, however there are no priors for comparison. 2. No acute fractures. 3. Moderate right neural foraminal stenosis at C4-5. ___ CT Head w/o contrast Skin staples overlying a small right frontoparietal scalp hematoma without evidence of underlying fracture or intracranial hemorrhage. ___ MRI Cervical Spine 1. Grade 1 spondylolisthesis without evidence of ligamentous injury. 2. Mild multilevel degenerative changes of the cervical spine, as detailed above. 3. No evidence of bony or ligamentous injury. PATHOLOGY ================================= ___ final report SPECIMEN_1: LYMPH NODE, MEDIASTINAL 4R LYMPH NODE, EXCISION SPECIMEN_4: LYMPH NODE, MEDIASTINAL 4L LYMPH NODE, EXCISION. DIAGNOSIS: NECROTIZING GRANULOMAS, SEE NOTE. DIAGNOSIS: NECROTIZING GRANULOMAS, SEE NOTE. Note: Sections from Part 1 labeled as 4R lymph node compose of fragments of lymph nodes with extensive anthracotic pigment and focal granulomatous lesion. Sections from part 4, labeled as 4L lymph node, composed of fragments of lymphoid tissue with fibrosis and extensive necrosis. Special stains for infectious microorganisms (AFB, GMS, and Gram stain) performed on both specimens 1 and 2 are negative. The differential diagnosis includes infectious etiologies such as tuberculosis, and non-infectious causes such as necrotizing sarcoidosis, which is a diagnosis of exclusion. Correlation with clinical findings and microbiology cultures is highlight recommended. Brief Hospital Course: Ms. ___ is a ___ year old woman with past medical history of dementia, diabetes type 2 complicated by diabetic kidney disease / ESRD on HD, HBV/HCV co-infection admitted ___ following a fall with head laceration, incidentally also reporting recent GI bleed, with imaging concerning for malignancy # Fall / head laceration / cervical anterolisthesis: Per family, patient presented following a mechanical fall with head strike and large forehead laceration with significant bleeding. ___ the ED laceration was stapled and hemostasis was obtained. CT Head and torso were reassuring that there was no serious traumatic injury. Imaging identified scalp hematoma. CT and MRI C-spine showed mild anterolisthesis prompting spine service consult, who felt she had no ligamentous injury, and no acute surgical need. They recommended soft c-collar as needed with activity. Patient incidentally found to have several additional new medical issues listed below # Lymphadenopathy - Admission CT torso incidentally showed significant lymphadenopathy, concerning for malignancy / lymphoma. Oncology was consulted and recommended advanced endoscopy for EUS and biopsy. Obtained EUS with biopsy which was non-diagnostic. Patient then underwent midastinoscopy with thoracic surgery on ___ with lymph node biopsy. Final pathology consistent with necrotizing granulomas. Patient was r/o for active TB with 3 negative concentrated smears from induced sputa and negative NAAT. Rheumatology was consulted for concern for sarcoid, but did not believe this was likely. Patient should ___ ___ ID and ___ clinic. # Acute blood loss Anemia / GI Bleed NOS - Patient Hgb nadired at 5.9 from prior baseline of > 10 ___ setting of above head wound with significant bleeding at ___. Family also reported recent isolated episode of blood ___ patient's stool several days prior to presentation. ___ setting of CT scan with colonic thickening, and enlarged lymph nodes (as below), there was concern for malignant cause of recent bleeding. Per discussion with oncology, initially attempted to obtain EUS (as below) + colonoscopy to evaluate, however patient was noncompliant with bowel preparation x 2 successive nights despite counseling with family and interpreter. Discussed with family, and team felt that acute benefit of colonoscopy was outweighed by risk of continued attempts at preparation when patient did not wish to bowel prep. Given that priority was to obtain lymph tissue without additional delay, advanced endoscopy performed EUS with biopsy as below. There were no additional signs of GI bleeding and Hgb remained stable. Consider outpatient colonoscopy should patient and family wish to pursue. Patient did require 1 unit pRBC transition while EPO was held, but EPO was restarted once lymphoma was ruled out. # Cough - Patient developed cough during hospitalization. Three induced sputa with concentrated smears were negative for TB, NAAT testing was also negative. Sputum grew moderate commensal flora and multiple CXR were not consistent with pneumonia. Patient may have underlying non-tuberculous mycobacteria. She will f/u with ID as outpatient. She was treated symptomatically with improvement of cough and did not receive any antibiotics. # Latent TB - Patient's guantiferon gold was positive but as stated above, active TB testing at time of discharge was negative. Treatment will be per ID. # Hypertension - ___ setting of acute bleed on presentation, patient's antihypertensives were held. Once she was hemodynamically stable, restarted ___ nifedipine, Lasix, metoprolol, losartan. Of note, patient's BP noted to be high ___ the mornings prior to morning medication administration. Consider retiming medications to evening. # Atrial fibrillation - Patient had episodes of non sustained afib with RVR while at dialysis ___ setting of holding ___ metoprolol. These episodes were self limited and patient monitored on telemetry without any episodes of atrial fibrillation. Would consider outpatient Holter monitor to evaluate for afib. CHADS2 score of 3 VASc of 4 corresponding to a 5.9% and 6.4% risk of annual strokerespectively. Acute onset of AFib with rapid resolution is likely triggered from recent events described above. She has no prior history and is now ___ sinus rhythm. # Chest pain - Patient complaining of intermittent chest pain during hospitalization, likely MSK-related ___ setting of recent mediastinoscopy and pain exacerbated with coughing. EKG without any evidence of ischemic changes. # Urinary Tract Infection - On admission, patient found to have UA with bacteria and WBCs, as well as leukocytosis. Although it was unclear if she had symptoms, given her recent history of sepsis secondary to a UTI. risk of not treatment was felt to be high. Culture grew Ecoli and patient completed 5 days of IV CTX. # Osteoporosis - Given patient ESRD, held alendronate; could consider restarting at PCP ___. # ESRD on HD - Continued lasix as above. Continued calcium/VitD, Triphrocaps. Patient received ___ dialysis during hospitalization for scheduling purposes but was transitioned back to ___ dialysis prior to discharge. Next dialysis session should be ___. # Diabetes type 2 - Continued ASA and insulin sliding scale. She very rarely required any insulin for as BG was generally < 150. Thus, insulin was discontinued at discharge. # Asthma - Continued albuterol, Dulera, montelukast # GERD Continued PPI # Gout - Decreased dose of allopurinol given ESRD. > 30 minutes were spent on discharge planning and care coordination. TRANSITIONAL ISSUES: - Patient should have ID and rheumatology ___ for continued workup of extensive lymphadenopathy - pathology sample to be sent for molecular beacon testing by ID, no empiric treatment of TB recommended at this time - insulin sliding scale discontinued as patient did not require insulin during hospitalization - consider outpatient Holder monitor to evaluate for paroxysmal atrial fibrillation as patient had limited episodes during hospitalization - pending labs at discharge: ACE level, C4, C4, vitamin D, and RF Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol ___ mg PO DAILY 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Furosemide 80 mg PO BID 8. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 9. Losartan Potassium 100 mg PO 4X/WEEK (___) 10. Montelukast 10 mg PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 14. LOPERamide 2 mg PO QID:PRN diarrhea 15. Metoprolol Succinate XL 200 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 19. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin 21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Benzonatate 100 mg PO TID 3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 4. Docusate Sodium 100 mg PO BID 5. GuaiFENesin ___ mL PO Q6H 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 8. Alendronate Sodium 35 mg PO QWED 9. Allopurinol ___ mg PO DAILY 10. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 11. Aspirin EC 325 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 14. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 15. Furosemide 80 mg PO BID 16. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 17. LOPERamide 2 mg PO QID:PRN diarrhea 18. Losartan Potassium 100 mg PO 4X/WEEK (___) 19. Metoprolol Succinate XL 200 mg PO DAILY 20. Montelukast 10 mg PO DAILY 21. NIFEdipine CR 90 mg PO DAILY 22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 23. Omeprazole 20 mg PO BID 24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 25. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 26. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: # Lymphadenopathy # latent tuberculosis # Colonic abnormality # Acute blood loss Anemia # Fall with Head trauma/laceration # Hypertension # Urinary Tract Infection # Cervical Anterolisthesis # Osteoporosis # end stage renal disease # Diabetes type 2 # Asthma # GERD # Dementia - high risk for delirium # Gout Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___: It was a pleasure caring for you at ___. You were admitted with a fall and a large cut on your forehead. On a CAT scan you were found to have enlarged lymph nodes ___ your abdomen. You underwent a biopsy that showed granulomas. We performed multiple tests and determined you do not have cancer. We are not sure what is causing these large lymph nodes. It may due to TB (an infection), but testing is currently pending. You should ___ with the infectious disease and rheumatology doctors to determine what is causing your lymph nodes to be large. You are now ready for discharge to rehab. Please take care, Your ___ Team Followup Instructions: ___

10035780-DS-17

DS

2133-02-01 00:00:00

2133-02-02 17:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___ ___ Complaint: Hypotension and ?Altered Mental Status during dialysis Major Surgical or Invasive Procedure: None History of Present Illness: ___ only; History obtained from chart, nephew/niece over phone call, and with the assistance of language line interpreter): Ms. ___ is a ___ year old ___ and ___ speaking woman with a history of extrapulmonary TB (lymphadenitis) on RIPE since ___, UTI treated on recent admission (___), DM2, ESRD on HD (MWF), chronic HBV/HCV, HTN, and CAD who presented with confusion and transient hypotension (SBPs to ___ during dialysis. Approximately one week prior to admission, the patient's daughter noted foul smelling urine that was very dark in color, and per the daughter, the patient experienced some dysuria. The patient endorsed "feeling drunk" at this time along with several episodes of vomiting, though both resolved at the time of admission. She also endorsed weakness; at baseline, she ambulates with the occasional assistance of a cane at home, and she noted that she has had to use the cane in the days leading up to admission due to this weakness and "shakiness" in the legs. Per ED note, the patient presented to her regular hemodialysis yesterday (___) and was noted to have transient hypotension to the ___ which corrected with administration of IV fluids. She was then transferred to the ___ ED. Notably, per chart review, she was recently hospitalized at the ___ from ___ to ___nd head strike with no traumatic injury identified on CT Head but extrapulmonary TB found incidentally on CT Torso after workup for lymphadenopathy; three induced sputa with concentrated smears were negative for TB and NAAT testing was negative. Urinalysis and urine culture were positive for E. coli on admission and she completed 5 days of IV ceftriaxone. She was discharged to ___ rehab on ___ and initiated RIPE on ___. She was discharged from ___ on ___. Regarding her baseline status, her niece, ___, last saw her at ___, but spoke with a cousin who last saw her approximately 5 days prior to admission. She noted that the patient seemed well this week: alert, attentive, and able to engage in conversation. She did note that the patient does not leave the home very often and it is very possible she is not aware of the date at baseline. Notably, the patient never learned how to read and has poor eyesight. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and has 7 children, all in apparently good health. No notable family hx. Physical Exam: ============== ADMISSION EXAM ============== Vital Signs: T 98.3 BP 179/106 HR 78 RR 16 O2 Sat 99RA General: Alert, oriented to person (gives last name only), place (initially says home but acknowledges when prompted with hospital), but not time ___ no acute distress HEENT: Cutaneous horn noted below left eye. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: 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 grossly intact. ============== DISCHARGE EXAM ============== Vitals: T 97.9 BP 178/77 P 69 RR 18 O2 Sat 96RA General: Alert, oriented to person and place, date ___ no acute distress HEENT: Cutaneous horn noted below left eye. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: 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 grossly intact. Pertinent Results: ADMISSION LABS ============== ___ 08:20PM BLOOD cTropnT-0.04* ___ 07:00AM BLOOD cTropnT-0.09* ___ 07:00AM BLOOD cTropnT-0.09* ___ 03:40PM BLOOD cTropnT-0.08* ___ 07:50AM BLOOD CK-MB-3 ___ 03:40PM BLOOD CK-MB-3 ___ 10:52PM BLOOD WBC-13.7*# RBC-3.34*# Hgb-11.4# Hct-34.9# MCV-105*# MCH-34.1* MCHC-32.7 RDW-16.3* RDWSD-61.8* Plt ___ ___ 10:52PM BLOOD Neuts-87.6* Lymphs-4.3* Monos-6.6 Eos-0.1* Baso-0.7 Im ___ AbsNeut-11.98*# AbsLymp-0.59* AbsMono-0.90* AbsEos-0.01* AbsBaso-0.09* ___ 08:20PM BLOOD Glucose-88 UreaN-9 Creat-2.0* Na-137 K-3.2* Cl-92* HCO3-23 AnGap-25* ___ 03:40PM BLOOD Glucose-99 UreaN-18 Creat-3.2*# Na-138 K-4.2 Cl-97 HCO3-24 AnGap-21* ___ 03:40PM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8 ___ 08:20PM BLOOD ALT-20 AST-54* AlkPhos-100 TotBili-0.2 ___ 08:20PM BLOOD Albumin-3.7 ___ 08:20PM BLOOD Lipase-29 DISCHARGE LABS ============== ___ 06:00AM BLOOD WBC-6.2# RBC-2.99* Hgb-10.2* Hct-30.4* MCV-102* MCH-34.1* MCHC-33.6 RDW-16.0* RDWSD-59.1* Plt ___ ___ 06:00AM BLOOD Glucose-97 UreaN-29* Creat-3.7* Na-137 K-3.9 Cl-97 HCO3-25 AnGap-19 ___ 06:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.8 ___ 03:11AM URINE RBC-1 WBC-17* Bacteri-FEW Yeast-NONE Epi-0 ___ 03:11AM URINE Blood-TR Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.5 Leuks-NEG ___ 03:11AM URINE Color-Yellow Appear-Clear Sp ___ IMAGING/STUDIES =============== ___ (PA & LAT) Chronic findings as noted above. No evidence of mass, hemorrhage or infarction. ___ CHEST/ABD/PELVIS W/O 1. No acute abnormality within the chest, abdomen, or pelvis. 2. Stable lymphadenopathy of mediastinal and porta hepatis lymph nodes remains unclear in etiology. ___ HEAD W/O CONTRAST Chronic findings as noted above. No evidence of mass, hemorrhage or infarction. Brief Hospital Course: ___ ___ speaking ONLY) with DM2, ESRD on HD (MWF), chronic HCV/HBV, HTN, extrapulmonary TB (lymphadenitis) on RIPE who presented from HD with hypotension and recent UTI. #Foul-smelling urine/ recent UTI: Started 5-day course of ciprofloxacin by PCP ___ ___ for symptomatic complaints, consistent with UTI. Received dose of ceftriaxone in ED on ___, to complete 5-day course of antibiotics. Afebrile, no chills or flank pain or CVA tenderness, not complaining of dysuria or other urinary symptoms, urine was not foul-smelling during admission. U/A was negative for leukocyte esterase and nitrites, few bacteria, 17 WBC, >300 mg/dL protein; the proteinuria is her baseline. Notably, she has had recurrent UTIs, several of which were cipro-resistant bacteria. Given entire picture, decided to hold further antibiotics. Pt was discharged prior to urine culture resulting; when culture finalized on ___, patient and PCP were contacted to inform them that the urine culture was negative and no further intervention was required. #Transient Hypotension in dialysis, elevated troponins: No records from dialysis, note indicates SBPs to ___ but unclear duration. Normotensive upon arrival to ___ ED. Pt had troponin leak (peak 0.09 with subsequent downtrend) w/ transient ST segment depressions in V5/6 on initial EKG that resolved on subsequent EKGs. Pt denied cardiac or pulmonary complaints. Unclear whether hypotension preceded troponin leak or vice versa. Suspect that hypotension occurred in the setting of UTI and poor PO intake preceding HD session on ___, which led her to become hypotensive while undergoing ultrafiltration. Troponin elevation was likely in the setting of demand ischemia, which improved with resolution of hypotensive episode. #Hypertension: SBPs in 170s-180s;asymptomatic. Did not receive home anti-hypertensives for >24 hours in ED. Restarted on all home antihypertensives with improvement of BP to 160s. #Altered Mental Status: Per son, who lives with patient, that patient was at her baseline mental status. Patient has a history of dementia noted during previous admission, but further details are unclear and family does not seem to be aware. Alert and oriented to person and place, and able to relate recent history clearly with no fluctuating consciousness. CT Head negative for acute changes, demonstrates chronic atrophic changes and white matter hypodensities. #Osteoporosis: Alendronate held at previous admission given ESRD, deferred to PCP ___: restarting. Continued to hold alendronate during admission. #ESRD on HD: has HD on ___ - did not require dialysis while admitted. Continued Calcium and Vit D. #DM2: blood glucose 99 at admission. Did not require insulin for glucose management during admission. #Asthma: Continued albuterol, montelukast. Given advair 250/50 instead of dulera; will restart Dulera as outpatient #GERD: Continued PPI #Gout: continued allopurinol, changed dosing to HD dosing, 150 mg after HD TRANSITIONAL ISSUES =================== [x] inpatient team will follow-up the result of urine culture and contact one of the ___ relatives ___, ___. ___, niece, ___ for any interventions that need to take place pending the results of the culture -- this was completed prior to completion of this discharge summary. Culture was negative; pt and PCP contacted, no antibiotics required. [ ] close follow-up of blood pressure with primary care physician ___ than 30 minutes was spent on this patient's discharge day management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol ___ mg PO DAILY 3. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 4. Aspirin EC 325 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. NIFEdipine CR 90 mg PO DAILY 11. Omeprazole 20 mg PO BID 12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 13. Benzonatate 100 mg PO TID 14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 15. Docusate Sodium 100 mg PO BID 16. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 17. Alendronate Sodium 35 mg PO QWED 18. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 20. LOPERamide 2 mg PO QID:PRN diarrhea 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 23. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 24. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 25. Polyethylene Glycol 17 g PO DAILY:PRN constipation 26. GuaiFENesin ___ mL PO Q6H 27. Rifampin 900 mg PO 3X/WEEK (___) 28. Isoniazid ___ mg PO 3X/WEEK (___) 29. Pyrazinamide ___ mg PO 3X/WEEK (___) 30. Ethambutol HCl 1200 mg PO 3X/WEEK (___) 31. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO 3X/WEEK (___) 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 7. Docusate Sodium 100 mg PO BID 8. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 9. Ethambutol HCl 1200 mg PO 3X/WEEK (___) 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 11. Furosemide 80 mg PO BID 12. Isoniazid ___ mg PO 3X/WEEK (___) 13. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 14. LOPERamide 2 mg PO QID:PRN diarrhea 15. Losartan Potassium 100 mg PO 4X/WEEK (___) 16. Metoprolol Succinate XL 200 mg PO DAILY 17. Montelukast 10 mg PO DAILY 18. NIFEdipine CR 90 mg PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Omeprazole 20 mg PO BID 21. Polyethylene Glycol 17 g PO DAILY:PRN constipation 22. Pyrazinamide ___ mg PO 3X/WEEK (___) 23. Pyridoxine 50 mg PO DAILY 24. Rifampin 900 mg PO 3X/WEEK (___) 25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 26. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 27. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 28. HELD- Alendronate Sodium 35 mg PO QWED This medication was held. Do not restart Alendronate Sodium until another physician tells you to start taking this again. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Hypotension during hemodialysis Demand ischemia Secondary diagnoses: End stage renal disease on hemodialysis Hypertension Diabetes Asthma 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 ___ from ___ to ___. WHY WERE YOU ADMITTED TO THE HOSPITAL? - Your blood pressure was quite low during dialysis. - There was concern that you were confused and may have a urinary tract infection (UTI). WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - Your blood pressure was monitored overnight; it remained high, instead of low. We gave you all of your home medications to control your blood pressure. - We tested your urine - it showed no signs of infection. WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL? - Continue to take all of your medicines, as prescribed. - We will follow the results of your urine study to ensure that no bacteria grow. If any bacteria does grow, and we need to treat you for a urinary tract infection, we will call both you and your primary care doctor, Dr ___, so we can prescribe you an antibiotic. - You should follow-up with your primary care doctor, Dr ___ ___, some time this week to check-in. We wish you the best with your health going forward. If you have any further questions regarding your care here, please do not hesitate to contact us at ___ ___ 7 front desk). Your ___ Medicine Team Followup Instructions: ___

10035780-DS-18

DS

2135-07-22 00:00:00

2135-07-22 18:21:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: AV fistula thrombectomy History of Present Illness: Ms ___ is a ___ y/o ___ speaking patient with PMH significant for Alzheimer's dementia, HTN, HLD, ESRD (on ___ HD), who originally presented to ___ thrombectomy, but was determined to not have capacity to consent to procedure, and ___ was unable to get consent from HCP, thus was sent to the ED. Patient presented to the ED from ___ after she was unable to provide consent for planned thrombectomy for clotted left fistula. They attempted to contact the patient's healthcare proxy multiple times but were unable to reach her. The ED was also unable to reach her. In the ED, the patient is mildly confused, which appears to be her baseline. She notes mild abdominal pain but no other symptoms. In the ED... - Initial vitals: 97.9 76 180/79 16 97% RA - Labs/studies notable for: Cr > 9, K 5.0 - Patient was given: 10 IV labetalol Past Medical History: - DMII - ESRD on HD ___, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and has 7 children, all in apparently good health. No notable family hx. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== ___ 2340 Temp: 98.1 PO BP: 190/95 HR: 81 RR: 18 Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: Chronically ill appearing, NAD HEENT: Conjunctiva clear, PERRL, MMM NECK: No JVD. LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. ABD: Mild epigastric tenderness normal bowel sounds. EXTREMITIES: No edema. WWP. Left AV fistula. SKIN: No rashes. NEURO: Alert, unable to establish orientation. DISCHARGE PHYSICAL EXAM: =========================== 24 HR Data (last updated ___ @ 1234) Temp: 98.0 (Tm 98.1), BP: 172/84 (154-179/68-84), HR: 78 (70-78), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: Ra, Wt: 95.46 lb/43.3 kg GEN: NAD HEENT: Jaundice, Normocephalic, atraumatic NECK: No JVD. LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. ABD: normal bowel sounds. EXTREMITIES: No edema. WWP. Left AV fistula with some bruising. Good thrill/bruit. SKIN: No rashes. NEURO: Alert, unable to establish orientation. Pertinent Results: Pertinent Results: ADMISSION LABS ============== ___ 03:20PM BLOOD WBC-8.7 RBC-3.00* Hgb-10.1* Hct-31.5* MCV-105* MCH-33.7* MCHC-32.1 RDW-14.2 RDWSD-53.3* Plt ___ ___ 03:20PM BLOOD Plt ___ ___ 03:20PM BLOOD Glucose-94 UreaN-53* Creat-9.4*# Na-135 K-5.0 Cl-94* HCO3-24 AnGap-17 RELEVANT LABS: ============== ___ 09:29AM BLOOD WBC-9.0 RBC-2.96* Hgb-10.1* Hct-30.9* MCV-104* MCH-34.1* MCHC-32.7 RDW-14.8 RDWSD-54.6* Plt ___ ___ 05:08AM BLOOD WBC-7.9 RBC-2.93* Hgb-10.0* Hct-30.7* MCV-105* MCH-34.1* MCHC-32.6 RDW-15.2 RDWSD-57.1* Plt ___ ___ 05:34AM BLOOD WBC-4.0 RBC-2.34* Hgb-7.9* Hct-25.4* MCV-109* MCH-33.8* MCHC-31.1* RDW-15.9* RDWSD-62.4* Plt Ct-71* ___ 06:03AM BLOOD WBC-4.5 RBC-2.13* Hgb-7.3* Hct-22.7* MCV-107* MCH-34.3* MCHC-32.2 RDW-15.6* RDWSD-61.2* Plt Ct-67* ___ 05:31AM BLOOD WBC-3.8* RBC-1.94* Hgb-6.6* Hct-21.3* MCV-110* MCH-34.0* MCHC-31.0* RDW-15.5 RDWSD-62.4* Plt Ct-56* ___ 05:00PM BLOOD WBC-5.5 RBC-2.90* Hgb-9.5* Hct-30.5* MCV-105* MCH-32.8* MCHC-31.1* RDW-18.7* RDWSD-72.4* Plt Ct-70* ___ 07:05AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.7* Hct-27.6* MCV-103* MCH-32.6* MCHC-31.5* RDW-18.5* RDWSD-70.4* Plt Ct-70* ___ 05:25AM BLOOD WBC-4.6 RBC-2.63* Hgb-8.6* Hct-27.9* MCV-106* MCH-32.7* MCHC-30.8* RDW-17.5* RDWSD-69.1* Plt Ct-60* ___ 07:05AM BLOOD Neuts-62.1 ___ Monos-9.6 Eos-5.4 Baso-0.4 Im ___ AbsNeut-2.90 AbsLymp-1.03* AbsMono-0.45 AbsEos-0.25 AbsBaso-0.02 ___ 09:29AM BLOOD Plt ___ ___ 07:37AM BLOOD Plt ___ ___ 05:32AM BLOOD Plt ___ ___ 05:34AM BLOOD Plt Smr-VERY LOW* Plt Ct-71* ___ 06:03AM BLOOD Plt Ct-67* ___ 05:31AM BLOOD Plt Ct-56* ___ 06:48AM BLOOD ___ PTT-29.1 ___ ___ 05:00PM BLOOD Plt Ct-70* ___ 07:05AM BLOOD Plt Ct-70* ___ 05:25AM BLOOD Plt Ct-60* ___ 08:00AM BLOOD Plt Ct-71* ___ 06:48AM BLOOD ___ ___ 06:03AM BLOOD Ret Aut-4.5* Abs Ret-0.10 ___ 05:31AM BLOOD Ret Aut-4.4* Abs Ret-0.09 ___ 09:19PM BLOOD HIT Ab-NEG HIT ___ ___ 09:29AM BLOOD Glucose-81 UreaN-58* Creat-10.4* Na-135 K-5.3 Cl-93* HCO3-25 AnGap-17 ___ 08:21PM BLOOD Glucose-197* UreaN-67* Creat-12.1* Na-132* K-4.9 Cl-91* HCO3-23 AnGap-18 ___ 05:32AM BLOOD Glucose-98 UreaN-18 Creat-5.2* Na-142 K-3.7 Cl-100 HCO3-27 AnGap-15 ___ 06:03AM BLOOD Glucose-112* UreaN-30* Creat-8.4*# Na-140 K-4.6 Cl-99 HCO3-21* AnGap-20* ___ 05:25AM BLOOD Glucose-89 UreaN-10 Creat-3.3*# Na-141 K-4.3 Cl-100 HCO3-31 AnGap-10 ___ 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140 K-4.3 Cl-101 HCO3-29 AnGap-10 ___ 05:34AM BLOOD ALT-12 LD(LDH)-202 AlkPhos-53 TotBili-0.5 ___ 06:03AM BLOOD ALT-13 AST-32 LD(LDH)-344* AlkPhos-46 TotBili-0.5 ___ 09:29AM BLOOD Calcium-8.8 Phos-6.2* Mg-2.2 ___ 08:21PM BLOOD Calcium-9.9 Phos-5.9* Mg-2.2 ___ 02:18AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0 ___ 06:03AM BLOOD Calcium-8.6 Phos-7.6* Mg-2.0 ___ 07:05AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0 ___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 ___ 06:03AM BLOOD Hapto-<10* ___ 05:31AM BLOOD Hapto-12* ___ 07:37AM BLOOD VitB12-1069* ___ 05:08AM BLOOD VitB12-1280* Folate->20 ___ 09:29AM BLOOD %HbA1c-4.2 eAG-74 ___ 05:31AM BLOOD TSH-2.4 ___ 09:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* ___ 08:00AM BLOOD IgM HBc-PND ___ 07:05AM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV IgG-PND EBNA-PND EBV IgM-PND EBVI-PND ___ 05:00PM BLOOD HCV VL-NOT DETECT ___ 07:05AM BLOOD HCV VL-NOT DETECT ___ 07:05AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND MICROBIOLOGY ============ ___ 5:00 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. IMAGING ======= ___ Imaging AV FISTULOGRAM SCH IMPRESSION: Satisfactory restoration of flow following chemical and mechanical thrombolysis with a good angiographic and clinical result. ___ Imaging ART DUP EXT UP UNI OR L IMPRESSION: Small pseudoaneurysm immediately anterior to the AV fistula in the left antecubital fossa. DISCHARGE LABS: =============== ___ 08:00AM BLOOD WBC-5.0 RBC-2.60* Hgb-8.5* Hct-27.3* MCV-105* MCH-32.7* MCHC-31.1* RDW-17.5* RDWSD-67.6* Plt Ct-71* ___ 08:00AM BLOOD Plt Ct-71* ___ 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140 K-4.3 Cl-101 HCO3-29 AnGap-10 ___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 Brief Hospital Course: Ms ___ is a ___ y/o ___ speaking patient with PMH significant for Alzheimer's dementia, ESRD, and HTN, who presented for thrombectomy, but was determined to not have capacity to consent to procedure, and ___ was unable to get consent, thus admitted for ___ procedure and dialysis. On ___, Ms. ___ received a temp. line and recieved HD given worsening of her condition. Eventually, HCP was contacted and She had a AVF thrombectomy on ___. Her course was complicated by pancytopenia requiring 1u pRBCs with improvement in cell counts prior to discharge. ACUTE ISSUES: # Thrombosed Fistula- Resolved Patient was originally transferred from nursing home for ___ intervention on clotted left AV fistula. She was unable to consent for the procedure and was admitted to medicine service. She had a temporary HD line placed to get HD while awaiting consent from HCP. Consent was obtained and she underwent thrombectomy on ___. She had HD successfully with her fistula after thrombectomy. She had temporary HD line removed afterwards. #Pancytopenia Patient was noted to have new onset pancytopenia during her hospitalization. Etiology was unclear and felt to likely be related to either viral infection or dysplastic bone marrow. Hematology was consulted and assisted in infectious work up which was unremarkable at time of discharge. Work up was notable for negative HIT antibodies, mild evidence of hemolysis that improved, normal bilirubin, normal B12 and folate, negative ___, and HCV VL not detected. Pending work up included CMV IgG Ab, CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19 antibodies. Hgb nadir was 6.6 for which the patient received 1u of PRBCs. Her discharge Hgb was 8.5. Platelets nadir of 60 with discharge platelet count of 71. She required no platelet transfusions during her hospitalization. Patient should have repeat CBC at HD on ___. Could consider outpatient hematology follow up if pancytopenia does not improve. # ESRD On MWF dialysis. As noted above, had temporary HD line placed for HD that was removed after fistula was fixed. Last HD session on ___. Will need HD on ___. Continue home calcium with meals, sevelamer with meals. # HTN Patient was persistently hypertensive during her hospitalization. Her losartan was increased from non-HD days to daily and she remained on her home metoprolol succinate. Could consider adding hydralazine as outpatient if BP remains elevated. CHRONIC/STABLE ISSUES: #Dementia Mental status was trended throughout her hospitalization and was felt to be at baseline. # COPD - Hold home dulera (NF), duonebs q6hr prn - Continue home montelukast # GERD - Continue ranitidine # Hx Hep C S/p treatment in ___. # CODE STATUS: DNR/DNI per MOLST on file. Transitional Issues: =============================== [ ] Recheck CBC on ___ with HD [ ] Consider hematology follow up if persistently pancytopenic [ ] Follow up infectious work up: CMV IgG Ab, CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19 antibodies [ ] Consider addition of hydralazine if BP remains elevated [ ] Discontinued aspirin for primary prevention [ ] Consider a family meeting regarding proxy - daughter hoping to transition HCP to son Patient seen and examined on day of discharge. Stable for discharge to facility. >30 minutes on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 150 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Allopurinol ___ mg PO BID 4. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 5. Loratadine 10 mg PO DAILY 6. Alendronate Sodium 35 mg PO QFRI 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Terazosin 2 mg PO QHS 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Montelukast 10 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. LOPERamide 2 mg PO QID:PRN diarrhea 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 14. Calcium Acetate 667 mg PO TID W/MEALS 15. Ferric Citrate 210 mg PO TID W/MEALS 16. sevelamer CARBONATE 800 mg PO TID W/MEALS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 2. Losartan Potassium 100 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Alendronate Sodium 35 mg PO QFRI 5. Allopurinol ___ mg PO BID 6. Calcium Acetate 667 mg PO TID W/MEALS 7. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 8. Ferric Citrate 210 mg PO TID W/MEALS Administer with food. Separate administration of other medications by at least 2 hours. 9. LOPERamide 2 mg PO QID:PRN diarrhea 10. Loratadine 10 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Ranitidine 150 mg PO DAILY 14. sevelamer CARBONATE 800 mg PO TID W/MEALS 15. Terazosin 2 mg PO QHS 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #Thrombocytopenia #Thrombosed Fistula 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: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you needed your fistula fixed. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had your fistula fixed so you could get dialysis. - You had low red blood cell counts and platelets. You were given one unit of red blood cells with improvement in your blood counts. 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. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10035844-DS-12

DS

2143-08-20 00:00:00

2143-08-24 09:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ------------------ ___ 01:22PM BLOOD WBC-11.5* RBC-4.96 Hgb-15.1 Hct-47.0* MCV-95 MCH-30.4 MCHC-32.1 RDW-13.4 RDWSD-47.3* Plt ___ ___ 01:22PM BLOOD Neuts-84.1* Lymphs-10.4* Monos-4.3* Eos-0.1* Baso-0.6 Im ___ AbsNeut-9.68* AbsLymp-1.20 AbsMono-0.49 AbsEos-0.01* AbsBaso-0.07 ___ 01:22PM BLOOD Plt ___ ___ 01:22PM BLOOD Glucose-263* UreaN-17 Creat-0.9 Na-134* K-5.5* Cl-102 HCO3-21* AnGap-11 ___ 01:22PM BLOOD CK(CPK)-216* ___ 06:01AM BLOOD ALT-27 AST-45* AlkPhos-144* TotBili-0.8 ___ 01:22PM BLOOD cTropnT-<0.01 ___ 07:12AM BLOOD CK-MB-3 cTropnT-0.01 ___ 07:12AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.3 Mg-2.0 Cholest-155 ___ 07:57AM BLOOD %HbA1c-7.1* eAG-157* ___ 07:12AM BLOOD HDL-34* CHOL/HD-4.6 ___ 06:01AM BLOOD Cortsol-16.5 ___ 01:22PM BLOOD TSH-2.2 ___ 01:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG Discharge Labs ------------------- ___ 09:10AM BLOOD WBC-8.0 RBC-4.74 Hgb-14.5 Hct-45.3* MCV-96 MCH-30.6 MCHC-32.0 RDW-13.2 RDWSD-46.6* Plt ___ ___ 09:10AM BLOOD Plt ___ ___ 09:10AM BLOOD Glucose-231* UreaN-12 Creat-0.8 Na-139 K-4.4 Cl-100 HCO3-24 AnGap-15 ___ 09:10AM BLOOD ALT-30 AST-43* ___ 09:10AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7 Imaging ------------------ CTA HEAD AND NECK IMPRESSION: 1. Head CT: Images degraded by motion artifact. Within this confine: No definite acute territorial infarct, intracranial hemorrhage, mass or mass effect. 2. Head CTA: Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. Mild atherosclerotic calcifications of the bilateral carotid siphons. 3. Neck CTA: Images degraded by motion artifact. Within these confines: Linear filling defect within the proximal right internal carotid artery (3:157) is felt to reflect artifact related to patient motion. There is approximately 20% stenosis of the left proximal internal carotid artery by NASCET criteria. Otherwise, patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion,or dissection. CAROTID U/S IMPRESSION: Right ICA <40% stenosis. Left ICA <40% stenosis. MRI IMPRESSION: 1. No acute intracranial abnormality. No evidence of acute or subacute infarct. 2. Mild nonspecific white matter signal changes most likely reflecting chronic small vessel disease in this age group Brief Hospital Course: ___ is a ___ female with a history of hypertension, diabetes on insulin who presented as a transfer from ___ with hypoglycemia secondary to overinsulinization found to have post-hypoglycemic tonic-clonic seizure complicated by ___ paralysis with normal neurologic imaging and mental status returning back to baseline. Her insulin regimen was adjusted by the ___ diabetes team with education provided by the diabetes educator. TRANSITIONAL ISSUES: ==================== [] Ensure ___ follow up, patient given contact information [] Would benefit from Dexcom glucose monitor [] Neuro follow up with seizure clinics [] Needs a Basqimi (intransal glucagon) prescription upon follow up ACUTE ISSUES: ============= #Hypoglycemic Seizure #Left common carotid artery calcification Patient presented to ___ with a tonic-clonic seizure that was likely precipitated by a hypoglycemic episode with residual right-sided hemiparesis secondary to a postictal state precipitated by an overly aggressive home insulin sliding scale. Work-up for her seizure was unremarkable with no signs of infectious, toxic or Metabolic processes. Neurological imaging with an CTA of the head and MRI was also unremarkable. She had no further episodes of seizures while she was admitted here. She will need follow up in the ___ seizure clinic for a routine outpatient sleep deprived extended EEG as an outpatient. #T2DM with repeated hypoglycemia Her home insulin regimen consisted of 50 units of Lantus in the AM followed by 'carb counting' resulting in ___ units of Novolog which was an overly aggressive insulin regimen. Her A1c during this admission was 7.1 She was evaluated by the ___ team and transition to a simpler insulin regimen of lantus 35u qAM with sliding scale humalog with meals. She also met with the diabetes nurse educator for further education. CHRONIC ISSUES: =============== #Hypothyroidism Her TSH level was 2.2. Continued home levothyroxine 275mcg daily. #Depression Continued her home sertraline 100mg daily #HTN Continued her home lisinopril #Hyperlipidemia Continued her home simvastatin. CORE MEASURES ============= #CODE: full confirmed #CONTACT: ___, husband. ___: ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Sertraline 100 mg PO DAILY 2. Simvastatin 20 mg PO QPM 3. Lisinopril 20 mg PO DAILY 4. Glargine 50 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Levothyroxine Sodium 275 mcg PO DAILY Discharge Medications: 1. Baqsimi (glucagon) 3 mg/actuation nasal PRN hypoglycemia RX *glucagon [Baqsimi] 3 mg/actuation 1 spray nasal PRN Disp #*3 Spray Refills:*0 2. Glargine 35 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Levothyroxine Sodium 275 mcg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Sertraline 100 mg PO DAILY 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary ========== Hypoglycemic Seizure Insulin depending diabetes mellitus Secondary ========== Hypothyroidism Depression Hypertension Hyperlipedmia 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 admission to ___. Below you will find information regarding your stay. WHY WAS I ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you had a seizure due to low blood sugars. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -While you are in the hospital you received a number of imaging diagnostic test to evaluate for causes of your seizure. These tests all came back normal. Additionally, you also met with the diabetes doctors as ___ as diabetes educator to work on a more stable insulin regimen. WHAT SHOULD I DO WHEN I GO HOME? -Take your medications as prescribed and attend your follow up appointments as scheduled. -Please call ___ on ___ and request a "hospital transition appointment" within ___s a Dietician appointment on the same day. Thank you for letting us be a part of your care! Your ___ Care Team Followup Instructions: ___

10036086-DS-22

DS

2200-11-09 00:00:00

2200-11-10 14:57:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___. Chief Complaint: left flank pain Major Surgical or Invasive Procedure: Cystoscopy left ureteral stent placement History of Present Illness: ___ w hx of HIV, DM, CKD with 5 days of left flank pain. The pain began this past ___ and was initially located in the periumbilical region. It gradually moved to the left flank over the following day. He describes the pain as sharp in nature and nonradiating. The pain has been constant but waxing and waning in intensity, ranging from ___. He has been taking ibuprofen twice a day for pain control. His PO intake has been minimal and reports low grade fever to 100 and chills. He denies nausea and vomiting. He denies dysuria, urinary frequency, urgency, or hematuria. He has one prior kidney stone episode which passed without instrumentation, he is unsure of when this occurred Past Medical History: PMHx/PSHx: 1. HIV, currently well controlled on antiretroviral therapy. 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus. 8. Obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: ___ Family History: Fam Hx: NC Physical Exam: AVSS NAD WWP unlabored breathing abd soft, NT, ND Pertinent Results: ___ 04:25PM BLOOD WBC-10.2# RBC-4.72 Hgb-14.8 Hct-46.0 MCV-98 MCH-31.3 MCHC-32.2 RDW-14.0 Plt ___ ___ 04:39AM BLOOD Glucose-92 UreaN-29* Creat-2.4* Na-141 K-4.7 Cl-108 HCO3-23 AnGap-15 ___ 08:45PM BLOOD Glucose-63* UreaN-29* Creat-2.5* Na-140 K-4.6 Cl-106 HCO3-23 AnGap-16 ___ 04:25PM BLOOD Glucose-82 UreaN-29* Creat-2.7*# Na-142 K-5.3* Cl-104 HCO3-24 AnGap-19 Brief Hospital Course: The patient was admitted to the Urology Service under Dr. ___. On HD1 he underwent a left ureteral stent placement. Please see the dictated note for further operative details. The case was uncomplicated and he tolerated the procedure well. He was discharged on HD1 after the procedure. He will follow up with Dr. ___ in 2 weeks for discussion of definitive stone management. He will see his nephrologist on ___ for repeat creatinine draw. On discharge his pain was well controlled, he was tolerating a diet, and voiding without issues. Medications on Admission: ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler. 2 puffs(s) oral as needed - (Prescribed by Other Provider) ATORVASTATIN [LIPITOR] - Lipitor 40 mg tablet. one Tablet(s) by mouth dialy - (Prescribed by Other Provider) EFAVIRENZ [SUSTIVA] - Sustiva 600 mg tablet. 1 Tablet(s) by mouth daily - (Prescribed by Other Provider) EMTRICITABINE [EMTRIVA] - Emtriva 200 mg capsule. one Capsule(s) by mouth daily - (Prescribed by Other Provider) EXENATIDE [BYETTA] - Byetta 10 mcg/0.04 mL per dose Sub-Q Pen Injector. one syringe subcutaneous twice daily - (Prescribed by Other Provider) FENOFIBRATE MICRONIZED - fenofibrate micronized 134 mg capsule. one capsule(s) by mouth daily - (Prescribed by Other Provider) INSULIN GLARGINE [LANTUS SOLOSTAR] - Lantus Solostar 100 unit/mL (3 mL) Sub-Q Insulin Pen. 75 u daily in AM - (Prescribed by Other Provider) LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth daily RALTEGRAVIR [ISENTRESS] - Isentress 400 mg tablet. one Tablet(s) by mouth twice a day - (Prescribed by Other Provider) SUPER IMMUNE - . 4 a day (super immune/nutrion brand) TRAMADOL - tramadol 50 mg tablet. 1 tablet(s) by mouth TWICE daily as needed for pain. Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg tablet,delayed release. 1 Tablet(s) by mouth daily On Hold - (Prescribed by Other Provider) CHONDROITIN SULFATE A [CHONDROITIN SULFATE] - Chondroitin Sulfate 250 mg capsule. 5 Capsule(s) by mouth daily 1200 mg dose, not ___. - (OTC) COENZYME Q10 - Dosage uncertain - (Prescribed by Other Provider) GLUCOSAMINE SULFATE 2KCL - glucosamine sulfate dipotassium chloride 500 mg capsule. 3 Capsule(s) by mouth daily - (Prescribed by Other Provider) MULTIVITAMIN - Dosage uncertain - (Prescribed by Other Provider) OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - Fish Oil 1,000 mg capsule. 2 Capsule(s) by mouth twice a day - (Prescribed by Other Provider) Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth ___ hours Disp #*30 Tablet Refills:*0 3. Tamsulosin 0.4 mg PO DAILY RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 Patient instructed to restart all home meds Discharge Disposition: Home Discharge Diagnosis: Left ureteral stone, acute on chronic renal failure 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 all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. Followup Instructions: ___

10036086-DS-24

DS

2203-12-04 00:00:00

2203-12-04 18:19:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___ Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Coronary Anatomy Right dominant, heart rotated to the left. LM: No significant disease. LAD: Proximal 40% smooth disease. Mid vessel 90% stenosis after large diag. LCx: Luminal irregularities. RCA: Luminal irregularities. 60% ostial PDA lesion. Interventional Details We proceeded with PCI of the mid LAD. XBLAD 3.5 guide. Vessel wired with a Runthrough wire. Angioplasty of the vessel followed by placement of a 3.0 x 18 mm Xience DES, post dilated with a 3.5 and 3.75 NC balloon at high pressure. TIMI III flow, 0% residual. Impressions: Successful PCI of severe mid LAD stenosis with single DES. Recommendations ASA for life, clopidogrel 75 daily x 3 months minimum History of Present Illness: Mr. ___ is a ___ year old male with PMH notable for HIV on HAART therapy, T2IDDM, HTN, HLD, obesity, CKD who presents with left arm pain. He was in his usual state of health until ___ when he was on the train when he noted severe dull left arm pain. These symptoms lasted for approx. 5 minutes and improved. Over the next few hours, he noted intermittent dull left arm pain that felt very similar to that same episode. He then presented to his PCP who referred him to the ED. Trops negative. Nuclear stress test completed on ___ showed reversible perfusion defect in the LAD territory. Since being here he has had intermittent arm pain that can range in severity from a 2 to an 8. Episodes of severe pain have been between 5 to 30 minutes. He slept in a recliner last night as he feels his pain is less when sitting upright. At baseline, he is typically very sedentary as he had been unemployed for 8 months. In ___, pt. began a new job and has been walking approximately 1.3 miles a day. When he goes a certain distance, he feels fatigued and short of breath which causes him to stop. Additionally, when he goes up a flight a steps, he feels very short of breath and can only do one flight at a time. He denies a history of chest, arm, jaw, or back pain, lightheadedness, dizziness, pre-syncope, syncope, worsening of his chronic ___ edema, orthopnea, PND, or palpitations. In the ED, pt. received crestor, losartan, fenofibrate, HAART therapy, Tylenol, and insulin. Past Medical History: PMHx/PSHx: 1. HIV (VL ___, CD4 490 in ___ on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: ___ Family History: nc Physical Exam: Physical Exam: Gen: Alert, no acute distress, sitting comfortably in recliner Neuro: Oriented x 3, speech clear, appropriate and comprehensible, Follows commands appropriately, MAE, mood and affect appropriate CV: Regular rate/rhythm Chest: Lungs clear bilaterally, diminished at bases, breathing non-labored ABD: Soft, non-tender, +bs Extr: BLE warm/well-perfused, ___ pulses Skin: Warm and dry Pertinent Results: ___ 05:00AM BLOOD WBC-8.8 RBC-4.93 Hgb-14.9 Hct-47.3 MCV-96 MCH-30.2 MCHC-31.5* RDW-17.3* RDWSD-59.3* Plt ___ ___ 05:50PM BLOOD WBC-9.4 RBC-5.39# Hgb-16.1# Hct-51.2*# MCV-95 MCH-29.9 MCHC-31.4* RDW-17.3* RDWSD-58.6* Plt ___ ___ 05:50PM BLOOD Neuts-62.6 ___ Monos-9.3 Eos-1.2 Baso-0.5 Im ___ AbsNeut-5.89 AbsLymp-2.43 AbsMono-0.87* AbsEos-0.11 AbsBaso-0.05 ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD ___ PTT-34.3 ___ ___ 09:39PM BLOOD PTT-31.1 ___ 12:45PM BLOOD ___ PTT-28.7 ___ ___ 05:50PM BLOOD Plt ___ ___ 05:00AM BLOOD Glucose-135* UreaN-26* Creat-1.3* Na-141 K-4.6 Cl-102 HCO3-27 AnGap-17 ___ 05:50PM BLOOD Glucose-126* UreaN-27* Creat-1.4* Na-142 K-4.8 Cl-99 HCO3-29 AnGap-19 ___ 11:35AM BLOOD cTropnT-<0.01 ___ 12:45PM BLOOD cTropnT-<0.01 ___ 12:00AM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD proBNP-118 Brief Hospital Course: Mr. ___ is a ___ year old man with a PMH notable for HIV on HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity, CKD who presented to the ED with left arm pain relieved with nitroglycerin. He underwent a stress test, which was notable for reversible ischemia in the LAD territory. He was started on heparin and nitro gtts pre-cath and underwent a cardiac catheterization on ___ and was found to have a severe mid LAD stenosis and one DES was placed via a right radial approach. his access site is clean without bleeding or hematoma. His CSM is normal. His left arm pain never resolved and continues despite coronary revascularization. He will be referred to his PCP to have outpatient work-up for other non-cardiac cause. He was started on ASA, Plavix and increased his dose of Crestor. He will follow-up with Dr. ___ long term cardiology care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 50 mg PO DAILY 2. Fish Oil (Omega 3) ___ mg PO BID 3. Fenofibrate 134 mg PO DAILY 4. rilpivirine 25 mg oral DAILY 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H 6. RiTONAvir 100 mg PO DAILY 7. Rosuvastatin Calcium 20 mg PO QPM 8. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 9. Glargine 60 Units Breakfast 10. Multivitamins 1 TAB PO DAILY 11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Darunavir 800 mg PO DAILY 4. Glargine 60 Units Breakfast 5. Rosuvastatin Calcium 40 mg PO QPM 6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H 8. Fenofibrate 134 mg PO DAILY 9. Fish Oil (Omega 3) ___ mg PO BID 10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 11. Losartan Potassium 50 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. rilpivirine 25 mg oral DAILY 14. RiTONAvir 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: CAD s/p DES to mid LAD Discharge Condition: Mr. ___ is a ___ year old man with a PMH notable for HIV on HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity, CKD who presented to the ED with left arm pain relieved with nitroglycerin. He underwent a stress test, which was notable for reversible ischemia in the LAD territory. He was started on heparin and nitro gtts and which were stopped after his cardiac catheterization. He is now s/p cardiac catheterization and DES to LAD: # Angina: fairly constant left arm discomfort since arrival to ___ on ___, worst was ___, currently ___, states has not been ___ since his arrival. Now s/p cardiac catheterization with PCI of severe mid LAD stenosis with ___ 1: -NTG gtt stopped post-cath -Heparin gtt stopped post-cath -ASA 81mg po daily lifelong -Start Plavix 75mg daily x minimum 3 months -Referral to cardiac rehab upon discharge -Follow-up with Dr. ___ for ___ cardiologist per patient request. # DM -continue Lantus -(takes victoza at home; may resume upon discharge, non-formulary here) monitor ___, ISS PRN -carb consistent diet # Hypertension: BP stable 120s/70s -Losartan held for cath (cr 1.4, now 1.3) -___ resume post discharge # Hyperlipidemia -Increase Crestor to 40 mg -cont Fenofibrate # CKD stage III GFR 51 Creat 1.4 -pre and post IV hydration -Holding Losartan for procedure; may resume upon discharge -Renal function labs on ___ #. HIV -cont home med regimen Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with left arm pain and were worked up for a cardiac source. You had an abnormal stress test followed by a cardiac catheterization. You were found to have a blockage in your left anterior descending artery and a drug coated stent was placed to improve blood flow to the heart. You will take Aspirin 81mg daily for life and Plavix 75mg daily. These will prevent a clot from forming in your stent. Do not stop taking either of these unless your cardiologist instructs you to do so. Stopping either of these will put you at risk for a life threatening heart attack. We also recommend that you consider attending a cardiac rehab program. A referral has been provided with your discharge paperwork. Care of your right wrist access site will be provided in your discharge instructions. We are providing you with a lab slip to get your kidney function tests checked on ___. We will request that the results be sent to your PCP. Your arm pain has not resolved despite your improved blood flow to the heart muscle. We recommend that you follow-up with your PCP to be worked up outpatient for other non-cardiac related sources. It has been a pleasure caring for you at ___! Followup Instructions: ___

10036086-DS-25

DS

2206-01-30 00:00:00

2206-01-30 19:30:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___ Chief Complaint: PE Major Surgical or Invasive Procedure: TEE/DCCV ___ History of Present Illness: ___ y/o male with hx of HIV on HAART therapy, prostate cancer s/p brachytherapy, T2IDDM, HTN, HLD, obesity, CKD, presents w tachycardia and dyspnea on exertion. Patient went to PCP today for bilateral lower ext edema but was found to have a a heart rate of 130s so sent here. He states that for the past few weeks he has had progressive dyspnea with exertion and b/l swelling. No history of blood clot. No chest pain. no fevers. no abdominal pain, n/v, cough or congestion. has had increased erythema over the left lower ext medial mal with pain progressively worsening. In the ED, initial vitals were: HR 132 BP 152/88 RR 18 O2 95 - Exam notable for: RLE swelling, erythema over bilat malls abrasions over the anterior shin. full ROM of all joint. - Labs notable for: 134 100 40 AGap=11 ------------<295 9.1 23 1.5 Repeat whole K: 4.5 proBNP: 843 Trop-T: 0.04 Lactate:3.1-->3.5 - Imaging was notable for: CTA 1. Pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe. No left-sided pulmonary emboli. Difficult to exclude right heart strain. Echocardiogram would further assess. 2. No focal consolidation. 3. Mild nodular contour of the liver raise concern for cirrhosis. Correlation with liver function test is recommended for further evaluation. 4. Status post splenectomy. ___ on right There is non-occlusive deep vein thrombus of a right posterior tibial vein. - Patient was given: ___ ___ 13:41 IV Piperacillin-Tazobactam ___ 13:41 IVF NS ___ 14:52 IV Vancomycin 1500mg ___ 17:33 IV Heparin 6500 UNIT ___ ___ 18:41 IVF NS ___ Started Upon arrival to the ICU, patient reports feeling fine without sx. Review of systems was negative except as detailed above. Past Medical History: PMHx/PSHx: 1. HIV (VL ___, CD4 490 in ___ on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: ___ Family History: nc Physical Exam: ADMISSION EXAM: =============== GENERAL: well-appearing sitting in bed with no distress HEENT: NCAT CARDIAC: RRR, no mgr. PULMONARY: Lungs clear to auscultation b/l. No wheezing. CHEST: no tenderness to palpation ABDOMEN: soft and non-distended. Non-tender to palpation. EXTREMITIES: RLE swelling, erythema over bilat malleoli w abrasions over the anterior shin. full ROM of all joints. SKIN: Abrasions over the anterior shin. NEURO: A&Ox3. Motor and sensory exam grossly normal. DISCHARGE EXAM: =============== GENERAL: Well appearing male in no acute distress. Comfortable. HEENT: NCAT. EOMI. MMM. CARDIAC: Rapid rate, regular rhythm. Distant heart sounds. No appreciable murmurs. PULMONARY: Clear to auscultation bilaterally. Breathing comfortably on nasal cannula. ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly. EXTREMITIES: Warm, well perfused, 1+ ___ on R>L. Right leg with multiple healing ulcers. Diffuse erythema around right ankle, tender, warm, no clear border between erythema and normal skin. NEURO: AAOx3. CNII-XII grossly intact. Moving all four extremities with purpose. Pertinent Results: ADMISSION LABS: =============== ___ 01:32PM BLOOD WBC-11.8* RBC-4.78 Hgb-15.8 Hct-47.6 MCV-100* MCH-33.1* MCHC-33.2 RDW-15.3 RDWSD-56.4* Plt ___ ___ 01:32PM BLOOD Neuts-78.8* Lymphs-11.6* Monos-7.4 Eos-0.1* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-9.27* AbsLymp-1.37 AbsMono-0.87* AbsEos-0.01* AbsBaso-0.02 ___ 01:32PM BLOOD ___ PTT-22.6* ___ ___ 01:32PM BLOOD Plt ___ ___ 01:32PM BLOOD Glucose-295* UreaN-40* Creat-1.5* Na-134* K-9.1* Cl-100 HCO3-23 AnGap-11 ___ 01:32PM BLOOD ALT-<5 AST-168* AlkPhos-41 TotBili-0.5 ___ 01:32PM BLOOD proBNP-843* ___ 01:32PM BLOOD cTropnT-0.04* ___ 01:32PM BLOOD Albumin-3.4* Calcium-9.4 Phos-4.1 Mg-2.1 ___ 04:58AM BLOOD PSA-<0.03 ___ 11:13PM BLOOD ___ Temp-36.8 pO2-60* pCO2-39 pH-7.43 calTCO2-27 Base XS-1 Intubat-NOT INTUBA ___ 01:51PM BLOOD Lactate-3.1* ___ 03:00PM BLOOD LMWH-1.01 DISCHARGE LABS: =============== ___ 06:51AM BLOOD WBC-10.1* RBC-4.32* Hgb-14.2 Hct-44.2 MCV-102* MCH-32.9* MCHC-32.1 RDW-15.6* RDWSD-59.1* Plt ___ ___ 06:51AM BLOOD Glucose-151* UreaN-42* Creat-1.2 Na-147 K-4.9 Cl-107 HCO3-25 AnGap-15 ___ 04:58AM BLOOD AST-20 AlkPhos-53 TotBili-0.4 ___ 06:51AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.3 PERTINENT STUDIES: ================== TEE ___ There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. The interatrial septum is dynamic, but not frankly aneurysmal. There is no evidence for an atrial septal defect by 2D/color Doppler though evaluation was limited by tachycardia and limited images obtained. Overall left ventricular systolic function is at least mildly depressed with beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The right ventricle has moderate global free wall hypokinesis. There are simple atheroma in the descending aorta to from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is mild to moderate [___] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is tricuspid regurgitation present (could not be qualified). IMPRESSION: No vegetations or intracardiac thrombus seen. Mild global biventricular systolic dysfunction. Mild to moderate mitral regurgitation. CTA Chest ___ IMPRESSION: 1. Pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe. No left-sided pulmonary emboli. Difficult to exclude right heart strain. Echocardiogram would further assess. 2. No focal consolidation. 3. Mild nodular contour of the liver raise concern for cirrhosis. Correlation with liver function test is recommended for further evaluation. 4. Status post splenectomy. U/S of ___ ___ IMPRESSION: Non-occlusive deep vein thrombus of one right posterior tibial vein. Brief Hospital Course: ___ man with history of CAD s/p DES to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy (___), and prior hepatitis B infection admitted w/ submassive PE and AF w/ RVR. ACUTE ISSUES ============ # SUBMASSIVE PULMONARY EMBOLISM # RIGHT LOWER EXTREMITY DVT Notable for TTE with evidence of right heart strain as well as mild troponin elevation. Never hypotensive, initiated on heparin gtt upon arrival, quickly weaned to RA. Appears unprovoked at this time: no signs of active malignancy, immobilization (although obese, not active), operations, or family history. Transitioned to warfarin, discharged on ___ bridge. # ATRIAL FIBRILLATION W/ RVR No prior records of Afib. Likely provoked ___ PE. Had rates difficult to control despite escalating doses of metoprolol and initiation of PO amiodarone. Hence, he had TEE and DCCV ___, successful, remained in sinus at time of discharge. Anticoagulation as above. Restarted on home dose metop succinate 25mg daily after DCCV, continued on PO amiodarone. # Acute on Chronic HFpEF: TTE this admission w/ poor image quality, noted depressed systolic function but could not determine EF. If EF was decreased, likely rate related I/s/o Afib w/ RVR. Mildly volume overloaded on exam initially, responded well to low dose IV diuresis, did not require PO diuretic at time of discharge. # RLE Cellulitis: noted upon arrival, nonpurulent, started on cephalexin for ___ORONARY ARTERY DISEASE s/p DES to LAD (___). Mild troponin elevation likely reflective of right heart strain from acute PE. Chest pain free. Continued ASA, statin, ___, and BB as above. D/c'd Plavix given initiation of AC, and > ___ year since stent placement. # RADIOGRAPHIC LIVER ABNORMALITY Mild nodular contour of the liver raises concern for cirrhosis. Consider. outpatient Fibroscan and possibly hepatology referral. CORE MEASURES: ================================= # HIV Most recent VL undetectable. CD4 of 500. Continued home HAART regimen (Darunavir 800 mg PO QHS, Cobicistat 150 mg PO QHS, Odefsey 200-25-25 mg oral QHS) # HYPERLIPIDEMIA: Fenofibrate 145 mg PO DAILY in addition to statin (both home meds) # DIABETES: held PO meds, placed on insulin sliding scale. TRANSITIONAL ISSUES =================== [] given unprovoked PE, ensure age appropriate malignancy screening has been done. if unremarkable, consider hypercoagulability w/u. [] currently on lovenox bridge until warfarin therapeutic. Increased warfarin dose to 10mg daily on day of discharge. Will need close monitoring and titration of warfarin dose, d/c lovenox when INR > 2. [] ___ of Hearts monitor at time of discharge [] PO amiodarone started I/s/o difficult to control AF w/ RVR. Please re-evaluate its need moving forward. [] cephalexin for RLE cellulitis for 7 day course. Please re-evaluate leg. pt diabetic and high risk for PVD, consider noninvasive flow studies. [] repeat TTE in several weeks to eval interval change from prior, define EF, ensure not newly reduced [] monitor for signs of increased volume, start diuretic as necessary [] outpatient Fibroscan and possibly hepatology referral given liver appearance on imaging, high risk for NASH [] on ASA/Plavix upon arrival for DES in ___. Given > ___ year, and placed on warfarin, d/c'd Plavix use. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fenofibrate 145 mg PO DAILY 2. Rosuvastatin Calcium 40 mg PO QPM 3. Losartan Potassium 50 mg PO DAILY 4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 5. Clopidogrel 75 mg PO DAILY 6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 7. Darunavir 800 mg PO DAILY 8. Cobicistat 150 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO TID 2. Cephalexin 500 mg PO Q6H Duration: 4 Days 3. Enoxaparin Sodium 120 mg SC BID 4. Warfarin 10 mg PO DAILY16 5. Glargine 60 Units Breakfast 6. Aspirin 81 mg PO DAILY 7. Cobicistat 150 mg PO DAILY 8. Darunavir 800 mg PO DAILY 9. Fenofibrate 145 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 13. Rosuvastatin Calcium 40 mg PO QPM 14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 15.Outpatient Lab Work Please obtain an INR ___ ICD-9 Code: ___ Contact: ___ Phone: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Pulmonary Embolism Right Lower Extremity Deep Vein Thrombosis Atrial Fibrillation with rapid ventricular response Acute on Chronic Heart Failure with preserved ejection fraction SECONDARY DIAGNOSIS =================== Coronary Artery Disease HIV Diabetes Mellitus II 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 ___! WHY WERE YOU ADMITTED ===================== You were admitted after we found blood clots in your lungs and legs. You were also in an abnormal heart rhythm. WHAT DID WE DO FOR YOU HERE =========================== We started you on blood thinners for the clots. We then shocked your heart back into a normal rhythm. WHAT DO YOU NEED TO DO WHEN YOU LEAVE ===================================== - It is really important that you take your blood thinner (warfarin) as prescribed. You need to have regular blood checks to make sure the blood thinner is at a good level (INR between 2 and 3). - You need to see a cardiologist (heart doctor) after you leave the hospital. - You were discharged on an event monitor that will record your heart rhythm if it is triggered. If you feel palpitations, trigger the monitor so your cardiologist can see if your heart goes back into an abnormal rhythm. - Please weigh yourself every morning. If your weight increases by more than 3lbs in one day or 5 lbs in one week, please call your cardiologist to consider adding a medicine that will keep the extra fluid out of your body. We wish you the best of health, Your ___ Care Team Followup Instructions: ___

10036086-DS-26

DS

2206-03-20 00:00:00

2206-03-20 19:46:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: ___ catheter insertion ___ filter placement ___ with duodenal ulcer clipping History of Present Illness: Mr. ___ is a ___ man with a history of CAD s/p DES to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy (___), and prior hepatitis B infection who was admitted with a submassive PE and AF with RVR on ___ until ___ at ___. He is now presenting with dyspnea in the setting of being off anticoagulation since ___ in the setting of GI and RP bleeding. Of note patient was recently admitted with submassive PE on ___. MASCOT was consulted and he was treated and discharged on warfarin with a lovenox bridge. During that admission, he also had a TEE/DCCV for new AF with RVR and started on amiodarone PO. After discharge on ___ patient was doing well until ___ when he developed severe abdominal pain and was admitted to ___ with GI and RP bleeding. After admission to the floor, his BP dropped to SBP ___, for which he required norepinephrine and 4 units pRBCs. Patient was then discharged to rehab on ___ off of all anticoagulation. He was doing well until ___ when he developed acute shortness of breath with mild activity getting around and new swelling in both his legs and his right arm. He had no chest pain, palpitations, lightheadedness,dizziness, or syncope. Given these symptoms he was sent from rehab to ___ where he was found to be hypoxemic and hypotensive to SBP ___. A CT was performed showing a saddle PE, for which he was started on heparin and transferred to ___. Past Medical History: PMHx/PSHx: 1. HIV (VL <20, CD4 500s in ___ on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. 14. Submassive PE/DVT in ___ 15. Retroperitoneal venous bleed in ___ 16. Saddle PE/DVT in ___ 17. Paroxysmal atrial fibrillation with h/o RVR Social History: ___ Family History: nc Physical Exam: Admission Physical Examination: =============================== VS: T 96.9, BP 126/72, HR 98, Resp rate 28 O2Sa 91% on 6L NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP not elevated. CARDIAC: RRR no m/r/g LUNGS: CTAB no r/r/w ABDOMEN: Soft, NT, ND, +BS, scattered bruising. EXTREMITIES: Bilateral leg edema R>L SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge Physical Examination: ================================ VS: 24 HR Data (last updated ___ @ 509) Temp: 97.5 (Tm 97.5), BP: 126/52 (115-126/52-62), HR: 71 (71-76), RR: 18, O2 sat: 98% (93-98), O2 delivery: 2.5L (2L NC-3L), Wt: 552.47 lb/250.6 kg Fluid Balance (last updated ___ @ 538) Last 8 hours Total cumulative 1206ml IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml OUT: Total 50ml, Urine Amt 50ml Last 24 hours Total cumulative 1206ml IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml OUT: Total 50ml, Urine Amt 50ml (Multiple missed voids) GEN: morbidly obese woman lying in bed in NAD HEENT: NC/AT. PERRLA, EOMI, MMM. NECK: supple CV: RRR, no murmurs PULM: CTAB no increased WOB ABD: obese, soft, NT, ND, +BS EXTR: WWP. No clubbing, cyanosis, or peripheral edema. SKIN: no significant lesions or rashes. PULSE: distal pulses palpable and symmetric. NEURO: AOx3, grossly intact. Pertinent Results: Admission Labs: =============== ___ 05:03PM TYPE-ART PO2-64* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-0 ___ 04:44PM HGB-10.0* HCT-33.9* ___ 04:44PM PTT-60.9* ___ 04:44PM ___ ___ 12:35PM TYPE-ART PO2-116* PCO2-58* PH-7.29* TOTAL CO2-29 BASE XS-0 ___ 12:00PM HGB-9.7* HCT-33.5* ___ 12:00PM ___ ___ 10:17AM TYPE-ART PO2-149* PCO2-58* PH-7.27* TOTAL CO2-28 BASE XS--1 ___ 10:01AM WBC-9.1 RBC-3.03* HGB-9.8* HCT-33.4* MCV-110* MCH-32.3* MCHC-29.3* RDW-19.1* RDWSD-75.8* ___ 10:01AM ___ PTT-47.1* ___ ___ 10:01AM ___ ___ 08:26AM TYPE-ART PO2-61* PCO2-51* PH-7.32* TOTAL CO2-27 BASE XS-0 ___ 08:26AM LACTATE-1.1 ___ 06:58AM TYPE-ART PO2-103 PCO2-56* PH-7.25* TOTAL CO2-26 BASE XS--3 ___ 06:58AM LACTATE-1.2 ___ 06:51AM GLUCOSE-227* UREA N-39* CREAT-1.3* SODIUM-141 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 ___ 06:51AM ALT(SGPT)-20 AST(SGOT)-26 LD(LDH)-720* ALK PHOS-67 TOT BILI-1.0 ___ 06:51AM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-5.3* MAGNESIUM-1.8 ___ 06:51AM WBC-9.5 RBC-3.26* HGB-10.4* HCT-35.9* MCV-110* MCH-31.9 MCHC-29.0* RDW-19.1* RDWSD-76.0* ___ 06:51AM ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* POLYCHROM-1+* ECHINO-1+* RBCM-SLIDE REVI ___ 06:51AM PLT SMR-NORMAL PLT COUNT-272 ___ 06:51AM ___ PTT-55.9* ___ ___ 03:00AM %HbA1c-7.1* eAG-157* ___ 02:36AM ___ PTT-56.6* ___ ___ 02:22AM ___ PO2-30* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-0 ___ 02:22AM LACTATE-1.1 ___ 02:22AM O2 SAT-50 ___ 12:37AM VoidSpec-SPECIMEN S ___ 11:51PM GLUCOSE-167* UREA N-41* CREAT-1.2 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 ___ 11:51PM estGFR-Using this ___ 11:51PM cTropnT-0.21* proBNP-5167* ___ 11:51PM WBC-9.9 RBC-3.32* HGB-10.7* HCT-36.3* MCV-109* MCH-32.2* MCHC-29.5* RDW-18.9* RDWSD-73.7* ___ 11:51PM NEUTS-70.8 LYMPHS-17.5* MONOS-9.0 EOS-0.4* BASOS-0.3 NUC RBCS-3.2* IM ___ AbsNeut-6.98* AbsLymp-1.73 AbsMono-0.89* AbsEos-0.04 AbsBaso-0.03 ___ 11:51PM PLT COUNT-292 ___ 11:51PM ___ PTT-76.6* ___ Pertinent Labs: ================== ___ 03:00AM BLOOD %HbA1c-7.1* eAG-157* ___ 05:29AM BLOOD VitB___ Folate-9 Pertinent Studies: ================== CXR: ___ FINDINGS: - Lung volumes are low bilaterally. There has been interval placement of a right chest port with tip overlying the cavoatrial junction. Streaky linear bibasilar opacities likely represent atelectasis. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is likely mildly enlarged although this is likely exaggerated by low lung volumes and the AP technique. No acute osseous abnormalities are identified. IMPRESSION: 1. Interval placement of a right chest port with tip overlying the cavoatrial junction. No pneumothorax. 2. Redemonstration hypoinflated lungs with lower lobe volume loss. ___ Pulmonary Arteriogram COMPARISON: CTA Chest ___ from outside facility. TECHNIQUE: Dr. ___ and Dr. ___ Interventional ___ and Dr. ___, Interventional Radiology fellow performed the procedure. ANESTHESIA: Mac sedation was provided by anesthesia. MEDICATIONS: A total of 8 mg of tPA were infused during the procedure. CONTRAST: 60 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 21.7 minutes, 1122 mGy PROCEDURE: 1. Right IJ central venous access under ultrasound guidance. 2. Left pulmonary arteriogram. 3. Left pulmonary artery chemical thrombolysis. 4. Lysis catheter placement in the left lower lobe pulmonary artery. 5. Right pulmonary arteriogram. 6. Right pulmonary artery mechanical and chemical thrombolysis. 7. Repeat right pulmonary arteriogram. 8. Lysis catheter placement in the right lower lobe pulmonary artery. PROCEDURE DETAILS: Following the discussion 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 neck and both groins were prepped and draped in the usual sterile fashion. Preliminary ultrasound images of the right IJ were stored. The overlying skin was anesthetized with 1% lidocaine solution. A 21 gauge needle was advanced into the right IJ under ultrasound guidance. A microwire was advanced through the needle into the ___. A small skin ___ was made at the needle insertion site. The needle was exchanged for a micropuncture access sheath. The wire and inner dilator were removed ___ wire was advanced into the ___. The micro sheath was then exchanged for a 6 ___ sheath. The inner dilator and ___ wire were then removed. A 5 ___ C2 Cobra glide catheter and Glidewire were then advanced through the sheath and used to navigate into the left pulmonary artery. The wire was removed. At this point, the catheter was used to measure pulmonary artery pressures (the left mean pulmonary artery pressure was 51). Contrast was injected to confirm positioning. A digital was retracted left pulmonary arteriogram was performed, demonstrating large filling defect in the proximal pulmonary artery and a paucity of lower lobe pulmonary artery branches. At this point, the patient's hemodynamic status began to decline. 2 mg of diluted tPA were injected directly into the proximal thrombus. A ___ wire was then advanced through the Cobra catheter, which was subsequently exchanged for a 6 cm EKOS infusion catheter. A 21 gauge needle was advanced into the right IJ at a separate access site under ultrasound guidance. A microwire was advanced through the needle into the ___. A small skin ___ was made at the needle insertion site. The needle was exchanged for a micropuncture access sheath. The wire and inner dilator were removed ___ wire was advanced into the ___. The micro sheath was then exchanged for a 6 ___ sheath. The Cobra catheter was advanced through the new sheath and navigated into the right pulmonary artery with a Glidewire. Glidewire was removed. Contrast was injected to confirm positioning. A digitally subtracted right pulmonary arteriogram was performed, demonstrating proximal thrombus and near complete occlusion of the right lung sparing only 2 segments in the right upper lobe. 2 mg of dilute tPA were infused directly into the thrombus. A ___ wire was advanced through the Cobra catheter. The Cobra catheter was exchanged for a Omni flush catheter. The Omni Flush catheter was used to perform mechanical thrombectomy as an additional 4 mg of tPA were infused. The ___ wire was injected advanced through the Omni Flush catheter. The Omni Flush catheter was then removed. The 6 ___ sheath was exchanged for an 8 ___ sheath. A penumbra aspiration catheter was advanced over the ___ wire and into the right pulmonary artery. The aspiration catheter was used for thrombectomy transiently. Shortly after initiation of thrombectomy, the patient's hemodynamic status significantly improved. The aspiration catheter was then exchanged over a ___ wire for the Omni Flush catheter. A repeat digitally subtracted right pulmonary arteriogram was performed demonstrating improved flow the right lung. The ___ wire was then advanced through the Omni Flush catheter and positioned in the right lung base. The Omni Flush catheter was then exchanged for a 12 cm EKOS infusion catheter. Contrast was injected through both EKOS catheters to confirm positioning. The coast catheters were then assembled unattached to respective devices. Both sheaths and infusion catheters were secured to the skin with 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well. There were no immediate post-procedure complications. The patient was transferred to the ICU in stable condition. FINDINGS: - Pulmonary arteriograms demonstrated extensive thrombosis bilaterally. - Local tPA was infused (total of 8 mg). - Post thrombolysis/thrombectomy arteriogram showed improvement in pulmonary arterial flow. - Successful placement of bilateral pulmonary arterial EKOS lysis catheters. IMPRESSION: - Successful pulmonary arterial thrombus debulking. - Successful placement of bilateral pulmonary arterial EKOS lysis catheters. TTE ___ CONCLUSION: There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 55-60%. Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. There is abnormal interventricular septal motion c/w right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Dilated right ventricle with moderate global RV systolic dysfunction. Moderate pulmonary hypertension. ___ IVC Filter Placement Final Report INDICATION: ___ year old man with DVT and history of bleeding from anticoagulation// IVC filter placement COMPARISON: Lower extremity venous duplex dated ___ TECHNIQUE: Dr. ___ Interventional ___, performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1% lidocaine CONTRAST: 25 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 4.7, 484 mGy PROCEDURE: 1. IVC venogram. 2. Infrarenal Denali IVC filter deployment. 3. Post-filter placement venogram. PROCEDURE DETAILS: Following the discussion 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 right neck was prepped and draped in the usual sterile fashion. An Amplatz wire was placed through the existing 8 ___ sheath. The sheath was removed over the wire and a new 8 ___ sheath was placed. The Amplatz wire was passed down into the distal IVC and left iliac vein. Over the wire, a straight flush catheter was placed. A inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a Denali filter. The catheter and sheath were removed over the wire and the sheath of a Denali filter was advanced over the wire into the IVC past the take-off of the renal vessels. An Denali vena cava filter was advanced over the wire until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 5 minutes,at which point hemostasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal Denali IVC filter. ___ CXR Portable FINDINGS: - There is no evidence of pneumoperitoneum, though detection is severely limited given patient positioning. Lung volumes are low bilaterally. No focal consolidation is seen. Blunting of the left costophrenic angle is unchanged and likely secondary to pericardial fat as demonstrated on CT from ___. The right internal jugular central line has been removed. IMPRESSION: - No evidence of pneumoperitoneum, though detection severely limited by patient positioning and portable technique. ___ EGD 1) Normal mucosa in the whole esophagus 2) Normal mucosa in the whole stomach 3) Oozing was noted upon entry into the duodenal bulb and duodenal sweep. A single cratered 8mm ulcer was found in the duodenal sweep. A visible vessel suggested recent bleeding. 2ml epinephrine was successfully applied for hemostasis. One endoclip was successfully applied for the purpose of hemostasis. ___ CXR for PICC Placement TECHNIQUE: Dr. ___ radiology attending) performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 0 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 1.1 minutes, 5.2 mGy PROCEDURE: 1. Replacement of right PICC. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing PICC line was aspirated and flushed and a Nitinol guidewire was introduced into the superior vena cava (SVC). A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava. A double lumen PIC line measuring 42 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Existing right arm approach PICC with tip in the axillary vein replaced with a new double lumen PIC line with tip in the distal SVC. IMPRESSION: Successful placement of a 42 cm right arm approach double lumen PowerPICC with tip in the distal SVC. The line is ready to use. Discharge Labs: =============== ___ 05:41AM BLOOD WBC-7.7 RBC-2.51* Hgb-8.4* Hct-28.7* MCV-114* MCH-33.5* MCHC-29.3* RDW-24.0* RDWSD-96.6* Plt ___ ___ 05:41AM BLOOD ___ PTT-24.8* ___ ___ 06:01AM BLOOD Glucose-137* UreaN-31* Creat-1.2 Na-142 K-4.2 Cl-99 HCO3-31 AnGap-12 ___ 06:01AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 ___ 05:29AM BLOOD ALT-22 AST-20 LD(LDH)-551* AlkPhos-45 TotBili-0.5 Brief Hospital Course: Summary: ========= Mr. ___ is a ___ man with a history of CAD s/p DES to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy (___), and prior hepatitis B infection who was recently admitted with a submassive PE from ___ until ___ at ___. He now represents with a saddle PE on CT with hypoxemia and hypotension after a recent episode of retroperitoneal hemorrhage leading to hemorrhagic shock and withholding of all anticoagulation since ___. #CORONARIES: s/p DES to LAD (___) #PUMP: LVEF 55-60% (___) #RHYTHM: Sinus TRANSITIONAL ISSUES: ==================== Follow Ups: [] PLEASE ENSURE PATIENT KEEPS HIS F/U ___ ON ___ [] ___ will set up a clinic appointment to assess for IVC filter removal in ___ months. Medications: [] Patient started on Warfarin for treatment of massive PE, INR GOAL: 1.8-2.4 given severe RP and GI bleeds on anticoagulation. Bridge with enoxaparin 120 mg BID for INR < 1.8. [] Patient will need long-term management of anticoagulation with Warfarin, PCP ___ aware. [] Discharged on PPI BID given GI bleed on anticoagulation. Discontinue PO PPI in 8 weeks (___). [] Glargine 60u at home, discharged on 50u given lower requirements during hospitalization. Increase back prn. Issues: ***For Rehab*** [] Please monitor the patient's weight and attempt to uptitrate diuresis as needed to achieve his dry weight of 274lbs. ***For Cardiology*** [] PO amiodarone started I/s/o difficult to control AF w/ RVR. Please re-evaluate its need moving forward. [] Repeat TTE in 1 month to eval interval change from prior, define EF, ensure not newly reduced ***For PCP*** [] Given unprovoked PE, ensure age appropriate malignancy screening has been done. if unremarkable, consider hypercoagulability w/u. [] Mildly nodular contour seen on abdominal imaging. Consider outpatient Fibroscan and possibly hepatology referral. Pt is high risk for NASH Data: * Discharge Hb 8.4; no need to recheck if not having melena. * DRY WT: ~274 lbs. Last pre-discharge 281.08lbs, bed weight (on ___. CODE STATUS: FULL ACUTE ISSUES: ============= #Massive PULMONARY EMBOLISM #Acute on chronic hypoxic respiratory failure Patient recently admitted for submassive PE and discharged on ___ with warfarin and a lovenox bridge. Presented later that month to ___ and was found to have GI bleeding as well as a large RP bleed and the decision was made to stop his anticoagulation. He was discharged to rehab and represented ___ with dyspnea found to have a mass PE initially requiring pressor support. Immediately after arriving on the floor patient was taken to ___ suite where two EKOS catheters were placed for tPA administration. During procedure local tPA boluses were administered to the clot and a catheter was used break up the clot. The patient was started on a heparin drip. EKOS catheters were removed later that day. Transthoracic echo showed a dilated right ventricle associated with dysfunction. Patient also had moderate pulmonary hypertension. Given his edematous appearance, the patient was diuresed with IV Lasix and eventually transitioned to PO Lasix 20mg daily. On ___, patient had a IVC filter placed successfully. The patient was continued on a heparin drip, and converted to warfarin. His INR goal was determined to be 1.8-2.4 given high risk of major bleed as well as high risk of life-threatening clot. On discharge INR was 1.8. #UGIB on AC #S/p Clipping of duodenal ulcer The patient was started on warfarin ___. Overnight on ___, the patient had multiple melanotic stools, with associated hemoglobin drop from 8.7 to 7. The patient received 2 units of packed red blood cells with good response 9.1. He was taken to endoscopy by gastroenterology, and had a duodenal ulcer clipped with appropriate hemostasis. On discharge he was having soft brown BMs. He will be continued on a PPI on discharge for 8 weeks. Discharge hemoglobin was 8.4. #ATRIAL FIBRILLATION W/ RVR Had new onset afib with RVR during previous hospitalization to submassive PE. Had DCCV ___, successful, remained in sinus at time of discharge. Anticoagulation as above. His home metoprolol was held in the setting of acute pulmonary embolus associated with right ventricular dysfunction. His amiodarone was adjusted to 200 mg twice daily, as he had already been appropriately loaded with amiodarone on his prior hospitalization. on discharge we continued him home metoprolol succinate #CORONARY ARTERY DISEASE s/p DES to LAD (___). Mild troponin elevation likely reflective of right heart strain from acute PE. He was chest pain-free throughout the hospitalization. He was continued on his home rosuvastatin and losartan. His metoprolol was held during the admission in the setting of severe RV systolic dysfunction as well as the UGIB. It was able to restarted on discharge. #Acute on Chronic HFpEF The patient had increased volume on examination with a TTE showing an LV EF of 55-60. He was volume overloaded on examination and required Lasix 20 IV which had good effect. We converted him to po Lasix regimen and would like his facility to continue to monitor the patients weight with a plan to have him lose another ___ pounds from his admission to the facility. He should have daily weights at the facility. CHRONIC ISSUES: =============== #HIV Most recent VL undetectable. CD4 of 500. Continue the patient on his home darunavir/cobicistat and Odefsey. #HYPERLIPIDEMIA Continued Fenofibrate 145 mg PO DAILY in addition to statin (both home meds) #DIABETES: Held PO meds and home liraglutide (as it was nonformulary), placed on 40u glargine qAM (60u at home) as well as insulin sliding scale instead in the setting of acute illness. On discharge uptitrated glargine to 50u. #RADIOGRAPHIC LIVER ABNORMALITY Mild nodular contour of the liver raises concern for cirrhosis. Consider outpatient Fibroscan and possibly hepatology referral. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Fenofibrate 145 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Glargine 60 Units Breakfast 5. liraglutide 1.8 mg subcutaneous DAILY 6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 7. Amiodarone 200 mg PO TID 8. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. ___ MD to order daily dose PO DAILY16 6. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days 7. Amiodarone 200 mg PO DAILY 8. Glargine 50 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. Fenofibrate 145 mg PO DAILY 10. liraglutide 1.8 mg subcutaneous DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 13. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY 14. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== 1) Massive Pulmonary Embolism 2) Upper GI Bleeding s/p duodenal ulcer clipping 3) Acute on chronic hypoxic respiratory 4) Afib with RVR 5) Coronary Artery Disease . 6) Acute on Chronic Heart Failure with Preserved Ejection Fraction Secondary Diagnosis: ==================== 1) HIV 2) Hyperlipidemia 3) Diabetes Mellitus 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: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you had blood clots in your lungs WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? -We gave you medications to break up the clots –We started you on a blood thinning medication –Unfortunately you had a small gastrointestinal bleed, which was fixed by our gastroenterologist. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? -Take all of your medications as prescribed (listed below), especially your warfarin -Your goal INR is 1.8-2.4 -Follow up with your doctors as listed below -Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs. -___ medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team Followup Instructions: ___

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2151-04-24 00:00:00

2151-04-24 17:06:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o Hodgkin disease (Dx ___, s/p ABVD x6), newly diagnosed gastric cancer (cT3N2M0 Stage III, Her-2 neg) currently C1D7 ___ chemotherapy. He was referred in from home today due to acute onset of severe abdominal pain starting this morning sometime before lunch. States he ate breakfast and had a bowel movement without any difficulty then pain later came on spontaneously. He describes it as generalized abdominal pain and "muscle cramping ". Currently ___ however was more severe when he initially presented to ED and he received total of 1.5 mg Dilaudid with some relief but notes that when it wears off the pain does return. Denies any bony or joint pain. Denies nausea, vomiting, diarrhea. He was taking Zofran regularly after his chemo cycle and did have some mild constipation but does not feel this is the cause of his current pain. Has not had any difficulty eating or drinking and does still have appetite. In the ED he also underwent abdominal CT which did not show any acute pathology. REVIEW OF SYSTEMS: No fevers, night sweats, or weight loss. Appetite is good. No chest pain, shortness of breath, or cough. No abdominal pain, nausea/vomiting, or diarrhea. No urinary symptoms. No headaches, vision changes, or focal numbness/weakness. No bone or back pain. A comprehensive 14-point review of systems was otherwise negative. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed ___. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr ___, ___. Gastric Cancer: - ___: presented with reflux symptoms - ___: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - ___: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - ___: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child ___ years old) s/p R knee arthroscopy Social History: ___ Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: ___ 2149 Temp: 98.5 PO BP: 132/79 HR: 78 RR: 18 O2 sat: 95% O2 delivery: RA General appearance: Generally well appearing, comfortable appearing and in no acute distress. Head, eyes, ears, nose, and throat: Pupils round and equally reactive to light. Oropharynx clear with moist mucous membranes. Lymph: No palpable cervical or supraclavicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, S1, S2, no audible murmurs. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Bowel sounds present, soft, nondistended. No palpable hepatosplenomegaly. Trivial tenderness to deep palpation in the RUQ and RLQ. Extremities: Warm, without edema. Neurologic: Alert and oriented. Grossly normal strength, coordination, and gait. ___ strength in lower extremities. Intact and symmetric fine touch sensation on abdominal wall and in lower extremities. 2+ and symmetric patellar reflexes. Skin: No rashes. Pertinent Results: LABS: ___ 03:42AM BLOOD WBC-9.3 RBC-4.89 Hgb-11.8* Hct-36.5* MCV-75* MCH-24.1* MCHC-32.3 RDW-17.0* RDWSD-45.1 Plt ___ ___ 03:42AM BLOOD Neuts-60 Bands-6* ___ Monos-9 Eos-1 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-6.14* AbsLymp-2.05 AbsMono-0.84* AbsEos-0.09 AbsBaso-0.00* ___ 03:42AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-3+* Polychr-NORMAL ___ 03:42AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-138 K-4.1 Cl-98 HCO3-29 AnGap-11 ___ 03:42AM BLOOD ALT-27 AST-15 AlkPhos-92 TotBili-0.5 ___ 03:42AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7 ___ 04:12PM BLOOD Lactate-1.2 CT ABDOMEN/PELVIS W/ CONTRAST: 1. No pneumoperitoneum. 2. Upper abdominal lymphadenopathy is again seen, with some unchanged in size, some with interval decrease in size, and interval development of central necrosis in 1 lymph node. Haziness of the left omentum is again seen. CXR No evidence of acute thoracic process. No free subdiaphragmatic free air. Brief Hospital Course: ___ w/ Hodgkin disease (Dx ___, s/p ABVD x6), newly diagnosed gastric cancer (T3N2M0 Stage III, Her-2 neg; C1D7 ___ on admission) who was admitted with acute-onset abdominal pain. Exam by surgery and by the admitting and discharging medicine physicians was unremarkable for any abdominal or neurological pathology to explain the symptoms. His CT showed only known pathology. LFTs and lipase also normal. He is far enough out from his chemo that we cannot invoke oxaliplatin toxicity, and he did not have bone pain consistent with a Neulasta side effect. His pain was initially ___ intensity, but subsided over about 12 hours and by the time of discharge he was fairly comfortable, although still intermittently requiring oral opiate analgesics. At discharge his PPI was empirically doubled to twice daily dosing and he was given a seven day supply of oral dilaudid to use as needed. He was instructed to return should his symptoms evolve or worsen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Dexamethasone 4 mg PO Q12H 3. Prochlorperazine 10 mg PO Q6H:PRN nausea 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*42 Tablet Refills:*0 2. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth BIDAC Disp #*60 Capsule Refills:*0 3. Dexamethasone 4 mg PO Q12H 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Tamsulosin 0.4 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Gastric cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with sudden-onset of severe abdominal pain. We remain unsure what caused this, but your CT scan, labs, and exam were all very reassuring. We are doubling your omeprazole to twice daily in case the pain is from some sort of irritation in the stomach. We are also giving you dilaudid pills that you can take as needed if the pain continues. If the pain keeps coming back in severe episodes, or worsens progressively, please return to the ED for consideration of further workup. With any more minor issues, or if you aren't sure whether you should come in, call the ___ clinic at ___ and ask to speak to one of the nurses. Followup Instructions: ___

10036821-DS-7

DS

2151-10-12 00:00:00

2151-10-12 15:05:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: Abdominal pain following total gastrectomy with roux-en-y esophagojejunostomy (___). Major Surgical or Invasive Procedure: Underwent drain repositioning with Interventional Radiology on ___. History of Present Illness: ___ history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant chemotherapy, robotic total gastrectomy with roux-en-y esophagojejunostomy (___) who presents with abdominal pain after recent discharge on ___. His post-operative course was complicated by left gastrocnemius DVT for which he continues on lovenox as well as an abscess adjacent to the esophagojejunostomy anastomosis, for which his surgical drain remains in place with scant purulent output. He completed a course of oral cipro/flagyl at home as planned on ___. During his hospital stay, he was unable to tolerate solids and was discharged to rehab on fulls with J-tube feed supplementation. He recently underwent repeat UGI on ___ after one episode of dysphagia showing a persistent small leakage at the EJ anastomosis site. He presents today complaining of acute onset of lower abdominal pain starting at 7pm tonight that has since worsened to a ___ in intensity. He describes the pain as sharp and coming in waves. He was discharged home on fulls and JTfeeds, which he has tolerated per his baseline with occasional episodes of dry heaving but no retching. He reports have normal bowel function with last BM and flatus tonight and no constipation or diarrhea. No fevers or chills. Reports persistent, scant purulent drainage from the surgical drain. No dysuria. No prior similar episodes of pain. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed ___. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr ___, ___. Gastric Cancer: - ___: presented with reflux symptoms - ___: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - ___: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - ___: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child ___ years old) s/p R knee arthroscopy Social History: ___ Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: Admission Physical Exam ======================= Vitals-98.4 68 138/72 16 100% RA General- no acute distress, uncomfortable-appearing HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB on RA Abdomen- soft, TTP in LLQ >RLQ with voluntary guarding, no rebound, mildly distended. Incisions well-healed without erythema or drainage. Drain x1 with scant purulent output. Jtube site c/d/I. Ext- WWP, no notable edema or TTP, compression stockings in place b/l Discharge Physical Exam ======================= ___ 0004 Temp: 99.1 PO BP: 110/67 R Lying HR: 66 RR: 18 O2 sat: 98% O2 delivery: Ra General- no acute distress HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- Regular rate Chest- no increased WOB on RA Abdomen- soft, no tenderness to palpation, no rebound, minimally distended. Incisions well-healed without erythema or drainage. Drain x1 with scant serous output, bulb holding suction. Jtube site without clinical signs of infection. Ext- WWP Pertinent Results: Lab Results =========== ___ 12:00PM BLOOD WBC-7.1 RBC-3.81* Hgb-8.8* Hct-27.9* MCV-73* MCH-23.1* MCHC-31.5* RDW-19.2* RDWSD-50.8* Plt ___ ___ 05:06AM BLOOD WBC-4.0 RBC-3.88* Hgb-8.9* Hct-28.4* MCV-73* MCH-22.9* MCHC-31.3* RDW-19.7* RDWSD-52.0* Plt ___ ___ 01:55AM BLOOD WBC-5.1 RBC-3.75* Hgb-8.6* Hct-27.5* MCV-73* MCH-22.9* MCHC-31.3* RDW-20.0* RDWSD-52.3* Plt ___ ___ 01:55AM BLOOD Neuts-40.6 ___ Monos-7.4 Eos-3.3 Baso-0.4 Im ___ AbsNeut-2.07 AbsLymp-2.46 AbsMono-0.38 AbsEos-0.17 AbsBaso-0.02 ___ 05:15AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-139 K-4.2 Cl-95* HCO3-33* AnGap-11 ___ 05:06AM BLOOD Glucose-66* UreaN-10 Creat-0.7 Na-138 K-4.5 Cl-97 HCO3-28 AnGap-13 ___ 01:55AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-137 K-4.4 Cl-99 HCO3-29 AnGap-9* ___ 01:55AM BLOOD ALT-42* AST-30 AlkPhos-95 TotBili-0.3 ___ 01:55AM BLOOD Lipase-38 ___ 05:15AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 ___ 05:06AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.5* ___ 01:55AM BLOOD Albumin-3.4* Imaging ======= DRAIN CATHETER MANIPULATION ___ IMPRESSION: Successful fluoroscopy guided reposition of surgical drain with tip now adjacent to the esophago-jejunal anastomosis. CT abd/pelvis with IV/oral contrast (___): 1. Evaluation of the upper abdomen is slightly limited by extensive streak artifact from dense contrast opacification of the right colon. Within this limitation, no acute intra-abdominal process. Oral contrast extends at least to the level of the transverse colon without evidence of extraluminal contrast. No bowel obstruction. 2. Interval resolution of previously seen left subdiaphragmatic fluid collection adjacent to the esophageal jejunal anastomosis. 3. Decreased size of now trace left pleural effusion. 4. Marked prostatomegaly. UGI IMPRESSION ___: 1. Small leak at the esophagojejunostomy site tracking along abdominal drain. 2. No overt abnormality of the jejunojejunostomy site. Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain, in the setting of recent total gastrectomy with roux-en-y esophagojejunostomy (___). He was previously found to have an abscess adjacent to the esophagojejunostomy anastomosis, and within this admission underwent drain repositioning with interventional radiology with placement confirmed by fluoroscopy. Throughout his stay, Mr. ___ remained nutritionally supported with his home tube feeding regimen via his J-tube. Nutrition services followed him within admission, and changed the formulation of his tube feeds, which were better tolerated by the patient, causing less diarrhea. At the time of discharge his diet included full liquids, and tubefeeds of Jevity 1.2. 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 his usual lovenox during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating his home tube feeds, as well as diet as above per oral, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to rehab per ___ recommendations. 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 may be inaccurate and requires futher investigation. 1. Enoxaparin Sodium 80 mg SC Q12H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 3. Tamsulosin 0.8 mg PO QHS 4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 5. LOPERamide 2 mg PO BID:PRN loose stools 6. Simethicone 80 mg PO QID:PRN bloating/gas 7. Pyridoxine 100 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Multivitamins 1 TAB PO DAILY 3. Pregabalin 50 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Docusate Sodium 100 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN bloating/gas 7. Enoxaparin Sodium 80 mg SC Q12H 8. LOPERamide 2 mg PO BID:PRN loose stools 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Pyridoxine 100 mg PO DAILY 11. Tamsulosin 0.8 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant therapy, robotic total gastrectomy with roux-en-y esophagojejunostomy (___) with resolving lower abdominal pain, now s/p drain repositioning to address fluid collection adjacent to the esophageal jejunal anastomosis. Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital for abdominal pain following your total gastrectomy with roux-en-y esophagojejunostomy (___). You were previously found to have an abscess adjacent to your esophagojejunostomy anastomosis, and underwent drain repositioning with interventional radiology. The drain is functioning appropriately, and you have recovered and are now ready to be discharged back to rehab. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. Diarrhea is a common side effect of tube feeds. You were seen by nutrition at ___, and nutritionists at your rehabilitation facility should be able to address either of these issues for you. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. If diarrhea does not resolve, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. 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: ___

10036942-DS-15

DS

2174-09-17 00:00:00

2174-09-19 12:29:00

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: TEE on ___ Midline placement ___ attach Pertinent Results: ADMISSION LABS: ================ ___ 04:10PM BLOOD WBC-10.1* RBC-4.22* Hgb-12.7* Hct-38.3* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.7 RDWSD-41.7 Plt ___ ___ 04:10PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-6.6 Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.75* AbsLymp-1.52 AbsMono-0.67 AbsEos-0.08 AbsBaso-0.03 ___ 04:10PM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-135 K-4.0 Cl-97 HCO3-28 AnGap-10 ___ 04:40AM BLOOD ALT-15 AST-14 AlkPhos-66 TotBili-0.7 ___ 04:40AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.0 Mg-1.7 ___ 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* ___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 04:40AM BLOOD HCV Ab-NEG ___ 4:10 pm BLOOD CULTURE **FINAL REPORT ___ STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S <=0.12 S OXACILLIN------------- 0.5 S 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S ___ 5:18 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. ___ 6:25 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. ___ 7:34 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. CXR ___ Borderline cardiac silhouette size, likely accentuated by AP technique. Otherwise, no definite acute intrathoracic process. CT HEAD W/O CONTRAST ___ IMPRESSION: No acute intracranial process or fracture. TTE 1) Possibly very small vegetation on the pulmonary valve. Image quality is excellent. We seldomly see the pulmonary valve this well depicted and therefore the nodularity could be part of a normal variant including Lambl's exrescene. 2) Mitral valve appears without vegetation. There is a very small mobile structure on the atrial side , the differential is likely torn mitral valve, beam hardening artifact, howver in this clinical scenario vegetation (less likely) cannot be excluded. CHEST CT W/ CONTRAST 1. Possible minimal bronchial inflammation. The lungs are otherwise clear. 2. No evidence of rib fracture or other osseous or soft tissue abnormality. DISCHARGE LABS: ================ ___ 07:50AM BLOOD WBC-9.0 RBC-4.38* Hgb-13.3* Hct-40.5 MCV-93 MCH-30.4 MCHC-32.8 RDW-12.1 RDWSD-41.3 Plt ___ ___ 06:20AM BLOOD Neuts-52.6 ___ Monos-9.2 Eos-0.9* Baso-0.6 Im ___ AbsNeut-3.42 AbsLymp-2.35 AbsMono-0.60 AbsEos-0.06 AbsBaso-0.04 ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-142 K-4.5 Cl-101 HCO3-24 AnGap-17 ___ 07:50AM BLOOD ALT-20 AST-24 LD(LDH)-176 AlkPhos-71 TotBili-0.2 ___ 07:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9 ___ 02:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-POS* ___ 04:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG ___ 11:25AM URINE AMPHETAMINES, LC/MS-PND Brief Hospital Course: BRIEF HOSPITAL COURSE: ======================= This is a ___ male patient with a history of IVDU w/ last use of heroin ___ who presents with 5 days of persistent exertional chest pressure w/o radiation and dyspnea who was found to be running a low grade fever, found to have MSSA bacteremia with TEE without signs of endocarditis TRANSITIONAL ISSUES: ===================== [] Continue treatment with IV cefazolin for a total of 14 days from first negative blood culture (until ___ [] Will need to ensure has established with a ___ clinic on discharge [] Needs to establish care with a PCP at discharge [] Confirmatory testing for amphetamines on Utox was pending at time of discharge ACUTE ISSUES: ============= #MSSA bacteremia Bacteremia iso IVDU with last positive blood culture on ___. TTE with question of vegetation on pulmonary valve but no evidence of endocarditis on TEE. ID following with inpatient - patient meets all criteria of uncomplicated MSSA bacteremia (TEE negative, clearance of blood culture by 72h, defervescence within 72 hrs of therapy, no evidence/sxs of metastatic infection), will plan for 2 total weeks of therapy from first negative blood culture (___). On cefazolin 2g q8hr until ___ with midline in place. #Left costochondral pain Focal pain on exam on the left concerning for septic costochondritis vs abscess vs osteo given GPC bacteremia. However, chest CT negative on ___ for soft tissue abnormality/infectious process. In the hospital patient was treated with IV ketorolac for 3 days then transitioned to PO ibuprofen, which was alternated with Tylenol. #Opioid use disorder Uses heroin every day ___ times based on how he's feeling). Last treated for substance use in ___ with naltrexone injections. Was previously on suboxone. Patient began to exhibit sxs of withdrawal while inpatient, scoring >10 on ___ scale. Patient seen by addiction psychiatry - stated that he is interested in methadone maintenance therapy and feels that daily ___ clinic visits would be good for him to provide some daily structure - wishes to receive methadone daily at ___ clinic on ___. Started patient on 40mg methadone qd while inpatient. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. CeFAZolin 2 g IV Q8H 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 4. Lidocaine 5% Patch 1 PTCH TD QPM upper back pain 5. Methadone 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 7. Ramelteon 8 mg PO QHS:PRN Insomia Should be given 30 minutes before bedtime 8. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Staph aureus bacteremia Opioid use disorder Left costochondral pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital with 5 days of chest pain and concern for an infection. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your blood cultures grew a bacteria called staph aureus. We started you on IV antibiotics for this - We got a picture (called an echocardiogram) of your heart which did not show any infection of your heart valves. - You will continue on antibiotics for a total of 14 day, end date ___. 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. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10037598-DS-15

DS

2162-03-17 00:00:00

2162-03-18 18:14:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a pmh of morbid obesity, HTN, DMII and OSA presenting with worsening shortness of breath and bilateral lower extremity swelling. Transferred from ___ due to lack of beds. His main complaint is worsening b/l leg swelling over the last two weeks that, as per pt, work-up has been unable to find an explanation. States that his R leg was initially swollen, then his L, and is now symmetrical and gradually worsening. Endorses intermittent erythema, denies calf pain/leg pain. He endorses 20 pound weight gain in the last month and 50 pounds in the last year. He also complains of SOB with exertion, worsening over the last year, never at rest, walks about ___ block (5min) before stopping. Denies PND (but wakes up due to his OSA), and sleeps with three pillow orthopnea (45 degrees). Denies chronic cough. Endorses nocturia (___). He denies fevers/chills. Denies CP/syncope, diarrhea/constipation, n/v. Denies blood in his stool, denies dysuria, HA. In the ED, initial vs were 98.3 78 170/95 24 94% on 2L. He was noted to have bibasilar rales and 2+ pitting edema to mid-thigh. Troponin <0.01, BNP 614, D-dimer 1046. EKG: NS @ 77 bpm, LAD, TWI I, aVL, no STE/STD. Unable to get a CTA due to weight (>500 pounds), admitted for V/Q scan. Started on Heparin IV drip. Transfer VS 98.1 80 155/84 17 95% 4L. On arrival to the floor, patient reports feeling better, breathing comfortably on nasal cannula. Feels at ease being in the hospital. REVIEW OF SYSTEMS: See HPI. Past Medical History: HTN, DMII, OSA, morbid obesity, depression. Social History: ___ Family History: Father was planned for CABG before he had a fall and passed away, also with a h/o stroke, on HD. Mother with DM, CAD/MI, deceased. One healthy daughter. Physical Exam: ADMISSION PHYSICAL EXAM: VS 98.3 150/dopp 74 20 94-95% 3L GEN Alert, oriented, no acute distress, morbidly obese HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, unable to visualize JVD, no LAD PULM Good air entry, no crackles, no wheezes CV Distant heart sounds S1S2 RRR ABD Soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c, significant symmetrical b/l ___ edema to knee/hip, no erythema, no calf tenderness NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions DRE occult negative brown stool DISCHARGE PHYSICAL EXAM: 98.6 ___ 17 93-94%RA GEN Alert, oriented, no acute distress, morbidly obese HEENT MMM, PERRLA NECK Supple, unable to visualize JVD, no LAD PULM CTAB but difficult to assess CV Distant heart sounds S1S2 RRR systolic murmur that is difficult to characterize due to habitus ABD Soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c, symmetrical b/l ___ edema to knee (1+) that improved with diuresis, no erythema, no calf tenderness NEURO Grossly nonfocal SKIN No ulcers or lesions Pertinent Results: ADMISSION LABS: ___ 09:40AM BLOOD WBC-10.6 RBC-5.03 Hgb-13.6* Hct-43.2 MCV-86 MCH-27.0 MCHC-31.4 RDW-15.5 Plt ___ ___ 09:40AM BLOOD Neuts-72.7* ___ Monos-4.1 Eos-3.4 Baso-0.3 ___ 09:40AM BLOOD ___ PTT-30.9 ___ ___ 09:40AM BLOOD Glucose-159* UreaN-12 Creat-0.8 Na-140 K-3.0* Cl-95* HCO3-34* AnGap-14 ___ 09:40AM BLOOD proBNP-614* ___ 09:40AM BLOOD cTropnT-<0.01 ___ 05:25AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.2 Cholest-125 ___ 10:53AM BLOOD D-Dimer-1046* ___ 05:25AM BLOOD Triglyc-106 HDL-30 CHOL/HD-4.2 LDLcalc-74 DISCHARGE LABS: ___ 05:45AM BLOOD Glucose-117* UreaN-10 Creat-0.8 Na-142 K-3.4 Cl-94* HCO3-34* AnGap-17 ___ 05:45AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.2 ___ 05:25AM BLOOD %HbA1c-7.2* eAG-160* IMAGING: ___ CXR IMPRESSION: Findings compatible with pulmonary edema in the setting of mild-to-moderate cardiomegaly. ___ KNEE XR IMPRESSION: Moderate degenerative changes. No evidence of fracture or dislocation. ___ ___ R IMPRESSION: 1. No evidence of deep vein thrombosis in the right lower extremity. 2. Moderate-sized complex right ___ cyst. ___ V/Q Scan IMPRESSION: No evidence for acute pulmonary embolism. Limited exam secondary to obesity. EKG ___ Normal sinus rhythm with A-V conduction delay. Delayed R wave progression and intraventricular conduction defect. MICRO: None Brief Hospital Course: ___ with a past medical history of morbid obesity, HTN, DMII and OSA presenting with worsening DOE and bilateral lower extremity swelling. #SOB/Hypoxia due to presumed acute diastolic CHF: Acute on chronic CHF versus PE. H/o progressively worsening DOE over one year, stable chronic orthopnea, and worsening b/l ___ edema over last two weeks suggests chronicity, no acute change. On exam, there was evidence of b/l symmetrical lower extremity edema with clear lung fields on exam (although limited by habitus). Initially admitted due to suspicion for PE, positive d-dimer and negative R ___, started on heparin drip in ED. Unable to fit in CT scan for a CTA, completed a limited V/Q scan (due to habitus) which did not suggest PE. Given history and very low suspicion for PE, heparin drip was d/c. Admission CXR read as pulmonary edema, no evidence of crackles one exam, but with O2 requirement. Pro BNP slightly elevated but not significantly elevated to suggest overwhelmingly a CHF exacerbation. H/o OSA predisposes pt to R sided HF 2/t pul htn and his h/o HTN/morbid obesity and possible underlying CAD given risk factors predisposes him to L sided HF. Denies CP, and had a negative trop x1 which makes MI unlikely as a cause for CHF. EKG also was unremarkable. Bicarb of 34 suggests chronic CO2 retainer likely from OSA. Pt was diuresed with 10mg IV Lasix over two days and improved, weaning the O2 requirement. With diuresis, pt ambulated on RA and saturations decreased to 88% but responded back into the mid ___ with deep breaths. TTE was unable to be done during the admission but it should be done as an outpt. Patient was discharged on 20mg Lasix daily and 40meq potassium daily with CLEAR instructions that he MUST f/u with PCP within ___ week for electrolytes/fluid status check, as well as to get him set up with outpatient sleep study/TTE. Pt agreed with the plan. #Lower Extremity Swelling: Symmetrical with no erythema. Likely sxs of R sided CHF/venous insufficiency, due to OSA/pul htn or new L sided CHF. R ___ negative. Improved with diuresis, likely due to CHF. #R Knee Pain: Negative Xrays. Large ___ cyst on ___ with no signs of a DVT. Likely due to fall about a month ago. Received Tylenol prn. #DM2, controlled with complications: Holding oral hyperglycemics, started on ISS. No Hgb A1C in system, ordered while in house and it was 7.2%. Morbid obesity suggests possible underlying uncontrolled DM. #Obesity: ___ be related to depression, lipid panel and A1C done during this admission. Being worked-up for possible gastric bypass but pt would like to attempt weight loss first. #HTN: Endorses a h/o HTN, hypertensive while in ED. CP free. BP improved with reinitiation of home meds. Continue Metoprolol XLl, Lisinopril, HCTZ, and Nifedipine. #Depression: Recent stresses in life (i.e. homeless, deaths), see HPI. Continued Paxil, Trazodone for sleep. #OSA: Likely due to morbid obesity. Likely has pul htn. See above for discussion. Monitored on tele. Continued on CPAP. Sleep study as outpt. TRANSITIONAL ISSUES: -F/u with PCP, recheck ___ status as outpt since discharged on Lasix -Needs outpt TTE and sleep study Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY Start: In am 2. Lisinopril 40 mg PO DAILY Start: In am 3. GlipiZIDE XL 5 mg PO DAILY 4. Paroxetine 20 mg PO DAILY Start: In am 5. Hydrochlorothiazide 25 mg PO DAILY Start: In am 6. NIFEdipine CR 60 mg PO DAILY Start: In am 7. Aspirin 81 mg PO DAILY Start: In am Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. NIFEdipine CR 60 mg PO DAILY 6. Paroxetine 20 mg PO DAILY 7. GlipiZIDE XL 5 mg PO DAILY 8. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 9. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours RX *potassium chloride 10 mEq 4 capsules by mouth daily Disp #*56 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Heart Failure Secondary: Obstructive Sleep Apnea 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 worsening lower leg swelling and worsening shortness of breath with walking. We were concerned that you may have had a clot travel to your lungs and you were started on a blood thinner. Tests showed that you most likely did not have a lung clot. The blood thinner medication was stopped. You most likely have heart failure due to a combination of factors including your obstructive sleep apnea, weight, and high blood pressure given that these symptoms have been getting worse over the last year to weeks. You were given a pill to help you urinate which helped remove fluid from your lungs. You improved during your stay: leg swelling improved, and you did not require oxygen at time of discharge. You were sent home with this medication (to help remove extra fluid) as well as potassium supplements. Before you left, you noticed that the tops of your feet were red. We were not concerned for infection and we encouraged you to keep your feet elevated when sitting. Please bring this to your PCP's attention if it has not resolved by the time of your appointment. NEW MEDICATIONS: Lasix 20mg daily Potassium chloride 40meq once daily (But please be sure NOT to take one medication without the other. If you do NOT take the lasix, do NOT take the potassium. Please take both together.) Followup Instructions: ___

10037602-DS-20

DS

2151-04-20 00:00:00

2151-04-20 17:25:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: quaternium 15 / potassium dichronate / balsam of ___ / nickel / paraben / fragrances / glycerol monothiogylconate / tea tree oil / benzoyl peroxide Attending: ___ ___ Complaint: Right knee osteoarthritis Major Surgical or Invasive Procedure: ___: R TKR History of Present Illness: ___ year old female with right knee osteoarthritis now s/p R TKR. Past Medical History: PMH: HLD, HTN, OA, Thyroid nodule, GERD, Depression Shx: ___ Family History: non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:30AM BLOOD WBC-12.3* RBC-3.33* Hgb-8.9* Hct-28.4* MCV-85 MCH-26.7 MCHC-31.3* RDW-14.3 RDWSD-44.9 Plt ___ ___ 05:40AM BLOOD WBC-12.3* RBC-3.53* Hgb-9.6* Hct-30.0* MCV-85 MCH-27.2 MCHC-32.0 RDW-14.0 RDWSD-43.0 Plt ___ ___ 06:06AM BLOOD WBC-11.0* RBC-3.73* Hgb-10.0*# Hct-31.9*# MCV-86 MCH-26.8 MCHC-31.3* RDW-13.9 RDWSD-43.6 Plt ___ ___ 06:30AM BLOOD Plt ___ ___ 05:40AM BLOOD Plt ___ ___ 06:06AM BLOOD Plt ___ ___ 06:06AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-138 K-4.2 Cl-100 HCO3-26 AnGap-12 ___ 06:06AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 ___ 11:00AM BLOOD HBsAg-NEG HBsAb-POS ___ 11:00AM BLOOD HIV Ab-NEG ___ 11:00AM BLOOD HCV Ab-NEG ___ 06:06AM BLOOD ___ 11:00AM BLOOD Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was unremarkable. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 325 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. ___ is discharged to home with services in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 320 mg PO DAILY 2. betamethasone, augmented 0.05 % topical BID 3. Atorvastatin 20 mg PO QPM 4. Omeprazole 40 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. Sertraline 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 6. Senna 8.6 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. betamethasone, augmented 0.05 % topical BID 9. Loratadine 10 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Valsartan 320 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 325 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices (___) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices (___) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: Remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___

10037818-DS-4

DS

2189-03-23 00:00:00

2189-03-23 17:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / iodine / shellfish derived Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___, generally health presenting with acute pancreatitis. 2 days ago out of her normal state of health she noticed that she was experiencing chills. One day ago at approximately 3 pm she started to vomit which laster for about 3 hours. She has not vomitted since yesterday, but she has had a dull ___ epigastric constant pain since then radiating to her back. Lying on her side make it feel worse, nothing makes it feel better. She has not had any fever, shortness of breath, dysuria, hematuria, vaginal bleeding or discharge. On admission to ED VS: 14:56 7 98.0 93 116/85 18 98% ra, PE notable for epigastric tenderness Labs notable for lactate of 2.7, leukocytosis 13.2 neu 89%, Hct 51, mod pos UA with SG 1.031, lipase 651. RUQ ultrasound - Mildly prominent pancreatic duct. In the setting of an elevated lipase concerning for acute pancreatitis. CXR - non acute. . She denies alcohol and smoking. She does not have any personal of family history of gallstones. She denies any medications or supplements except as below. Past Medical History: MIGRAINE HEADACHES OSTEOPENIA VITAMIN D DEFICIENCY H/O ANGIOEDEMA H/O IDIOPATHIC THROMBOCYTOPENIA PURPURA H/O FIBROADENOMA Social History: Marital status: Married Children: Yes, Description: 2 Lives with: ___ Children Work: ___ Sexual activity: Past Sexual orientation: Male Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use Holidays comments: Recreational drugs Denies (marijuana, heroin, crack pills or other): Depression: Patient does not report symptoms of depression Exercise: Activities Exercise comments: walksdog Diet: healthy Seat belt/vehicle Always restraint use: Family History: ___ COLON CANCER Physical Exam: 99.6 124/82 91 16 96RA 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, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, significant epigastric tenderness, 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: ___ 04:08PM BLOOD WBC-13.2*# RBC-5.11 Hgb-17.0* Hct-51.4* MCV-101* MCH-33.3* MCHC-33.1 RDW-12.4 Plt ___ ___ 04:08PM BLOOD Neuts-89.0* Lymphs-5.9* Monos-4.3 Eos-0.5 Baso-0.3 ___ 04:08PM BLOOD Glucose-152* UreaN-21* Creat-0.9 Na-140 K-4.1 Cl-99 HCO3-30 AnGap-15 ___ 04:08PM BLOOD ALT-19 AST-19 AlkPhos-95 TotBili-1.1 ___ 04:08PM BLOOD Lipase-655* ___ 04:12PM BLOOD Lactate-2.7* Prelim RUQ u/s: Mildly prominent pancreatic duct. In the setting of an elevated lipase, these findings are concerning for acute pancreatitis. No evidence of cholecystitis. A small gallbladder polyp is noted without thickening of the gallbladder wall. Brief Hospital Course: ___ generally healthy who presents with two days of epigastric pain and vomiting with laboratory and ultrasonographic picture concerning for acute pancreatitis. Acute Pancreatitis Initially patient was kept NPO and received IV narcotics. On HD#2 she was feeling better and able to transition to PO pain medications (which she took very rarely) and a clear diet. She was discharged home able to tolerate POs. There was no clear etiology of her pancreatitis. She denied any Etoh use and her RUQ ultrasound was unremarkable. Triglycerides and calcium were normal. A follow-up appointment was made with the pancreatic clinic at ___ to see if further work-up is necesssary and whether there is any role of cholecystectomy after this first time unexplained pancreatitis episode. Possible UTI She had some WBC in her urine and culture grew group b strep. Though she was relatively asx (she reported some blood in urine), I chose to treat with ciprofloxacin x 3 days for uncomplicated UTI (pen allergic). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Loratadine 10 mg PO DAILY:PRN allergy/sinusitis 2. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q12H RX *ciprofloxacin [Cipro] 250 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 3. Loratadine 10 mg PO DAILY:PRN allergy/sinusitis 4. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pancreatitis, UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for pancreatitis. Why you developed pancreatitis is unclear. As we discussed in some cases, the cause is unknown. Followup Instructions: ___

10037928-DS-13

DS

2177-07-24 00:00:00

2177-07-24 19:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine Attending: ___. Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ female Spanishh speaking with a history of Type 2DM on insulin (Detemir BID and Glipizide BID and metformin) who presents with malaise x 5 days "not feeling herself" per her daughter. ___ any cough, fever, no nausea vomitting, abdominal pain. No dysuria. Her daughter notes that she is concerned that her mother ___ know how to take her meds at home (she lives alone) and she also takes ambien every day which makes her have MS changes and makes her forgetful. Daughter called EMS today after seeing her mother "not act herself" she was oriented but her house was messy which is not like her. EMS found her to have profound hyperglycemia in ED (Gluc 996), transferred to ___ for HHS on Insulin gtt. She denies chest pain, shortness of breath, nausea, vomiting, diarrhea, dysuria. No other localizing symptoms of infection. In the ED, Tmax 98.2 HR ___, 110s-120s/40s-50s 96%RA. FSBG Crit High, Glucose on chem panel 996, Na 126 (144 corrected), K 5.3, AG 14, BUN 36, Cr 1.9. Given Insulin 5 SQ then 10IV(bolus), then started on Insulin gtt, initially at 3u/hr, then increased to 5/hr. Received total of 3L NS. She was mentating well, and was able to ambulate to the bathroom on her own. Also, in ED noted to have Guaiac positive stool (checked in setting of Hct 26, previous in our system was 36 9mo ago). On arrival to the MICU, she is no apparant distress, daughter says that her mental status is at her baseline. Pt feels hungry Past Medical History: DM2, HTN, Hyperlipidemia, Depression, Anxiety, Iron Deficiency Anemia, GERD, Chronic Back Pain, Insomnia. Tongue cancer, sees specialist at ___, chronic anemia (per pt she has had since she was a little girl, h/o stomach ulcers years ago. Social History: ___ Family History: She had brother with lung CA, daughter with endometrial cancer Physical Exam: On admission: VS: Please see Metavision General: Well appearing female in no acute distress HEENT: Mucous membs moist Neck: JVP nonelevated CV: Regular Rate and Rhythm, no murmurs/gallops appreciated Lungs: Crackles at the bases Abdomen: Soft, nontender, normoactive bowel sounds GU: Ulcer about 2cm left labia majora, appears to be adhesions, labia minor are very small and not seen very well, very narrow vaginal entroitis, and it is difficult to see the urethra Ext: Warm/no peripheral edema, peripheral pulses 2+ ___ Neuro: strength ___ all ext On discharge: Physical Exam: Vitals: Tm 100.5 T: 98.4 BP: 114/43 HR 83 RR 20 99%RA 24hr Glucose Range: 60, 214, 368, 372, 196, 295, 185 General: Well appearing elderly/female in no acute distress CV: RRR no murmurs/gallops appreciated Lungs: clear bilaterally no w/r Abdomen: Soft, nontender, normoactive bowel sounds Ext: Warm/no peripheral edema Neuro: alert, answering questions appropriately in ___ Pertinent Results: On admission: ___ 03:15PM BLOOD WBC-4.4 RBC-3.63* Hgb-7.0*# Hct-26.8* MCV-74* MCH-19.4*# MCHC-26.2*# RDW-17.3* Plt ___ ___ 03:15PM BLOOD Neuts-78* Lymphs-13* Monos-9 Eos-0 Baso-0 ___ 03:15PM BLOOD ___ PTT-23.7* ___ ___ 03:15PM BLOOD Glucose-996* UreaN-36* Creat-1.9* Na-126* K-5.3* Cl-88* HCO3-24 AnGap-19 ___ 03:15PM BLOOD cTropnT-<0.01 ___ 03:15PM BLOOD Calcium-10.5* Phos-5.5* Mg-2.2 ___ 06:39PM BLOOD Comment-GREEN TOP ___ 03:26PM BLOOD Glucose-GREATER TH Na-130* K-5.2* Cl-88* calHCO3-27 ___ 03:26PM BLOOD Hgb-7.8* calcHCT-23 ___ 09:20PM BLOOD freeCa-1.16 Microbiology: BCx x2 (___): Pending Imaging: CXR PA/lateral (___): No acute cardiopulmonary process. ___ 05:40AM BLOOD WBC-6.9 RBC-3.45* Hgb-8.0* Hct-26.3* MCV-76* MCH-23.2* MCHC-30.3* RDW-23.0* Plt ___ ___ 09:19AM BLOOD Neuts-64.5 ___ Monos-5.9 Eos-1.6 Baso-0.2 ___ 05:40AM BLOOD Plt ___ ___ 05:40AM BLOOD Glucose-275* UreaN-26* Creat-1.3* Na-136 K-4.6 Cl-101 HCO3-27 AnGap-13 ___ 05:40AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.6 SPEP and UPEP negative Brief Hospital Course: Ms. ___ is a ___ with type 2 diabetes mellitus who presents in a hyperosmolar, hyperglycemic state in the setting of poor medication compliance. # Type II diabetes, uncontrolled with hyperosmolarity/HHS - diagnosed by Serum Glucose > 600(996), HCO3 > 15(24), no ketonuria,no ketonemia . This is most likely from med non compliance as daughter has worries about this and patient notes there are times she forgets to take her insulin. No signs of infection though she does have a labial ulcer but it is not erythematous or painful. She was intially on an insulin drip and was weaned off, given long acting insulin and her BG levels returned to the 100s. Her MS was at baseline by the time she reached the MICU. ___ was consulted for recommendations on control of her BG levels. Her K was repleted. She received 4 L of NS in ER and ICU. At discharge glucose remained labile but was in the range of 150-300 the day prior to discharge. Insulin regimen was limited by the pateint's schedule (she often sleeps until ___ and does not eat until noon) and the fact that her family can only administer insulin early in the morning and in the evening. Given these limitations, she was discharged on a regimen of Lantus 38 units in the morning and ___ 30 units at dinner. She was advised to continue to check her blood sugar 4 times daily. She has a follow up appointment scheduled in the ___ on ___. # Elevated Lactate - 4.9 on arrival and went down to 1.9. Likely related to hypovolemia, and/ or metformin in setting of poor GFR. Lactate resolved # Met Acidosis with AG: AG initially 19 (from lactate), improved with HHS rx as above # Microcytic Anemia with low MCV elev RDW. Differential includes iron deficiency (guaiac pos brown stool, h.o ulcer in the past per daughter though not ___ in records) vs thallasemia (per pt she has been anemic all her life). Also on differential is MM in setting of renal failure. SPEP and UPEP were checked and were negative. Labs showed more of iron deficiency picture though it is possible she also has thallasemia. In setting of guaiac pos brown stool, history of angioectasisas seen on ___ and ___ ulcers pt should follow up with GI. H. pylori testing was positive, and patient should discuss with PCP and GI in follow up next week whether to treat for this. # Acute on chronic kidney disease: Initial Cr 1.9, likely due to hypovolemia in the setting of hyperglycemia. Improved to 1.3 on discharge. #Urinary tract infection: Complaints of urinary frequency- UA was positive and culture was positive for pan sensitive E. Coli. She was treated with oral ciprofloxacin and will complete a 7 day course. Of note, she did have a low grade fever the day prior to discharge. She had no new symptoms of infection and WBC count was not elevated therefore no further infectious work up was pursued. # Gyn: pt with labia majora ulcer and vaginal atrophy possible lichen sclerosis atrophicus. Could not insert foley because entroitus was so narrowed. Started on topical steroids and estrogen for atrophic vaginitis v. lichen. Will need gyn f/u. CHRONIC ISSUES #HTN: continued hctz, losartan, propanolol #Depression: continued buspirone and paroxitene Transitional issues: #Anemia Consistent with iron deficiency- started on PO Iron but needs outpatient evaluation with Colonoscopy/EGD. Also H. Pylori antigen positive. Treatment not started in house. #Vaginal atrophy Needs GYN follow up Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Hydrocortisone Cream 2.5% 1 Appl TP 3X/WEEK (___) 3. BusPIRone 10 mg PO TID 4. Zolpidem Tartrate 10 mg PO HS 5. Fluconazole 150 mg PO BID 6. Clotrimazole Cream 1 Appl TP DAILY 7. Propranolol 20 mg PO BID 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. Amlodipine 10 mg PO DAILY 10. Atorvastatin 20 mg PO DAILY 11. Detemir 30 Units Breakfast Detemir 30 Units Bedtime 12. Ferrous Sulfate 325 mg PO DAILY 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain 15. Omeprazole 40 mg PO DAILY 16. Paroxetine 40 mg PO DAILY 17. GlipiZIDE 10 mg PO BID 18. Hydrochlorothiazide 25 mg PO DAILY 19. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. BusPIRone 10 mg PO TID 3. Ferrous Sulfate 325 mg PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Paroxetine 40 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Amlodipine 10 mg PO DAILY 11. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain 12. Hydrocortisone Cream 2.5% 1 Appl TP 3X/WEEK (___) 13. Omeprazole 40 mg PO DAILY 14. Propranolol 20 mg PO BID 15. Docusate Sodium (Liquid) 100 mg PO BID You can buy this over the counter if needed. 16. Estrogens Conjugated 1 gm VG DAILY Duration: 3 Weeks 17. Clotrimazole Cream 1 Appl TP DAILY 18. Glargine 38 Units Breakfast Humalog ___ 30 Units Dinner RX *insulin lispro protam & lispro [Humalog Mix ___ KwikPen] 100 unit/mL (75-25) ___ Units before dinner Disp #*1 Box Refills:*3 RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) ___ Units before Breakfast Disp #*1 Box Refills:*3 19. Ciprofloxacin HCl 500 mg PO Q12H Last day ___ RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*5 Tablet Refills:*0 20. linagliptin *NF* 5 mg Oral daily RX *linagliptin [Tradjenta] 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Diabetes mellitus, type II, poorly controlled with complications Acute renal failure Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted due to dangerously high blood sugars. You required a continuous infusion of insulin when your first arrived. This was changed back to your usual insulin and the dose was adjusted with the help of the ___ Diabetes specialists. You should continue to follow a diabetic diet. You need to check your sugars in the morning when you wake up and before every meal. This is very important to regulate your sugars so you do not need to go to the ICU again. You will also need to take insulin twice daily. Stop taking Glipizide, Determir Start Linagliptin 5mg daily for diabetes Start Lantus (Glargine) 38 units in the morning and ___ 30 units in the evening Start Ciprofloxacin 500mg twice daily- last dose is ___ Followup Instructions: ___

10037928-DS-15

DS

2177-12-23 00:00:00

2177-12-23 19:01:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine Attending: ___. Chief Complaint: #Cough Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ with DM2 on insulin who presents with cough for 3d. Reports sore throat, productive cough with green sputum. Denies f/c, cp, n/v. Normal po intake. Per report she did not take her insulin today because she wasnt feeling well. Her symptoms remind her of when she has PNA in the beginnign of ___. In the ED intial vitals were: 98.7 108 151/55 22 98% Labs notable for BG 667 Cr 1.6 (baseline 1.2-1.5) anion gap =15 VBG pH 7.39 pCO2 52 pO2 CXR showed Streaky bibasilar opacities most likely reflective of atelectasis she was given albuterol nebs, 10 of humalog plan to admit pt for cough and hyperglycemia On the floor she says she feels better but still has a cough Past Medical History: DM2, HTN, Hyperlipidemia, Depression, Anxiety, Iron Deficiency Anemia, GERD, Chronic Back Pain, Insomnia. Tongue cancer, sees specialist at ___, chronic anemia (per pt she has had since she was a little girl, h/o stomach ulcers years ago. Social History: ___ Family History: She had brother with lung CA, daughter with endometrial cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 100.3 141/43 105 16 97%RA General- Alert, oriented, coughing HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- lots of cough on exam, slightly decr breath sounds no wheeze or crackles CV- slightly tachycardic low 100s Regular 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 DISCHARGE PHYSICAL EXAM: Vitals- Tm 98.8 130s-140s/40s-60s HR ___ RR ___ Sa02 97% r/a General- Alert, oriented, coughing HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- minimal cough today, minimal scattered coarse breath sounds and no crackles CV- RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ___ 06:25PM BLOOD WBC-10.7# RBC-4.04* Hgb-12.3 Hct-40.2 MCV-100*# MCH-30.5 MCHC-30.6* RDW-13.3 Plt ___ ___ 06:25PM BLOOD Neuts-78.1* Lymphs-12.2* Monos-8.9 Eos-0.4 Baso-0.4 ___ 06:25PM BLOOD Glucose-677* UreaN-23* Creat-1.6* Na-130* K-4.5 Cl-91* HCO3-25 AnGap-19 ___ 06:36PM BLOOD ___ pO2-33* pCO2-52* pH-7.39 calTCO2-33* Base XS-4 ========================================================== DISCHARGE LABS ___ 06:10AM BLOOD WBC-12.2* RBC-4.00* Hgb-12.2 Hct-39.0 MCV-97 MCH-30.5 MCHC-31.3 RDW-13.4 Plt ___ ___ 06:10AM BLOOD Glucose-165* UreaN-17 Creat-1.0 Na-139 K-4.5 Cl-102 HCO3-23 AnGap-19 ========================================================== IMAGING: ___ CXR HISTORY: Cough and dyspnea. TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: The cardiac, mediastinal and hilar contours are within normal limits. The pulmonary vasculature is normal. Streaky opacities in the lung bases likely reflect atelectasis, and no focal consolidation is demonstrated. There is no pleural effusion or pneumothorax. There is evidence of prior vertebroplasty within a total body at the thoracolumbar junction. IMPRESSION: Streaky bibasilar opacities most likely reflective of atelectasis. ---------- EKG: Sinus tachycardia. Left atrial abnormality. Baseline artifact. Diffuse non-specific ST-T wave changes, new as compared to the previous tracing of ___, while the rate has increased. Clinical correlation is suggested. Brief Hospital Course: ___ F h/o IDDM presents with cough for 3 days, sore throat, and found to be hyperglycemic to 600s in the ER with ___. #Acute bronchitis versus community acquired pneumonia: Initially, thought to be acute viral bronchitis based on symptoms, lack of CXR findings consistent with PNA. However, gven that she was initially hypovolemic at the time of her CXR, we thought it possible that a consolidation had not radiographically developed yet. Her initial pneumonia severity index was intermediate with inpatient stay being appropriate. Because the risk of not treating a possible pneumonia seemed quite high, she was treated with azithromycin with a planned 5 day course. Sputum gram stain showed 4+ GPCs and some GNC/GNRs as well. Culture preliminarily showed commensal respiratory flora. She had significant cough, wheezing, and dyspnea without hypoxemia requiring scheduled q6 hour nebulizers. She improved significantly by ___ AM from a respiratory status standpoint and was felt to be safe to discharge home with antibiotic course ending ___. Given that this is her second admission for respiratory infection this year without a history of COPD, smoking, or fibrotic lung disease, there was some suspicion that she may have developed a chronic underlying process such as bronchiectasis that predisposes to infection. This requires ongoing outpatient evaluation potentially with PFTs vs chest CT at some point if she were to have ongoing respiratory complaints. She was prescribed a spacer to help optimize her outpatient MDI. #Acute Kidney Injury: Cr 1.6 on admission from a baseline of ~1.2. This is most likely pre-renal azotemia in the setting of poor PO intake, osmotic diuresis from hyperglycemia, and insensible losses with fever. Her sCr improved to baseline with IV fluids. #Diabetes/Hyperglycemia: In the ER BS in the 600s. There was no elevated anion gap on labs. This was thought to be due to not taking her insulin the day of admission because she was feeling sick. While an inpatient her blood sugars were extremely hard to control. She varied between hypoglycemic to hyperglycemic throughout the day on her home regimen. Her outpatient HgbA1c has reflected poorly controlled diabetes. This may be due to labile blood sugars on her insulin regimen, not medication non-compliance, given that she was difficult to control while here. She was seen by ___ and ___ diabetic education RN. She had follow up appointments scheduled for ___. She was discharged on her outpatient Lantus and Humalog sliding scale. Chronic Issues -------------- # HTN: Losartan was held in the setting of ___, but was restarted at the time of discharge. HCTZ and Propranolol were continued. # Hyperlipidemia: Atorvastatin was continued # Depression and Anxiety: Paroxetine and Buspirone were continued # GERD: Ranitidine was continued TRANSITIONAL ISSUES: -Outpatient titration of her insulin regimen -Monitoring of respiratory complaints with further workup if frequent, recurrent lower respiratory tract infections. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH HS asthma 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. BusPIRone 10 mg PO TID 5. Cyanocobalamin 1000 mcg PO DAILY 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Losartan Potassium 100 mg PO DAILY 10. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Oral BID 11. Paroxetine 40 mg PO DAILY 12. Propranolol 20 mg PO BID 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Glargine 36 Units Dinner Insulin SC Sliding Scale using HUM Insulin 15. Furosemide 10 mg PO DAILY 16. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH HS asthma 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. BusPIRone 10 mg PO TID 5. Cyanocobalamin 1000 mcg PO DAILY 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Paroxetine 40 mg PO DAILY 10. Ranitidine 150 mg PO DAILY 11. Propranolol 20 mg PO BID 12. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Oral BID 13. Ferrous Sulfate 325 mg PO DAILY 14. Furosemide 10 mg PO DAILY 15. Losartan Potassium 100 mg PO DAILY 16. Multivitamins W/minerals 1 TAB PO DAILY 17. Glargine 36 Units Dinner Insulin SC Sliding Scale using HUM Insulin 18. Azithromycin 250 mg PO Q24H Duration: 2 Days final day of 5 day course is ___ RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 19. Omeprazole 20 mg PO DAILY 20. Spacer for metered dose inhaler Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: #Acute bronchitis versus community acquired pneumonia #Hyperglycemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, it was a pleasure to be part of your care at ___. You were admitted for concern for pneumonia and for very high blood sugar. We suspect that your cough and shortness of breath is due to an infection of the lungs. A sputum culture grew a few types of bacteria, so this may represent a pneumonia. You were treated with antibiotics (azithromycin) and will continue to take this medication through ___. We gave you breathing treatments with nebulizers to help open your airways and improve your breathing. At home, you will continue to use albuterol as needed with a spacer which we showed you how to use in the hospital. Also, when you were admitted your blood sugar was dangerously high, likely because of a missed insulin dose, but severe illness can raise blood sugars too. We think high sugars and your respiratory infection caused you to become dehydrated. We gave you IV fluids to improve your hydration. We had doctors ___ come see you to discuss your diabetes because your blood sugars were very high and very low during this admission. They would like you to follow up in clinic (SEE BELOW). Followup Instructions: ___

10037928-DS-16

DS

2178-10-02 00:00:00

2178-10-03 06:05:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine Attending: ___. Chief Complaint: Right ear pain and drainage Major Surgical or Invasive Procedure: ENT fiberoptic scope Cleaning of right external ear canal and wick placement History of Present Illness: Ms. ___ is a ___ year old woman with a past medical history of Type 2 Diabetes Mellitus (insulin-controlled), hypertension, GERD, depression, and tongue cancer, who presented with 1 day of ear pain and serosanguinous drainage and subjective fevers/chills following URI. According to her family, her BP had been somewhat elevated and she had missed some medication doses, her blood sugars at home had been in the 300s, and she had been incontinent of urine. In the ED initial vitals were: 97.6 96 121/65 16 94%. Labs were significant for leukocytosis, normal bicarb, elevated creatinine (baseline 1.4), elevated glucose, and UA concerning for UTI. CXR was normal and ear drainage was sent for cultures. She received insulin and IV cefepime was administered to cover pseudomonas. She was started on ciproflaxacin and dexamethasone drops for otitis externa. ESR was elevated raising concern for for malignant otitis externa. She was admitted to the floor for further workup of otitis, blood sugar and UTI management. On admission to the floor, patient remained afebrile with stable vitals. She noted very mild right ear pain but denied chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, dysuria or increased urinary frequency. ROS was otherwise negative. Past Medical History: DM2, HTN, Hyperlipidemia, Depression, Anxiety, Iron Deficiency Anemia, GERD, Chronic Back Pain, Insomnia. Tongue cancer, sees specialist at ___, chronic anemia (per pt she has had since she was a little girl, h/o stomach ulcers years ago. Social History: ___ Family History: She had brother with lung CA, daughter with endometrial cancer Physical Exam: ON ADMISSION: Vitals - T: 98.3 BP: 173/74 to 162/64 HR: 100 RR: 22 02 sat: 95%RA GENERAL: Well and comfortable appearing woman lying in bed in NAD HEENT: AT/NC, EOMI, PERRL, MMM. No tenderness, swelling, erythema, or rash over R mastoid. Ruptured R TM with small amount of serous fluid present in auditory canal, minimal erythema. L TM intact, nonbulging, no erythema. NECK: no LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, AAOx3, motor and sensory exam grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes ON DISCHARGE: PE: 97.7 131/53 ___ 18 100% on RA Gen: Alert and responsive, NAD sitting up on bed Chest: Sparse crackles at lung bases, no rhonchi or wheezes CV: RRR, no murmurs, rubs, and gallops HEENT: R ear clean, no active drainage, wick removed Pertinent Results: ON ADMISSION: ___ 08:45PM WBC-16.7*# RBC-4.37 HGB-14.3 HCT-44.1 MCV-101* MCH-32.8* MCHC-32.5 RDW-12.3 ___ 08:45PM NEUTS-86* BANDS-1 LYMPHS-4* MONOS-9 EOS-0 BASOS-0 ___ MYELOS-0 NUC RBCS-1* ___ 08:45PM PLT COUNT-357 ___ 08:45PM SED RATE-65* ___ 10:05PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 10:05PM URINE RBC-1 WBC->182* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 10:05PM URINE MUCOUS-RARE ___ 09:25PM ___ PO2-36* PCO2-51* PH-7.40 TOTAL CO2-33* BASE XS-4 ___ 08:55PM LACTATE-2.0 ___ 08:45PM GLUCOSE-529* UREA N-23* CREAT-1.6* SODIUM-132* POTASSIUM-5.0 CHLORIDE-89* TOTAL CO2-29 ANION GAP-19 MICRO: ___ 10:05 pm URINE _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S 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-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Time Taken WOUND CULTURE (Final ___: BETA STREPTOCOCCUS GROUP A. HEAVY GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. ON DISCHARGE: ___ 04:55AM BLOOD WBC-9.9 RBC-3.93* Hgb-12.8 Hct-39.4 MCV-100* MCH-32.6* MCHC-32.5 RDW-12.4 Plt ___ ___ 04:55AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-141 K-3.5 Cl-102 HCO3-27 AnGap-16 ___ 04:55AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.8 REPORTS: CT TEMPORAL BONE ___. Soft tissue density in the right external auditory canal and middle ear with inflammatory changes extending into the soft tissues, findings are concerning for malignant otitis externa, recommend skullbase MRI for further assessment. No bony destruction identified. 2. Asymmetric fullness of the ___ fossa on the right, new from ___, could be secondary to inflammation in this region however, underlying mass is a concern, recommend direct visualization. This finding can also be assessed on a contrast enhanced skullbase MRI. Brief Hospital Course: Ms. ___ is an ___ year old woman with Type II Diabetes Mellitus, hypertension, GERD, depression and tongue cancer who was admitted with right ear pain. ACUTE MEDICAL ISSUES: #Otitis externa: Pt presented with one day of ear pain and serosanguineous drainage. Given recent history of poorly controlled Type II diabetes, leukocytosis and elevated ESR, this raised concerns for malignant otitis externa, although there was no granulation tissue on exam by ENT. This was further evaluated with CT, which showed soft tissue involvement and inflammation but no bony involvement, and also raised question of possible mass which may have represented inflammation from her current infection. Pt was treated for pseudomonas coverage with cefepime, PO cipro and cipro ear drops. Pt's wound culture then grew group A strep and she was narrowed to ceftriaxone per Infectious Disease recommendations. Both ENT and Infectious Disease consultants did not feel the patients presentation represented malignant otitis externa given her physical exam and culture data. MRI was considered as inpatient for further evaluation of questionable mass seen on CT, but patient was clinically improved with no pain or drainage, and the decision was made to follow up as outpatient with ENT in 1 week. She was discharged on 4 days Augmentin to complete antibiotic course as well as cipro ear drops. #DM: Pt was hyperglycemic >500 upon arrival with concern that she might not have been taking all of her medication at home. Given her infections, the goal was for tight glucose control. Her home glipizide, liraglutide were discontinued and she was started on sliding scale standing insulin (which she also self-administers at home) and Glargine (on Levemir at home), with input from ___. With this regimen, the pt's blood glucose decreased to 100s-200s. On discharge, pt will resume her levemir pen and humalog, with adjustments to sliding scale. Family has been provided with copy of sliding scale regimen and the pt is already trained to administer insulin at home via pen mechanism. #UTI: Pt presented with reports of urinary incontinence and dysuria and her UA was grossly positive. Urine culures grew E. coli. On discharge, patient reports some ongoing burning on urination, but no other urinary symptoms and she is afebrile. She will be covered with Augmentin to finish course. ___: On admission, had rise in Creatinine to 1.6 from baseline (1.3-1.5). This resolved to baseline with fluids and reached 1.1 on discharge day, suggesting hypovolemia likely from dehydration. Pt's lasix and losartan were held CHRONIC MEDICAL ISSUES: #HLD: Pt was continued on home atorvastatin #GERD: Pt was continued home ranitidine, omeprazole #Depression/anxiety: Pt was continued home paroxetine, buspirone #HTN: Pt was continued home amlodipine and propanolol. Losartan-HCTZ and lasix were held given ___, however creatinine improved by discharge day, thus losartan-HCTZ was resumed as outpatient. Given her decreased PO intake and lack of volume overload, her lasix was held and can be restarted as an outpatient. TRANSITIONAL ISSUES [] Complete 4 more days of PO augmentin (last day ___ [] Pt to follow up with ENT [] Pt to continue cipro ear drops until she is seen by ENT [] Pt's CT temporal bone showed questionable mass. She will follow up with ENT regarding if further imaging with outpatient MRI is necessary [] Pt to follow up in ___ given her poorly controlled diabetes [] Pt discharged on 33 units Levamir at night and humalog sliding scale [] Pt noted to be dehydrated with ___ on admission. Lasix 20 mg held on discharge and to be restarted as needed by PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. losartan-hydrochlorothiazide 100-25 mg oral daily 2. Clobetasol Propionate 0.05% Ointment 1 Appl TP HS 3. BusPIRone 10 mg PO TID 4. Propranolol 20 mg PO BID 5. Amlodipine 10 mg PO DAILY 6. Estrogens Conjugated 1 gm VG DAILY 7. Ranitidine 150 mg PO DAILY 8. Atorvastatin 20 mg PO HS 9. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous daily 10. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous QAC 11. Ferrous Sulfate 325 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 16. Paroxetine 40 mg PO DAILY 17. Cyanocobalamin 1000 mcg PO DAILY 18. GlipiZIDE XL 10 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atorvastatin 20 mg PO HS 3. BusPIRone 10 mg PO TID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Paroxetine 40 mg PO DAILY 8. Propranolol 20 mg PO BID 9. Ranitidine 150 mg PO DAILY 10. Ciprofloxacin 0.3% Ophth Soln 3 DROP RIGHT EAR TID RX *ofloxacin 0.3 % 3 drops ear three times per day Disp #*1 Bottle Refills:*1 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 12. Clobetasol Propionate 0.05% Ointment 1 Appl TP HS 13. Estrogens Conjugated 1 gm VG DAILY 14. Omeprazole 40 mg PO DAILY 15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every 12 hours Disp #*8 Tablet Refills:*0 16. Levemir Flexpen (insulin detemir) 100 unit/mL (3 mL) subcutaneous daily 33 units daily RX *insulin detemir [Levemir] 100 unit/mL 33 units SC daily Disp #*10 Vial Refills:*0 17. losartan-hydrochlorothiazide 100-25 mg oral daily 18. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous QAC RX *insulin lispro [Humalog KwikPen] 100 unit/mL per sliding scale with meals Disp #*15 Syringe Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. acute otitis externa Secondary: 2. Urinary tract infection 3. acute kidney injury, likely due to hypovolemia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted for right ear pain and drainage. You were seen by the Ear, Nose, and Throat doctor and the Infectious ___ doctors to ___ up with a plan. You were treated with antibiotics for an infection of your external ear canal. During this hospitalization you were also seen by the diabetes doctors who ___ your doses of insulin and you were treated for a bladder infection. Sincerely, Your team at ___ Followup Instructions: ___

10037928-DS-18

DS

2179-04-04 00:00:00

2179-04-07 08:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine Attending: ___. Chief Complaint: Diarrhea, Cough, Decreased Appetite, Weakness Major Surgical or Invasive Procedure: ___: Flexible bronchoscopy History of Present Illness: ___ pmh HTN, HLD, DMII, and h/o tongue cancer who p/w 1 day of diarrhea, weakness, and a non productive cough. Pt reports that she developed diarrhea yesterday, non bloody or non melena, and had about 10 BMs, did not allow her to sleep. She denies n/v, f/c, lightheadedness/dizzines. She also reports dysuria (which appears chronic per documentation), denies back pain. She completed a 14d course of Nitrofurantoin per PCP (cx appears to have been resistant). She also reports weakness for 3 days associated with poor PO intake. BS this AM was in the 200s. She also reports a cough which has gone from non productive to productive recently, present for a week. No SOB, no CP. No HA, no neck pain. In the ED, initial vitals: 99.8 97 176/86 32 88% RA Labs were significant for +UA, hemolyzed chem 7 with hyponatremia, normal K and a cr of 1.3 (slightly above baseline of 1.2-1.3. No CBC sent. Imaging w/ normal CXR. Given Ceftriaxone x1. Blood and urine cxs sent. Negative flu. Vitals prior to transfer: 97.8 93 155/65 16 96% NC Currently, feels tired, coughing but has not had a BM today. Endorses dysuria as well. Past Medical History: DM2 HTN Hyperlipidemia Depression Anxiety Iron deficiency anemia GERD Chronic back pain Insomnia Tongue cancer, sees specialist at ___ H/o stomach ulcers Social History: ___ Family History: She had brother with lung CA, daughter with endometrial cancer Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 99.5 162/53 95 22 95%4L GEN: Sleepy, laying in bed, calm HEENT: MMM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD or JVD PULM: Bibasilar crackles that seem atelactic in nature COR: RRR (+)S1/S2 no m/r/g but heart sounds are distant ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal, AAOx3 GYN: Erythematous labia majora and minora with white discharge DISCHARGE PHYSICAL EXAM: ======================== Vitals: 99.9 98.0 116-157/50-64 ___ 99% RA GEN: Awake sitting up in bed, no acute distress, on RA HEENT: MMM, anicteric sclerae, no conjunctival pallor PULM: B/l crackles diffusely. Stable from yesterday. COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, +BS EXTREM: Warm, well-perfused. Erythema, swelling and tender (less so today) area on the L radial aspect of wrist. NEURO: Alert and interactive. Grossly intact. Pertinent Results: ADMISSION LABS: =============== ___ 09:46PM BLOOD WBC-8.3 RBC-4.77 Hgb-14.9 Hct-45.1 MCV-94 MCH-31.2 MCHC-33.0 RDW-13.9 Plt ___ ___ 09:46PM BLOOD Neuts-77* Bands-5 Lymphs-8* Monos-9 Eos-0 Baso-0 ___ Metas-1* Myelos-0 ___ 09:46PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 09:46PM BLOOD ___ PTT-26.1 ___ ___ 09:46PM BLOOD Plt Smr-NORMAL Plt ___ ___ 02:34PM BLOOD Glucose-433* UreaN-33* Creat-1.4* Na-132* K-4.1 Cl-93* HCO3-22 AnGap-21* ___ 02:34PM BLOOD ALT-23 AST-46* LD(LDH)-456* AlkPhos-84 TotBili-0.3 ___ 02:34PM BLOOD Albumin-4.0 ___ 09:46PM BLOOD Calcium-8.9 Phos-3.5 Mg-1.2* ___ 02:41PM BLOOD Lactate-1.4 ___ 05:33PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:33PM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 05:33PM URINE RBC->182* WBC->182* Bacteri-FEW Yeast-MANY Epi-0 PERTINENT LABS: =============== ___ 06:45AM BLOOD ALT-19 AST-29 LD(___)-288* AlkPhos-66 Amylase-65 TotBili-0.2 ___ 06:45AM BLOOD proBNP-1003* ___ 10:44AM BLOOD Type-ART Temp-36.7 pO2-64* pCO2-33* pH-7.46* calTCO2-24 Base XS-0 ___ 03:20PM BLOOD HIV Ab-NEGATIVE DISCHARGE LABS: =============== ___ 07:10AM BLOOD WBC-11.6*# RBC-3.88* Hgb-12.2 Hct-36.9 MCV-95 MCH-31.5 MCHC-33.1 RDW-13.1 Plt ___ ___ 07:10AM BLOOD Neuts-73.4* Lymphs-17.8* Monos-8.2 Eos-0.4 Baso-0.3 ___ 07:10AM BLOOD Plt ___ ___ 07:10AM BLOOD Glucose-152* UreaN-12 Creat-1.2* Na-136 K-4.4 Cl-98 HCO3-26 AnGap-16 ___ 07:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.6 MICROBIOLOGY: ============= ___ BLOOD CULTURE Blood Culture, Routine (Final ___: NO GROWTH. ___ BLOOD CULTURE Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:04 pm STOOL C. difficile DNA amplification assay (Final ___: 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. ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ___ RML BRONCHIAL LAVAGE. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ RUL BRONCHIAL LAVAGE. Respiratory Viral Antigen Screen (Final ___: COMBINED WITH SPECIMEN #___ ___. Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Respiratory Virus Identification (Final ___: Reported to and read back by ___. ___ 15:43 ___. POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. Viral antigen identified by immunofluorescence. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): IMAGING: ======== CXR (___): No acute cardiopulmonary abnormality. CXR (___): Cardiomediastinal silhouette is normal. There are no signs for focal consolidation or overt pulmonary edema. There are no pleural effusions or pneumothoraces. CXR (___): No relevant change. No pneumonia. No pulmonary edema. Normal size of the cardiac silhouette. No pleural effusions. The lateral radiograph reveals a status post vertebroplasty. ECHO (___): The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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 are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic regurgitation. Normal estimated RV/LV filling pressures. CT CHEST W/O CONTRAST (___): Combination of ground-glass opacities, solid nodules and solid/ground-glass nodules within hello might be consistent with diffuse infectious process. Alternatively atypical mycobacterial infection, hypersensitivity reaction, aspiration or vasculitis would be a possibility. Neoplasm is substantially less likely. Cryptogenic organizing pneumonia is another less likely possibility. Diffuse bronchial wall thickening and endobronchial secretions might reflect part of the in infection/inflammatory process. Irregularity of the upper trachea with be beneficial to proceed with direct evaluation. PROCEDURES: =========== BRONCHOSCOPY ___: The bronchoscope was passed through the mouth and the into the oropharynx where the cords were visualized and appeared normal. The cords were anesthatized with topical lidocaine. The bronchoscope was then passed through the cords and into the trachea. Thick, yellow, adherent mucous was noted on the posterior segment of the trachea. This did not clear with suctioning or with instilled saline. The bronchoscope was then passed into the right mainstem and into the RUL where lavage was performed in the anterior segment of the RUL. The bronchoscope was then withdrawn and passed into the BI and into the RML where another lavage was performed. The remained of the bilateral bronchi were inspected and patent. A cytorush was used to brush the upper airway adherent mucous. The airways appeared edemetous and hyperemic throughout. Impression: Diffuse parenchymal lung disease Recommendations: ___ microbiology, cytology and pathology Followup cytology Brief Hospital Course: ___ F PMhx HTN, DMII on insulin, recent UTI status post ___ of nitrofurantoin, admitted ___ w hypoxiam, cough and diarrhea, found to have Cdiff colitis, initially flu negative on admission, subsequently undergoing CT chest with concerning features and bronchoscopy with a viral culture demonstrating influenza A as well as evidence of pneumonia, started on antibiotics, discharged home #) Hypoxic Respiratory Failure / Acute Influenza A Infection / Community Acquired Pneumonia - Patient admitted with hypoxia and cough, initially presumed PNA and placed on azithromycin/ceftriaxone, which was subsequently discontinued when no infiltrates were seen on CXR. Given persistant systems, CT chest was obtained and showed "combination of ground-glass opacities, solid nodules and solid/ground-glass nodules". Pulmonary consult recommended Bronchoscopy, which showed "diffuse parenchymal lung disease", and possible concern for residual PNA. She was started on levofloxacin (7-day course, day 1 = ___ for CAP. In addition, viral studies sent from bronchoscopy returned positive for influenza A prompting initiation of oseltamivir (5-day course, day 1 = ___. Her saturation normalized and she was discharged home with PCP and ___. #) C. DIFF INFECTION/DIARRHEA: Stool positive for C. diff. Thought to be secondary to recent outpatient course of nitrofurantoin. Patient treated with PO vancomycin. She was having 10 BMs/day on admission, and by the day of discharge these had reduced to 3 loose stools/day. This should be continued for 14 days after completion of Levofloxacin course as above. #) CELLULITIS: Pt developed L hand cellulitis at site of prior phlebotomy. This was clinically improving on the day of discharge, on levofloxacin for her pneumonia would also cover cellulitis. PCP should ___ for improvement. #) DM TYPE II: Uncontrolled with renal complications (Proteinuria), last A1C 11.6. Levemir was uptitrated to 31units from 25units #) YEAST INFECTION: On presentation, patient found to have yeast infection, thought to be secondary to recent antibiotics. Resolved with fluconazole q72hr. Nystatin cream was also used to groin area. #) HYPERTENSION: Continued home amlodipine, held Losartan-HCTZ given mild ___ and infections. This should be restarted per PCP. #) HLD: Continued home atorvastatin. #) ANXIETY: Continued home Buspar, paroxetine. #) GERD: Continued PPI, held H2 blocker. TRANSITIONAL ISSUES: [] Will need to follow up with Pulmonology and obtain PFTs as an outpatient (scheduled) [] F/u resolution of yeast infection [] Levofloxacin course for 8 days (d1 = ___ [] Tamiflu course for 5 days (d1 = ___ [] Vancomycin course to end on ___ (2 weeks after Levofloxacin ends) [] We have held her ___ and ___ HCTZ. Please resume at PCP's discretion. [] Patient has uncontrolled diabetes. Please evaluate home medication regimen and patient compliance. Uptitrated insulin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. BusPIRone 10 mg PO TID 4. Levemir 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. losartan-hydrochlorothiazide 100-25 mg oral daily 6. Omeprazole 40 mg PO DAILY 7. Paroxetine 40 mg PO DAILY 8. Propranolol 20 mg PO BID 9. Ranitidine 150 mg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 12. Ferrous Sulfate 325 mg PO DAILY 13. Docusate Sodium 100 mg PO BID:PRN constipation 14. Estrogens Conjugated 1 gm VG WEEKLY 15. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 18 Days RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp #*72 Capsule Refills:*0 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. BusPIRone 10 mg PO TID 5. Levemir 31 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Omeprazole 40 mg PO DAILY 7. Paroxetine 40 mg PO DAILY 8. Propranolol 20 mg PO BID 9. Acetaminophen 650 mg PO Q6H:PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 10. Levofloxacin 500 mg PO Q48H Duration: 2 Doses RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp #*3 Tablet Refills:*0 11. Nystatin Cream 1 Appl TP BID RX *nystatin 100,000 unit/gram apply to groin rash twice a day Refills:*0 12. OSELTAMivir 75 mg PO Q24H RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth daily Disp #*3 Capsule Refills:*0 13. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 14. Cyanocobalamin 1000 mcg PO DAILY 15. Docusate Sodium 100 mg PO BID:PRN constipation 16. Estrogens Conjugated 1 gm VG WEEKLY 17. Ferrous Sulfate 325 mg PO DAILY 18. Multivitamins W/minerals 1 TAB PO DAILY 19. Ranitidine 150 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Influenza A Community-acquired pneumonia Clostridium difficile infection Yeast infection Secondary diagnoses: Type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ on ___ for a cough, weakness, and diarrhea. You tested negative for influenza in the emergency department. We initially treated you for pneumonia, but because you also had a concurrent Clostridium difficile (C. diff) infection causing your diarrhea, when it was clear on imaging and in your bloodwork that you did not have a pneumonia, we stopped the antibiotics, treating only your C. diff infection with an antibiotic. It was also thought that you had a urinary tract infection, given your report of discomfort with urination, but with your concurrent yeast infection, it was decided to treat that, and your symptoms improved. Your diarrhea was still occurring on the day of discharge, but it was significantly improved from your arrival. Unfortunately, your oxygen levels remained low despite our initial treatment. A picture of your heart was normal. We obtained a CT scan of your lungs, which was concerning was for a widespread lung infection or a medication-related insult to your lungs, possibly related to the treatment of your previous urinary tract infection. You were seen by our Pulmonology Fellow, who recommended that we use a scope to look inside your lungs and obtain fluid for analysis (bronchoscopy). While many of the results of this study have not yet returned, it was determined that you were positive for influenza and you were started on an antiviral medication called oseltamivir. Additionally, we decided to treat you with a full course of antibiotics in case you had a pneumonia that had only partially resolved. Throughout this time, your breathing was slowly improving, and you did not require extra oxygen for the last few days of your admission. You will follow up with Pulmonology as an outpatient. Thank you for allowing us to take part in your care. ___ MDs Followup Instructions: ___

10038141-DS-21

DS

2170-10-30 00:00:00

2170-10-31 14:06:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: alendronate sodium Attending: ___. Chief Complaint: Disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ yo woman with medical history of HTN, GERD, and recent personality changes presenting to the ED sent from her assisted living facility with ___ weeks of disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Per discussion with her son she has been in ___ ___ with subtle cognitive decline. She had been doing well there until the end of ___, however he reports in the last ___ weeks she has shown significant personality changes including disinhibition, aggression (yelling/hitting staff), and becoming very confrontational which is out of her character. He also complains she has developed gait instability, initially requiring a walker and much worse in the last week to the point that she is unable to stand on her own and has been requiring a wheelchair to get around. She also has large volume urinary incontinence during the same period which is new for her. Per her PCP ___ (___) she was initially evaluated in ___. At the time she was having mild psychiatric issues which she describes as hallucinations and flight of ideas. She was started on Seroquel bid with significant improvement. At the time she was described as "verbose but appropriate". She was seen again by Dr. ___ ___ weeks ago for evaluation of falls up to three times per day. She was also acting inappropriately disrobing herself in her living facility. At the time the case was discussed with a neurologist at ___ which thought she may have "frontal lobe syndrome". MRI/MRA was performed which per report showed lacunar infarcts, moderate atrophy, and small vessel ischemic disease. At some point during the last ___ weeks he was admitted to a psych facility and started on Zoloft, Remeron, and Seroquel. Her son reports she takes Ativan 1mg TID for many decades for anxiety. On arrival to the ED she was agitated requiring lorazepam 2mg PO total, Seroquel 25mg PO x1, and home Depakote 125 mg. Psychiatry evaluated and confirmed ___. Recommended Thiamine supplementation due to concerns for Wernike's. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Reports bladder incontinence. Firmly denies difficulty with gait. On general review of systems, the patient denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Past Medical History: HTN GERD LT radial fracture with hardware in place Recently seen by neurologist at ___ w/"frontal lobe syndrome" Per psych note: "No psych history prior ___ who is sent via ___ from her assisted living facility for significantly worsening aggression, impulsivity, and gait disturbance over the last two months". Social History: ___ Family History: Mother: died of possible MI at ___ yo Dad: died at age ___ of unknown causes Son: Healthy Physical ___: ============== ADMISSION EXAM ============== Vitals: 98.1 74 137/81 16 99% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3. Able to relate history with difficulty as rationalizes her gait issues by saying her socks are sticky, her shoes were tight, or her toenails were too long. Inattentive, unable to name ___ backwards as she writes them down FWD and then reads them in BW order. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech bizarre as describes formed hallucinations ("when I close my eyes I see a bunny"). Mood is labile. Able to follow both midline and appendicular commands. Cranial Nerves: PERRL 4-3mm brisk. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. Motor - Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 4+ 5 5 5 5 5 R 5 ___ ___ 4+ 5 5 5 5 5 - Sensory - No deficits to light touch, but patient would not allow us to touch her feet any further to assess for proprioception -DTRs: Bi Tri ___ Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 Plantar response upgoing bilaterally. Unable to test for jaw jerk due to poor cooperation. Coordination: No dysmetria with finger to nose testing bilaterally. Gait testing attempted but patient with broad base stance and significant retropulsion, unable to stand unassisted. ============== DISCHARGE EXAM ============== Essentially unchanged. -VS: T:98.___.5 BP: 145-153/79-84 HR: ___ RR: 18 O2: 97% RA -GEN: Awake in bed, NAD -HEENT: NC/AT -NECK: Supple -CV: warm, well perfused -PULM: normal inspiratory effort -ABD: Soft, NT/ND. -EXT: No clubbing, cyanosis, or edema. -MS: Alert, oriented x3. Verbally combative throughout exam. Unable to perform luria sequence. States MOYF and MOYB. ___ recall ___ with categories. Spontaneously repeated the 3 words correctly ~10 minutes later. Naming intact. Repetition and comprehension intact. Able to read and write. Follows commands, but perseverates on prior task. -CN: PERRL ___. Limited upgaze, otherwise EOMI. Face symmetric. Tongue midline. Intact sensation in V1-V3. -Motor: Mildly increased tone. Postural tremor L>R. ___ bilateral delt/bic/tri, 4+ IP b/l, giveway weakness bilateral quad/ham, ___ bilateral TA/Gas -DTR: R toe down. L toe mute. (+)palmar-mental reflex R>L, (-) glabellar reflex. (+) jaw jerk Bi Tri ___ Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 -Sensory: Intact to light touch throughout. -Coordination: Intact finger to nose, mild postural tremor bilaterally. Finger tapping more clumsy on L. -Gait: Requires assistance to sit at the edge of bed, retropulses when attempts to stand. Requires two-person assist to stand upright. Pertinent Results: ==== LABS ==== ___ 06:24PM BLOOD WBC-10.8* RBC-4.64 Hgb-12.9 Hct-41.1 MCV-89 MCH-27.8 MCHC-31.4* RDW-14.3 RDWSD-46.1 Plt ___ ___ 06:24PM BLOOD Neuts-74.9* Lymphs-14.7* Monos-6.5 Eos-3.0 Baso-0.4 Im ___ AbsNeut-8.13* AbsLymp-1.59 AbsMono-0.71 AbsEos-0.32 AbsBaso-0.04 ___ 05:00AM BLOOD WBC-8.2 RBC-4.39 Hgb-12.3 Hct-39.7 MCV-90 MCH-28.0 MCHC-31.0* RDW-14.3 RDWSD-47.6* Plt ___ ___ 05:00AM BLOOD ___ PTT-31.7 ___ ___ 06:24PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-140 K-3.7 Cl-101 HCO3-25 AnGap-18 ___ 05:00AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-143 K-3.8 Cl-104 HCO3-28 AnGap-15 ___ 06:24PM BLOOD ALT-8 AST-13 AlkPhos-114* TotBili-0.3 ___ 05:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1 ___ 05:00AM BLOOD VitB12-580 Folate-10 ___ 05:00AM BLOOD TSH-1.0 ___ 06:24PM BLOOD Valproa-23* ___ 06:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:22AM URINE Color-Straw Appear-Hazy Sp ___ ___ 12:22AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG - CSF ___ 04:07PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-94* Polys-5 ___ Monos-24 Eos-1 TotProt-55* Glucose-54 FLUID CULTURE-PRELIMINARY; ACID FAST CULTURE-PRELIMINARY NEG - Micro SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING URINE CULTURE-NEGATIVE ======= IMAGING ======= - ___ CT Head 1. No evidence of acute intracranial abnormalities. Specifically, no evidence for normal pressure hydrocephalus. 2. Age related global atrophy and chronic microangiopathy. 3. Mild left sphenoid sinus disease. Brief Hospital Course: Ms. ___ is a ___ yo woman with medical history of HTN, GERD, and progressive personality changes presenting to the ED sent from her assisted living facility with ___ weeks of worsening disinhibited conduct, worsening gait, and large volume urinary incontinence, diagnosed with Fronto-Temporal Dementia. Neurologic exam is limited by labile mood but notable for numerous frontal signs including inattention, disinhibition, inability to perform Luria sequence, brisk but symmetric reflexes, and significant retropulsion with attempted gait assessment. NCHCT with evidence of atrophy (especially frontally) and small vessel ischemic disease. History, exam, and imaging most consistent with fronto-temporal dementia, likely exacerbated by chronic vascular dementia. CSF studies were normal and showed no evidence of infection or inflammatory process. Opening pressure was slightly elevated at 21cm, however this done in ___ with the patient supine rather in flexed lateral position and likely represents false elevation. Suspicion was low for NPH. She is medically cleared for discharge. Studies for Lyme and syphilis are pending, but these are sufficiently unlikely given the overall clinical presentation that their pending status should not be a barrier to discharge to an appropriate care facility. She was evaluated by psychiatry who assessed the determined her to meet ___ for inability to care for self in the community, absence of insight into her care needs or presentation, and that she would benefit from an admission to a ___ facility (see note from Dr. ___, ___. # Dementia: Likely frontotemporal dementia. - Continue divalproex ___ TID. Consider increasing if LFTs stable. - Stop memantine. - Continue quetiapine 25mg QHS PRN. - Continue lorazepam taper to discontinuation. Currently 0.5mg BID (home 1mg TID). Contributing to disinhibition. CV: # Hypertension: - Continue atenolol 25mg BID. Consider resumption of home 50mg dose, or switch to agent with more CNS effects, such as propranolol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Sertraline 50 mg PO DAILY 3. QUEtiapine Fumarate 25 mg PO BID 4. Atenolol 50 mg PO BID 5. Divalproex (DELayed Release) 125 mg PO TID 6. Mirtazapine 7.5 mg PO QHS 7. LORazepam 1 mg PO TID 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 100 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Divalproex Sod. Sprinkles 125 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC BID 5. Senna 17.2 mg PO HS 6. Thiamine 100 mg PO DAILY 7. Atenolol 25 mg PO BID 8. LORazepam 0.5 mg PO BID 9. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation 10. Cyanocobalamin 100 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Sertraline 50 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Frontotemporal Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___, You were admitted for symptoms of disinhibited conduct, including physical aggression, and worsening gait. Upon evaluation, you did not have evidence for any infectious, inflammatory, or other treatable cause for these symptoms. You showed neuropsychiatric signs consistent with a form of dementia that initially affects executive function (inhibition and planning). You will be referred to a care facility that specializes in this and similar conditions, and they will be best able to care for you. We made the following changes to your medications: - Weaning your Ativan (lorazepam). This worsens cognitive function and disinhibition. - STOP Remeron (mirtazapine). As it did not be appear to be having any effect and in order to simplify your medication regimen. - REDUCE Seroquel (quetiapine) from 25mg TWICE PER DAY to 25mg AT NIGHT IF NEEDED. This medicine is for agitation - which was not prominent during your stay - and can be used for now only when needed, in order to avoid excessive sedation. Thank you, Your ___ Neurology Team Followup Instructions: ___

10038332-DS-22

DS

2172-11-24 00:00:00

2172-11-24 15:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: CC: ___, Wound Eval Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with h/o T10 paraplegia and recurrent UTIs, who presents via own wheelchair to the ___ ED with multiple concerns including "bed sores", new UTI and fever, as well as wanting detox from heroin. On review of the record, the patient was last seen in clinic by Dr. ___ on ___, at which time he was sober and being followed by ___ (___) ___. He was subsequently seen in the BID ED on ___ for recurrent UTI, discharged with cipro (despite cultures showing resistance to this). He appears to have most recently contacted his PCP ___ ___ with recurrent UTI Sx, was prescribed 9d of fosfomycin. Of note, discharged ___ on 6 wks of fosfomycin for E. coli prostatitis with resistance to ampicillin/Augmentin, ciprofloxacin, TMP-SMX, but susceptible to cephalosporins, had single follow-up visit with ID in early ___. His most recent positive urine culture was from ___, once again showed E. coli, with similar resistance pattern and additional resistance to gentamicin. In terms of his opioid use disorder, patient reports he has been to multiple detox facilities as well has had outpatient services. He was previously on suboxone, last 2 months ago at which time he relapsed. He has intermittently relapsed and has been discharged from multiple facilities due to inability to keep appointments. He feels depressed with ___ when he relapses, which is what prompted him to come to the ED during this time. He is motivated to stay sober this time around. In the ED, initial VS were: 6 98.4 111 147/90 18 98% RA Exam notable for: paraplegia, abdomen soft, stage 1 sacral ulcers, bilateral EKG: Not visible on Dash Labs showed: CBC 8.0 > 13.7 / 40.9 < 296, MCV: 89, N:60.2% BMP: K+ 4.2, BUN/Cr ___, Gluc 153 UA: ___, SG 1.030, Leuk Lg, Prot 30, Glu 150, Ket Tr, WBC > 182, Bact Few, Epi 2 Tox Serum Negative - ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Urine Positive - Cocaine Urine Negative - Benzos, Barbs, Opiates, Amphet, Mthdne, Oxycodone Imaging showed: CXR ___ FINDINGS: The lungs are hyperexpanded expanded but clear. There is no pleural abnormality the heart size is within normal limits. The mediastinal and hilar contours unremarkable. Calcific density projecting over the lower thoracic vertebra are unchanged in configuration. Consults: Psychiatry: "No s12, will contact BEST to look for EATS (dual-diagnosis unlocked unit), if patient attempting to leave prior to placement, please call psych for re-eval. For opioid withdrawal, would recommend: - Clonidine 0.1mg BID (hold for SBP <100, HR <55, or orthostatic changes) - Robaxin 750mg Q6H PRN muscle pain/cramps - Bentyl 20mg PO Q4H PRN GI cramps - Vistaril 50mg IM/PO Q4H PRN anxiety - Kaopectate 30 mL PO PRN after each loose stool - Acetaminophen 650mg Q6H PRN pain Page ___ with questions." Patient received: - Ceftriaxone 1gm IV x2 - NS 1L x1 Transfer VS were: 98.4 77 138/78 18 100% RA On arrival to the floor, patient reports feeling well. Endorses story above. He reports he was supposed to have an appointment with his PCP today but went to the ED due to symptoms of dysuria and urinary frequency for the past 2 days despite taking fosfomycin as well as wanting to be placed in a facility to detox. He was also concerned that he possibly may have pyelonephritis as he has had this previously and persistent pain in his L buttock where he has a pressure ulcer. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad ___ training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on ___ who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ but was found with cocaine in his urine on this admission in ___. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS: 98.3 PO 132 / 82 R Sitting 70 20 94 RA GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly EXTREMITIES: ___ muscle wasting NEURO: A&Ox3, ___ strength in UE bilaterally, intact rectal tone GU: No prostate tenderness on DRE SKIN: warm and well perfused, stage 1 pressure ulcer on the L buttock DISCHARGE PHYSICAL EXAM: VS: ___ 0710 Temp: 98.5 PO BP: 119/52 L HR: 90 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly EXTREMITIES: ___ muscle wasting NEURO: A&Ox3, ___ strength in UE bilaterally, intact rectal tone SKIN: warm and well perfused Pertinent Results: ADMISSION LABS ___ 01:59AM WBC-8.0 RBC-4.59* HGB-13.7 HCT-40.9 MCV-89 MCH-29.8 MCHC-33.5 RDW-11.8 RDWSD-38.1 ___ 01:59AM NEUTS-60.2 ___ MONOS-12.3 EOS-2.0 BASOS-0.5 IM ___ AbsNeut-4.79 AbsLymp-1.97 AbsMono-0.98* AbsEos-0.16 AbsBaso-0.04 ___ 01:59AM PLT COUNT-296 ___ 01:35AM URINE HOURS-RANDOM ___ 01:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 01:35AM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-150* KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG* ___ 01:35AM URINE RBC-0 WBC->182* BACTERIA-FEW* YEAST-NONE EPI-2 ___ 01:35AM URINE MUCOUS-FEW* ___ 12:40AM GLUCOSE-153* UREA N-14 CREAT-1.0 SODIUM-140 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12 ___ 12:40AM estGFR-Using this ___ 12:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG IMAGING: CXR ___ IMPRESSION: No focal consolidation. No evidence of pneumonia. CT A/P ___ IMPRESSION: 1. 2.2 x 1 cm oval-shaped hypodensity in the right posterolateral prostatic apex is similar in appearance to prior MRI from ___ and may represent a chronic abscess or phlegmon. Consider pelvic MRI for further evaluation. 2. No CT evidence of pyelonephritis or renal abscess. 3. Diffuse fecal loading throughout the large bowel. MRI ___ IMPRESSION: 1. No prostatic abscess or phlegmon. Specifically, abnormality noted on CT from ___ within right peripheral zone corresponds to normal prostatic parenchyma. 2. Evidence of prior prostatitis within left peripheral zone. 3. Chronic bilateral sacral decubitus ulcers. Of note, study is not dedicated for evaluation of osteomyelitis and the findings are markedly improved compared to prior MR. ___: **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. STAPHYLOCOCCUS SAPROPHYTICUS, PRESUMPTIVE IDENTIFICATION. 10,000-100,000 CFU/mL. Routine susceptibility testing of urine isolates of S. saprophyticus is not advised because infections respond to concentrations achieved in urine of antimicrobial agents commonly used to treat acute uncomplicated urinary infections (e.g., nitrofurantoin, trimethoprim, trimethoprim sulfamethoxazole or a fluoroquinolone).. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS: ___ 06:20AM BLOOD WBC-8.3 RBC-4.01* Hgb-12.0* Hct-38.0* MCV-95 MCH-29.9 MCHC-31.6* RDW-12.6 RDWSD-43.5 Plt ___ ___ 06:20AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-143 K-4.5 Cl-102 HCO3-27 AnGap-14 ___ 06:20AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old man with paraplegia as a result of a GSW, neurogenic bladder with chronic intermittent straight caths, with recurrent UTIs with various organisms, now on chronic suppressive methenamine presenting with urinary tract infection, passive ___, and opioid withdrawal symptoms. ACUTE ISSUES: ============= # Opioid withdrawal, detox # History of polysubstance abuse # Passive ___ Serum and urine tox screens on admission only positive for cocaine. As per prior records, enrolled in multiple detox programs previously but discharged due to inconsistent medication use and lost to follow-up. Evaluated by psych given passive ___ on presentation but not sectionable on their evaluation. Recommended BEST screening for placement vs. CCS, dual diagnosis unit. Unable to successfully place this patient in above during the hospitalization. HIV/HCV checked for risk stratification and returned negative. Initiated on suboxone while inpatient as patient was having mild withdrawal symptoms not controlled with other medications with improvement. Plan to follow-up with Dr. ___ from psychiatry for suboxone. # UTI w/ history of drug-resistant E. Coli # History of prostatitis Symtpoms and UA consistent with UTI, started on IV ceftriaxone. On prophylactic methenamine hippurate on admission though from prior ID notes likely not providing much benefit as urine pH on testing has been too high to activate the drug. Urine culture growing cephalosporin/fluoroquinoline sensitive enterobacter. CT A/P obtained to r/o chronic abscess vs. phlegmon, though no signs of this on pelvic MRI. Transitioned from IV ceftriaxone to PO ciprofloxacin on discharge. Plan for 2 week course for early seeding of the prostate (end date ___. On discharge, for UTI ppx, ID recommended 3g fosfomycin PO q10 days rather than methanamine. CHRONIC ISSUES: =============== # Neurogenic bladder: Continued xxybutynin 10 mg PO BID (takes ER 20 mg daily at home), Tamsulosin 0.4 mg PO QHS with intermittent straight caths. # Chronic constipation: Continue bowel regimen PRN # history of ?bipolar vs schizophrenia - not currently taking any medications. # chronic low back pain: Continued Gabapentin 800 mg PO TID, Acetaminophen 650 mg PO Q8H:PRN Pain - Mild TRANSTIONAL ISSUES =================== - Last date of ciprofloxacin ___. - Start fosfomycin 3g PO q10 days on ___ - ID, PCP, and psychiatry for suboxone follow-up as above. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gabapentin 800 mg PO TID 2. Tamsulosin 0.4 mg PO QHS 3. Ascorbic Acid ___ mg PO BID 4. methenamine hippurate 1 gram oral BID 5. oxybutynin chloride 20 mg oral DAILY Discharge Medications: 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 3. Docusate Sodium 200 mg PO BID:PRN constipation RX *docusate sodium 100 mg 2 tablet(s) by mouth BID:PRN Disp #*60 Tablet Refills:*0 4. Fosfomycin Tromethamine 3 g PO Q10DAYS UTI prophylaxis Dissolve in ___ oz (90-120 mL) water and take immediately RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth Q10days Disp #*3 Packet Refills:*0 5. Polyethylene Glycol 17 g PO TID:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth TID:PRN Disp #*24 Packet Refills:*0 6. Senna 17.2 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 2 tablets by mouth BID:PRN Disp #*60 Tablet Refills:*0 7. Gabapentin 800 mg PO TID RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 8. oxybutynin chloride 20 mg oral DAILY RX *oxybutynin chloride 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 9. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Complicated urinary tract infection Opioid dependence with withdrawal 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. ___, You were admitted to ___ for a urinary tract infection. We started you on intravenous antibiotics. We did imaging to make sure that you did not have an abscess of your prostate. We transitioned you to an oral antibiotic that you will take until ___. You also started experiencing withdrawal symptoms while here. We started you on suboxone and arranged for you to follow up with Dr. ___ for this. It was a pleasure caring for you. Wishing you the best, Your ___ Team Followup Instructions: ___

10038332-DS-23

DS

2173-08-11 00:00:00

2173-08-11 15:24:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with PMH of history of unspecified psychotic disorder (bipolar vs schizophrenia) and significant cocaine and opioid use disorders (sober >9 mo), prostatic abscess, and T10 paraplegia ___ GSW in ___ with neurogenic bladder resulting in recurrent UTIs who presents today with flank pain and foul smelling urine. The symptoms started a week ago but have worsened over the past 2 days, prompting him to present to the ED. Over the past week the patient noticed a foul odor in his urine with purulent discharge and bilateral flank pain. These symptoms felt similar to his prior kidney infections. He describes subjective fevers and chills, neck pain, and joint pains in the small joints of his hands. He has had chronic mild abdominal tenderness that initially improved after having a bowel movement yesterday but worsened somewhat today. He is taking all his medications as prescribed but forgot to take fosfomycin over the past 2 weeks and feels this may have triggered a UTI. Of note, pt was seen in ___ clinic in ___. He had been performing straight catheterization every few hours and has noted improvement over the past several months with weekly fosfomycin therapy as the frequencies of infections has decreased. However, earlier that month he had sign/symptoms of a UTI for which he was prescribed ciprofloxacin and treated with 7 days. ROS: He denies any URI symptoms, n/v, dysuria, chest pain, dyspnea, palpitations, headache, or paresthesias. He states that he feels like is developing an ulcer in his left buttock area as well. Has had bilateral blurry vision since starting Zoloft 2 weeks ago, which prompted him to discontinue the medication. ED COURSE: Exam: NAD b/l flank pain, normal mentation, wheelchair bound Labs notable for WBC 8, UA pos for nitrites and leuks with >182 WBC and bacteria. Pt received iL NS and 1g CTX at 10:45 pm. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad ___ training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on ___ who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ but was found with cocaine in his urine on this admission in ___. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: GENERAL: Pleasant gentleman in hospital bed, in no apparent distress. EYES: PERRL, EOMI, anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No murmur. No JVD. PULM: Breathing comfortably on room air. A few bibasilar crackles on chest exam. Good air movement bilaterally. GI: Bowel sounds present. Abdomen non-distended, soft, non-tender to palpation. No HSM appreciated. GU: No flank tenderness to palpation. No suprapubic fullness or tenderness to palpation. EXT: No lower extremity edema, distal extremity pulses palpable throughout. SKIN: Bilateral well healing ulcers over ischial spines, intact skin and covered. NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, bilateral lower extremities without movement (baseline) and 50% sensation. PSYCH: Pleasant, appropriate affect. Pertinent Results: RECENT LABS, MICRO, STUDIES: ___ 06:42AM BLOOD WBC-6.2 RBC-4.15* Hgb-12.0* Hct-38.4* MCV-93 MCH-28.9 MCHC-31.3* RDW-12.4 RDWSD-41.9 Plt ___ ___ 06:42AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-142 K-4.8 Cl-100 HCO3-29 AnGap-13 ___ 06:42AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0 ___ UA: hazy, +nit, 30 prot, LG leuk, 4 RBC, >182 WBC, many bacteria, 2 epithelial cells ___ 6:15 pm URINE CULTURE URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Ertapenem AND Fosfomycin Susceptibility testing requested per ___ ___ (___) ___. Ertapenem = SENSITIVE. Fosfomycin = SENSITIVE. ______________________________ ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Mr. ___ is a ___ employee of ___ with T10 paraplegia s/p gunshot wound, neurogenic bladder (chronic self-caths) living in a sober house who is admitted for pyelonephritis. His urine culture growing multidrug-resistant E.coli. Most likely got pyelonephritis in setting of non-adherence with home suppressive fosfomycin. Final sensitivities showed sensitivity to pipercillin/tazobactam, meropenem, gentamycin, ertapenem, fosfomycin. His sober house can't manage IV antibiotics so had to be discharged to a facility to complete his antibiotics course. After initially started on ceftriaxone, when sensitivities he was switched to pip/tazo ___, per ID's suggestion; on discharge he was switched to ertapenem to complete a 7-day course (last day: ___. He was instructed to restart his home fosfomycin when he completes his IV antibiotics. While in the hospital his discomfort was treated with phenazopyridine (for dysuria), and his Suboxone was increased from daily to BID; he was discharged back on his home daily dosing. He was continued on his home dose of gabapentin for neuropathic pain. During the hospitalization his non-formulary Vyvanse for ADHD was held, and restarted at discharge. His home venlafaxine was continued. ___ PMP was checked and was appropriate. He had constipation while in the hospital, treated with miralax, senna, docusate, and prn lactulose. He was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self-catheterization. He had constipation while in the hospital, treated with miralax, senna, docusate, and prn lactulose. He was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self-catheterization. He also complained of neck pain and hand tingling and weakness, so MR of the c/s was done and showed djd at mult levels with cord contact and remodeling of cord without cord signal abnormality; neurosurgery was consulted and recommended that he follow up as an outpatient, no need for surgery or intervention at this time Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5. Oxybutynin XL (*NF*) 20 mg Other DAILY 6. Tamsulosin 0.4 mg PO BID:PRN urinary retention 7. alprostadil 20 mcg injection DAILY:PRN 8. Multivitamins 1 TAB PO DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 10. Naloxone Nasal Spray 4 mg IH ASDIR 11. Venlafaxine XR 75 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose give on ___ and ___, last day ___. Fosfomycin Tromethamine 3 g PO 3 G EVERY 7 DAYS Dissolve in ___ oz (90-120 mL) water and take immediately 3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 4. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. alprostadil 20 mcg injection DAILY:PRN 7. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 8. Gabapentin 800 mg PO TID 9. Multivitamins 1 TAB PO DAILY 10. Naloxone Nasal Spray 4 mg IH ASDIR 11. Oxybutynin XL (*NF*) 20 mg Other DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Tamsulosin 0.4 mg PO BID:PRN urinary retention 14. Venlafaxine XR 75 mg PO DAILY 15. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pyelonephritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Wheelchair/Bedbound (patient is paraplegic). Discharge Instructions: You were admitted for a kidney infection (pyelonephritis), probably related to not taking your fosfomycin. We treated you with fluids and antibiotics. Your infection is resistant to many antibiotics, requiring treatment with IV antibiotics instead of oral ones. You are being discharged to complete your IV antibiotics at a facility. Afterward, please restart your fosfomycin to help prevent future infections like this. Followup Instructions: ___

10038999-DS-10

DS

2132-05-23 00:00:00

2132-05-23 12:08:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Valium Attending: ___. Chief Complaint: right ankle pain Major Surgical or Invasive Procedure: right tibial intramedullary nail History of Present Illness: ___ hx of developmental mental delay, seizure disorder, and blindness resides at a group home and while at day care had a witnessed fall. No head strike per staff. Refused to bear weight to right lower extremity. Significant swelling and tenderness to right lower extremity, outside hospital images showed right ankle fracture, transferred to ___ for higher level care. Past Medical History: Blindness Mental delay Seizure disorder Social History: ___ Family History: Unknown Physical Exam: Exam on discharge: VS: Consistently tachycardic, oAVSS General: Unlabored breathing on RA RLE: -Leg in aircast boot, wrapped in ACE bandage -> dressing changed today, incisions clean/dry/intact, staples in place -Exam limited by patient cooperation: wiggles toes, attempts to dorsi/plantarflex ankle, sensation intact over dorsum and plantar aspects of forefoot as testable, -Foot warm and well perfused No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended Incision clean/dry/intact with no erythema or discharge, minimal ecchymosis Splint in place, clean, dry, and intact Aircast boot in place Right lower extremity - leg in aircast boot, ACE dressing clean/dry/intact, intact toe flexion/extension, no pain with toe range of motion, sensation intact over dorsum and plantar aspects of forefoot as testable, foot warm and well perfused Pertinent Results: ___ 01:00PM BLOOD WBC-7.7 RBC-4.59* Hgb-11.4* Hct-36.7* MCV-80* MCH-24.8* MCHC-31.1* RDW-15.0 RDWSD-43.6 Plt ___ ___ 11:50PM BLOOD Glucose-108* UreaN-20 Creat-0.7 Na-141 K-4.2 Cl-101 ___ AnGap-17* Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right tibial and right fibular fractures and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for a right tibial intramedullary nail, 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 his rehab 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 partial weight-bearing in an aircast boot in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient and his caretakers 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 and his caretakers were also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient and his caretakers expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 30 mg PO QHS 2. QUEtiapine Fumarate 150 mg PO QAM 3. QUEtiapine Fumarate 300 mg PO QHS 4. TraZODone 100 mg PO QHS 5. TraZODone 50 mg PO QAM 6. Divalproex (DELayed Release) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO DAILY 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain Do not drive while taking narcotics. Hold RR<12. RX *oxycodone 5 mg 1 tablet by mouth every six (6) hours Disp #*15 Tablet Refills:*0 5. Citalopram 30 mg PO QHS 6. Divalproex (DELayed Release) 500 mg PO BID 7. QUEtiapine Fumarate 150 mg PO QAM 8. QUEtiapine Fumarate 300 mg PO QHS 9. TraZODone 50 mg PO QAM 10. TraZODone 100 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right tibia fracture and right fibula fracture 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: 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: - partial weight-bearing right lower extremity in aircast boot 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 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. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Aircast boot must be left on until follow up appointment unless otherwise instructed 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 FOLLOW UP: Please follow up with Dr. ___ in the ___ Trauma Clinic ___ days post-operation for evaluation. Please call ___ to schedule appointment. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: partial weight-bearing right lower extremity in aircast boot Treatments Frequency: -dressing change as needed -staples remain until follow up visit Followup Instructions: ___

10038999-DS-9

DS

2131-06-04 00:00:00

2131-06-04 20:11:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: abdominal pain, found to have pericardial effusion Major Surgical or Invasive Procedure: pericardiocentesis intubation bronchoscopy History of Present Illness: This is a ___ yoM with a PMH significant for developmental mental delay, seizure disorder, and blindness who is being admitted to the CCU following pericardial drainage for a moderate to large pericardial effusion. He lives ___ a group home and he has been complaining of abdominal pain for about a week. He went to his PCP ___ ___, who was unable to examine him due to agitation. He then went to ___ ED on ___ with the same complaints and his vitals at the time were Afebrile, HR 110s-120s, SBP 130s, 91% RA. He was acutely agitated and required Haldol 5 mg IM, Haldol 5 mg IV, Ativan 2 mg IM, and dilaudid 0.5 mg IV. He then got a CT abdomen to evaluate his abdominal pain and it showed a moderate to large pericardial effusion, small bilateral pleural effusions, and no significant intra-abdominal process. He then received a bedside echocardiogram that showed RV collapse, he was given 2 L NS, and he was transferred to BID ED. ___ the ED here, his BP was 143/104, HR 128, RR 24, and 93% room air. Labs significant for wbc 10.8 (72% poly, 14% lymph), hgb 9.2, INR 1.3, K 5.7, Cr 0.8. An echocardiogram ___ the ED showed the IVC was non-collapsible, but the RA was not invaginating with diastole. EKG showed NSR, tachycardia, with PR depression ___ I/II, elevation ___ AVR, decreased voltages, no electrical alternans. He was acutely agitated and required intubation (fentanyl, versed). He was then taken to the cath lab to have a pericardial drain placed, but prior to the procedure his pulse was nonpalpable with a dropping BP, and he required 20 seconds of chest compressions with ROSC. He then received a pericardial drain without complications and ~400 mL of bloody fluid was drained. He only received about 300 mL of IVF ___ the cath lab. On arrival to the CCU: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He is on fentanyl and versed gtt. Past Medical History: Blindness Mental delay Seizure disorder Social History: ___ Family History: Unknown Physical Exam: ADMISSION: ========== Vitals: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He is on fentanyl and versed gtt. GENERAL: Intubated and sedated, ET tube ___ place HEENT: Normocephalic atraumatic. NECK: Supple. No appreciable JVP, but difficult to tell. CARDIAC: Tachycardia, normal S1, S2, no m,r,g LUNGS: Mechanical breath sounds bilaterally, no appreciable rales ABDOMEN: Distended, but soft without masses EXTREMITIES: Cool arms, non-pitting edema ___ bilateral lower extremities up to mid tibia. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ACCESS: Left AC 18 and right AC 20. DISCHARGE: ========== Pertinent physical: GENERAL: NAD, awake HEENT: Normocephalic atraumatic. NECK: Supple. No appreciable JVP, but difficult to tell. CARDIAC: Tachycardia, normal S1, S2, no m,r,g LUNGS: Slight rales bilateral bases, poor effort ABDOMEN: Distended, but soft without masses, NTTP EXTREMITIES: No pedal edema SKIN: Rashes from EKG leads on chest. PULSES: Distal pulses palpable and symmetric. ACCESS: None Pertinent Results: ADMISSION LABS: =============== ___ 09:00PM BLOOD WBC-10.8* RBC-3.66* Hgb-9.2* Hct-30.0* MCV-82 MCH-25.1* MCHC-30.7* RDW-15.2 RDWSD-45.4 Plt ___ ___ 09:00PM BLOOD Neuts-72.4* Lymphs-14.9* Monos-11.5 Eos-0.3* Baso-0.3 Im ___ AbsNeut-7.84* AbsLymp-1.61 AbsMono-1.25* AbsEos-0.03* AbsBaso-0.03 ___ 09:00PM BLOOD Plt ___ ___ 09:00PM BLOOD ___ PTT-27.7 ___ ___ 09:00PM BLOOD Glucose-123* UreaN-17 Creat-0.8 Na-136 K-5.7* Cl-102 HCO3-22 AnGap-18 ___ 10:45PM BLOOD CK(CPK)-258 ___ 04:54AM BLOOD ALT-54* AST-27 AlkPhos-95 TotBili-0.5 ___ 09:00PM BLOOD cTropnT-<0.01 ___ 10:45PM BLOOD Calcium-7.8* Phos-4.3 Mg-2.2 ___ 10:45PM BLOOD TSH-7.4* ___ 09:11PM BLOOD ___ pO2-47* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 Intubat-INTUBATED Comment-PERIPHERAL ___ 09:11PM BLOOD Lactate-2.1* ___ 09:11PM BLOOD O2 Sat-77 ___ 11:55PM BLOOD freeCa-1.02* ___ 09:59PM BLOOD SED RATE-Test ___ CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID DIAGNOSIS: PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. OTHER PERTINENT LABS: ===================== ___ 06:29PM BLOOD WBC-11.5* RBC-3.92* Hgb-9.8* Hct-31.1* MCV-79* MCH-25.0* MCHC-31.5* RDW-15.1 RDWSD-43.6 Plt ___ ___ 05:08AM BLOOD WBC-9.3 RBC-3.47* Hgb-8.6* Hct-27.9* MCV-80* MCH-24.8* MCHC-30.8* RDW-14.9 RDWSD-43.6 Plt ___ ___ 04:54AM BLOOD Glucose-64* UreaN-15 Creat-0.8 Na-139 K-4.3 Cl-99 HCO3-26 AnGap-18 ___ 06:29PM BLOOD calTIBC-264 VitB12-683 Folate-18.9 Hapto-474* Ferritn-457* TRF-203 ___ 04:44PM BLOOD calTIBC-234* VitB12-1087* Folate->20 Ferritn-529* TRF-180* ___ 06:29PM BLOOD T4-4.5* T3-67* ___ 06:38AM BLOOD Free T4-1.1 ___ 04:44PM BLOOD Free T4-0.9* ___ 09:28AM BLOOD ANCA-NEGATIVE B ___ 06:29PM BLOOD RheuFac-15* CRP->300.0* ___ 09:59PM BLOOD ___ ___ 06:38AM BLOOD CRP-327.1* ___ 09:28AM BLOOD IgG-1087 ___ 02:56AM BLOOD C3-180 C4-27 ___ 09:28AM BLOOD HIV Ab-Negative ___ 05:21AM BLOOD Type-ART pO2-98 pCO2-51* pH-7.41 calTCO2-33* Base XS-5 Intubat-INTUBATED ___ 02:30PM BLOOD Type-ART FiO2-40 pO2-93 pCO2-57* pH-7.41 calTCO2-37* Base XS-8 ___ 12:20PM BLOOD Lactate-1.5 ___ Page 1 of 2 CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID, Collected @ 16:45 DIAGNOSIS: PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Blood only. ___ CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE DIAGNOSIS: BRONCHIAL LAVAGE: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells and pulmonary macrophages ___ a background of numerous inflammatory cells including neutrophils, histiocytes and lymphocytes. MICROBIOLOGY: ============= ___ 10:06 pm FLUID,OTHER r/o coxsackievirus (types A and B) . Enterovirus Culture (Final ___: No Enterovirus isolated. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED ___ 6:25 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: GEMELLA SPECIES. PRESUMPTIVE IDENTIFICATION. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT ___. GRAM POSITIVE COCCI ___ CLUSTERS. ___ 9:46 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 9:46 pm URINE Source: Catheter. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, ___ infected patients the excretion of antigen ___ urine may vary. ___ 9:46 pm SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. RESPIRATORY CULTURE (Final ___: HEAVY GROWTH Commensal Respiratory Flora. ___ 8:42 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 8:42 am BRONCHIAL WASHINGS BRONCHIAL WASH. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 8:42 am Rapid Respiratory Viral Screen & Culture BRONCHIAL WASH . **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 ___: Less than 60 columnar epithelial cells;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Negative results should not be used to discontinue precautions.. Recommend new sample be submitted for confirmation.. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Reported to and read back by ___ ___ ___ AT 14:44. ___ 2:30 pm Immunology (CMV) Source: Line-a. **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use ___ the ___ patient population. ___ 8:38 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Blood Cultures (___): No growth final Urine Cultures (___): No growth final IMAGING: ======== TTE ___: The left atrium is normal ___ size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is unusually small. with normal free wall contractility. There is a large pericardial effusion. The effusion appears circumferential. Stranding is visualized within the pericardial space c/w organization. The pericardium appears thickened. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Large circumferential pericardial effusion. Thickened parietal pericardium. No echocardiographic evidence of tamponade. Normal LV function. Small RV cavity size with normal function. CXR (AP Portable) ___: IMPRESSION: Evidence for bilateral pleural effusions and consolidation or atelectasis ___ the left lower lobe. Prominent cardiac silhouette. TTE ___: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is significantly depressed. The apical The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. There is a small-moderate sized pericardial effusion ___ the apical views the fluid is all echodense and there does appear to be tagging of the RV wall to the pericardium raising question of constriction. ___ those views the effusion is small, all < 1.0cm, and the fluid is echodense. The subcostal windows are quite limited, but the posterolateral pocket may be a little bigger there measuring up to 1.3cm. It is hard to make out whether any of that fluid is simple, but I suspect it is also echodense like the rest of the pericardial fluid. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate sized echodense circumferential pericardial effusion. Pleural effusion. No 2D echo evidence of tamponade. Depressed global right ventricular systolic function. The images and the report from ___ are not available for review CTA Chest ___: IMPRESSION: 1. No evidence of pulmonary embolism within limitations of the study limited by patient motion. 2. There is a large nonhemorrhagic pericardial effusion with pericardial drain ___ place. There is associated leftward interventricular septal bowing and contrast reflux into the hepatic veins suggestive of right ventricular strain. 3. Bilateral nonhemorrhagic pleural effusions are larger compared to ___. 4. Bilateral compressive atelectasis with collapse of the left lower lobe and posterior basal segment of the right lower lobe. There is also linear atelectasis ___ the left upper lobe. CXR (AP Portable) ___: IMPRESSION: 1. Central pulmonary vascular congestion with new mild edema since the ___ examination. 2. The lung volumes remain low. Unchanged pleural effusions and bibasilar atelectasis. CT Chest w/ Contrast ___: IMPRESSION: Decrease ___ size of pericardial effusion. Extensive mediastinal lymphadenopathy is unchanged, the lymph nodes are borderline, likely reactive. Large bilateral layering pleural effusions associated with adjacent atelectasis are stable. No definitive new lung abnormalities are detected. TTE ___: Left ventricular wall thicknesses are normal. 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. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. However, ___ the presence of a non-free-flowing pericardial effusion, these signs may be absent despite impairment of right ventricular filling. Compared with the prior study (images reviewed) of ___ the pericardial effusion is larger. TTE ___: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is a small to moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. However, there is significant, accentuated respiratory variation ___ mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of ___ the effusion appears smaller. CXR ___: IMPRESSION: Compared to chest radiographs ___ through ___. Previous pulmonary vascular congestion has resolved, but moderate enlargement of the cardiac silhouette remains, exaggerated by very low lung volumes. There is no mediastinal venous engorgement to suggest elevated central venous pressure. Pleural effusions are likely, but not large. No pneumothorax. DISCHARGE LABS (most recent since discharge): ============================================== ___ 11:10AM BLOOD WBC-7.0 RBC-4.24* Hgb-10.1* Hct-33.6* MCV-79* MCH-23.8* MCHC-30.1* RDW-15.3 RDWSD-43.6 Plt ___ ___ 11:10AM BLOOD ___ PTT-31.8 ___ ___ 11:10AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-138 K-4.4 Cl-101 HCO3-21* AnGap-20 ___ 11:10AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ y/o man with history of developmental delay who presented to an OSH with abdominal pain was found to have a large pericardial effusion on CT Abd/Pelvis, transferred to ___ for further management. #Pericardial effusion/Pericarditis: Patient initially presented with abdominal pain with finding of pericardial effusion as incidental finding. Unclear if symptoms are related to effusion, however, as patient with limited ability to express himself clearly due to developmental delay. He underwent pericardiocentesis with findings consistent with inflammatory/bloody output. Serial TTE post-procedure showed persistent, but much improved and stable pericardial fluid as well as possible constrictive physiology. He also had positive inflammatory markers (CRP/ESR). Extensive work-up did not reveal clear etiology with work-up negative for TB, thyroid dysfunction, malignancy, and infection intrinsic to pericardial fluid. Most likely explanation would be that patient had pneumonia (as below), triggering para-pneumonic pericarditis and effusion with subsequent heart failure as a result of effusion and possible constriction. He was diuresed intermittently with Lasix while ___ the CCU and started on colchicine therapy for planned 90 days. He was evaluated by c-surg and after discussion with patient's guardian (mother) and essential return to baseline functional status, it was decided not to pursue any invasive procedures such as pericardial stripping vs. window. After evaluation and treatment with physical therapy, he was discharged back to his home facility. #Hypervolemia: Patient had low albumin, constrictive physiology and lower extremity edema, bilateral pleural effusions, and elevated CVP on admission. This was felt to be due to acute inflammation (leading to low albumin) and effusive/constrictive physiology, treated with Lasix while ___ the ICU. He was euvolemic at discharge off any maintenance diuretics. #Pleural effusions: Given extensive work-up (detailed above), patient was noticed to have large pleural effusions likely due to para-pneumonic inflammation and volume overload. He underwent U/S guided drainage of his left-sided effusion (exudative) without clear signs of infection with ___ during this admission and improvement noted on subsequent imaging. #HCAP: Patient was admitted with fever and pulmonary infiltrates, and overall picture that was felt to be consistent with pneumonia. He was treated with course of vancomycin/cefepime/azithro as such. Unfortunately, only positive growth from BAL and cultures from multiple sources was Gamella from blood (per ID felt to be likely contaminant). His respiratory status improved to baseline at time of discharge. #Rash: During this admission, patient noted to have rash on back from b/l shoulders to top of iliac crests, diffuse erythematous plaques and papules with poorly demarcated borders covering most of back; no sloughing, vesicles or purpura, blanchable ___ nature. This was felt to be possible heat rash or possible drug effect. However, no concerning findings c/w SJS/TEN or significant eosinophilia on lab work. This self resolved with mobilization from the bed, prior to discharge. #Hypoxic respiratory failure: The patient was initially intubated and sedated prior to admission due to report of hypoxia and agitation, which would have potentially complicated pericardial drainage. He was found as above to have pneumonia, pleural effusions, pericardial effusion, and atelectasis/incomplete collapse of bilateral lower lobes. CTA chest also showed no signs of PE. He was extubated with treatment of his multiple conditions as above on ___ and quickly was weaned to room air prior to discharge. #Bradycardia: While intubated, patient had multiple episodes of bradycardia with possible junctional rhythm, never lasting more than seconds to a minute. These were all felt to be vagal ___ nature as they occurred ___ the setting of bladder scan, trach adjustment, and ventilation changes. He was monitor closely on tele without further episodes post-discharge. #Anemia: Baseline H/H 13.2-___-40. Iron studies c/w slight anemia of chronic disease. Has been low likely because of hemodilution ___ the setting of IVF. His H&H improved with supportive care. #Malnutrition: He had low albumin possibly due to acute inflammation/illness and prolonged intubation. He did receive tube feeds while intubated and was quickly restarted on regular diet prior to discharge. #Coagulopathy: INR 1.2 on admission, today 1.7. Unknown etiology. ___ malnutrition, liver dysfunction, medication induced. This was most likely due to malnutrition and vitamin K dysfunction as INR improved quickly after initiation of nutrition. #Seizures (chronic): Continued on home Depakote 500 mg BID #Developmental delay/behavioral issues (chronic): Continued during hospitalization on home Seroquel, trazodone, and celexa. TRANSITIONAL ISSUES: - Colchicine for 3 month course for possible pericarditis (Day 1 - ___ - Outpatient cards f/u ___ ___ weeks - Repeat TTE ___ ___ weeks before cardiology appointment to assess for pericardial fluid reaccumulation - Decision made not to pursue pericardial stripping vs. pericardial window placement given ability to return to baseline functional status. Can consider ___ the future if recurrent pericardial effusion -During work-up for cause of pericardial effusion, patient had negative Quantiferon Gold assay for TB CODE STATUS: FULL CODE CONTACT: ___ (mother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 300 mg PO QHS 2. Divalproex (DELayed Release) 500 mg PO BID 3. Citalopram 40 mg PO DAILY 4. QUEtiapine Fumarate 150 mg PO QAM 5. TraZODone 100 mg PO QHS 6. TraZODone 50 mg PO QAM 7. Vitamin D ___ UNIT PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 10. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID Discharge Medications: 1. Colchicine 0.6 mg PO BID Duration: 90 Days Please continue for 90 days. Day 1 = ___. RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 2. Citalopram 40 mg PO DAILY 3. Divalproex (DELayed Release) 500 mg PO BID 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 6. QUEtiapine Fumarate 150 mg PO QAM 7. QUEtiapine Fumarate 300 mg PO QHS 8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 9. TraZODone 100 mg PO QHS 10. TraZODone 50 mg PO QAM 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Pericarditis Pericardial Effusion Health Care Associated Pneumonia Pleural Effusion Hyperkalemia Hypoxic Respiratory Failure SECONDARY DIAGNOSES: Developmental Delay Seizure disorder Discharge Condition: Mental Status: Confused - sometimes. At baseline the patient is AOx1 and he has returned to baseline on discharge. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Patient is legally blind so requires assistance at baseline. Discharge Instructions: Dear Mr. ___, You came to ___ because you were having stomach pain and it was discovered that you had fluid around your heart. What was found ___ the hospital? - Your had fluid around your heart, called a pericardial effusion. - Your had fluid ___ your lungs, called a pleural effusion. - You had an infection ___ your lungs, called pneumonia. - You had high levels of potassium ___ your blood, called hyperkalemia. - You had difficulty breathing and were on a mechanical ventilator for 1 week. What was done for you ___ the hospital? - The fluid around your heart was causing problems with pumping. You went to the catheterization lab. A drain was placed to remove fluid. After two days, most of the fluid was gone and the drain was pulled out. The fluid was sent for laboratory studies to look for a cause like infection or disease, but no cause was found. We continued to monitor your heart with pictures (transthoracic echocardiograms and chest xrays). You were given oral medications to keep the combat the inflammation around your heart. The fluid did not reaccumulate and you are safe to go home with follow-up with your doctor. - Samples of the fluid ___ your lungs were taken by two methods. The first was a bronchoscopy, where a tube with a video camera was placed down your throat to look inside your lungs. The second method was a pleurocentesis, where a needle was put ___ your side and the fluid was pulled off. These samples were sent to the laboratory for studies to look for a cause. We found indicators of infection, but no specific bacterium that was likely to cause it. You had chest x-rays to watch for reaccumulation, and that did not happen. - For your infection, you were see by specialists from the infectious diseases and pulmonary divisions. You most likely had a pneumonia. You received antibiotics for several days. You had a fever with this infection. You received acetaminophen. You had your intake and output monitored to make sure you did not become dehydrated. Your symptoms improved and you are safe to go home. - Initial laboratory studies showed that you had high levels of potassium ___ your blood. You received fluids and diuresis at different points during your hospitalization. You had frequent electrocardiograms and laboratory studies to monitor for effects of high potassium. Your potassium level returned to normal. - You came to ___ on a mechanical ventilator to help your breathing while you were sick. You were on the ventilator for several days. You showed us you could breathe on your own, so we stopped the ventilator and you were able to breathe on your own. You did not require re-intubation. What should you do when you go home? - For the fluid around the heart, you should take a new medicine, called colchicine, described below. - Follow-up with your primary care doctor. - Ask your primary care doctor to schedule follow-up appointment and transthoracic echocardiogram with a cardiologist. NEW MEDICATIONS - Colchicine 0.6 mg by mouth ___ the morning and at night, every day. This medication is for your pericarditis. You should take it for 3 months, last dose ___. Otherwise, you can continue taking the medications you had taken at home before coming to the hospital. Followup Instructions: ___

10039110-DS-14

DS

2165-12-14 00:00:00

2165-12-14 21:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Diflucan Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting with chest pain. Notably, she was seen the ED on ___ for chest and abdominal pain worsened with inspiration. She underwent CT abd/pelvis and was diagnosed with a right lower lobe pneumonia based on that CT, and was discharged on azithromycin. She initially felt better, but then the day prior to this admission developed left-sided chest pressure, constant, worse with deep breathing. She also reported dyspnea on exertion. She denied any nausea, vomiting, diaphoresis, or exertional component to the pain. She denied any unilateral leg pain, history of blood clots, or recent surgeries. She did report a flight to ___ 2 weeks prior (12 hours). She is a daily smoker. Not on OCPs. In the ED: Initial vital signs were notable for: 99.0 92 155/70 16 99% RA Labs were notable for: - D-Dimer ___ - Trop < 0.01 - BNP 113 - Lactate 0.7 - Hb 6.8 (has been ___ since ___ Studies performed include: ___ CTA CHEST 1. Segmental and subsegmental pulmonary emboli in the lingula, right middle lobe and bilateral lower lobes. Upper lobes are not particularly well assessed due to motion. No evidence of right heart strain. 2. Findings compatible with a pulmonary infarct in the lingula. Areas of atelectasis at the lung bases with suspected right basilar infarct as well. 3. Small right and trace left pleural effusions. 4. The rounded 1.5 cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in ___. Patient was given: ___ 09:06 PO Acetaminophen 1000 mg ___ 12:14 PO Ibuprofen 600 mg ___ 13:42 IVF NS 1000 mL ___ 14:11 IV Heparin 6900 UNIT ___ 14:11 IV Heparin Started 1550 units/hr ___ 16:15 PO Ibuprofen 600 mg Upon arrival to the floor, patient reports story as above. She reports continued left chest pain with inspiration and dyspnea with activity, but this has improved since initiation of the heparin gtt. She notes dysfunctional uterine bleeding and a history of anemia. We discussed blood transfusion given Hb < 7, although I relayed that this is chronic and she does not need urgent transfusion at this time. She preferred to think about it overnight. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: PMH 1. hypertension 2. genital herpes 3. fatty liver by ultrasound study PSH 1. S/P C-section x ___ and ___ 2. S/P multiple myomectomy for fibroids in ___ Social History: ___ Family History: Her family history is noted for hyperlipidemia and father living age ___ and diabetes in her mother living age ___. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.2PO 152/77 86 18 98Ra GENERAL: Alert and interactive. HEENT: NCAT. CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords. SKIN: Warm. No rash. NEUROLOGIC: CN2-12 intact. AOx3. ============================= DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 946) Temp: pt refused v/s (Tm 98.2), BP: 136/82 (136-152/77-82), HR: 78 (78-86), RR: 18, O2 sat: 98%, O2 delivery: Ra, Wt: 190.7 lb/86.5 kg GENERAL: Alert and interactive. HEENT: NCAT. CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords. SKIN: Warm. No rash. NEUROLOGIC: CN2-12 intact. AOx3. Pertinent Results: ADMISSION LABS: ___ 09:08AM BLOOD WBC-10.4* RBC-4.36 Hgb-6.8* Hct-25.2* MCV-58* MCH-15.6* MCHC-27.0* RDW-22.3* RDWSD-42.5 Plt ___ ___ 09:08AM BLOOD Glucose-86 UreaN-10 Creat-1.0 Na-142 K-4.2 Cl-104 HCO3-23 AnGap-15 ___ 09:08AM BLOOD ___ 09:08AM BLOOD cTropnT-<0.01 ___ 09:08AM BLOOD proBNP-113 ___ 09:08AM BLOOD Iron-15* ___ 09:08AM BLOOD calTIBC-529* Ferritn-29 TRF-407* ___ 09:12AM BLOOD Lactate-0.7 DISCHARGE LABS: ___ 06:35AM BLOOD WBC-10.3* RBC-4.00 Hgb-6.3* Hct-23.3* MCV-58* MCH-15.8* MCHC-27.0* RDW-22.3* RDWSD-42.8 Plt ___ ___ 06:35AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-23 ___ CXR: IMPRESSION: Perhaps minimal residual opacity at the right costophrenic angle as seen on prior CT. No new consolidation. ___ CHEST CTA: IMPRESSION: 1. Segmental and subsegmental pulmonary emboli in the lingula, right middle lobe and bilateral lower lobes. Upper lobes are not particularly well assessed due to motion. No evidence of right heart strain. 2. Findings compatible with a pulmonary infarct in the lingula. Areas of atelectasis at the lung bases with suspected right basilar infarct as well. 3. Small right and trace left pleural effusions. 4. The rounded 1.5 cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in ___. ___ TTE: IMPRESSION: LVEF 69%. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: Ms. ___ is a ___ year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting with chest pain, found to have a pulmonary embolism. # Non-submassive PE: Pt presented with a week of worsening dyspnea and left sided chest pain. ___ chest CTA notable for segmental PE in lingual, RML, b/l lower lobes with pulmonary infarct in lingual and suspected R. basilar infarct. She was hemodynamically stable. ___ TTE was obtained: LVEF 69%, there was no e/o R heart strain, but TTE notable for mild symmetric LVH with regional biventricular function, mild mitral regurg and mild pulm HTN. Risk factors include smoking (7 cig/day), recent ~12 hr flight from ___. She was started on a hep gtt and transitioned to PO Eliquis 10mg bid x7 days followed by 5mg bid. For her pain, she was given standing Tylenol ___ q8h + PRN ibuprofen. # Dysfunctional uterine bleeding # Iron deficiency anemia: Reports Hgb ___ since ___ im the setting of fibroids and dysfunctional uterine bleeding. She has undergone intermittent iron infusions. This admission Hb 6.8 (baseline), with most recent ferritin 6.8 in ___. Her Hgb was 6.3 on ___, but she was asymptomatic. Previously, she repeatedly refused blood transfusions, but was amenable to receiving 1U pRBC prior to being discharged. She was adamant about being discharged on ___, as she had to go home to take care of her two younger boys. She indicated she would present to the ED if she noticed any active bleeding or become symptomatic. She has an outpatient OBGYN appointment on ___ and said she would contact her PCP for an appointment. # Polysubstance use: Pt with active EtOH use ___ drinker daily) and daily crack cocaine inhalation. She was seen by addiction psychiatry in ___, started on acamprosate, and referred to social work. She stopped taking this medication and missed her most recent social work appointment. SW was initially consulted; however, pt did not seem amenable to meeting with them. She denied any illicit drug use after admission. Will suggest she f/u with outpatient PCP ___ Psychiatry regarding substance use. ==================== MEDICATION CHANGES ==================== []Started Eliquis 10mg bid x7 days (last day ___ followed by 5mg bid. ==================== TRANSITIONAL ISSUES ==================== [] Re-check H/H at next clinic visit, within 1 week of discharge. Continue to monitor for active bleeding. [] She has a f/u scheduled with OBGYN on ___. Please assess for vaginal bleeding at that time, as she was recently started on Eliquis for PE. [] She denied a history of polysubstance abuse during this admission. Please re-address possible illicit drug use either with PCP or ___. []Consider EGD to evaluate for anastamosis, colonoscopy for Fe-deficiency anemia. []s/p Roux-en-Y bypass. Consider multivitamin, Fe supplements, B12, vitamin D and calcium supplementation. # CONTACT: Husband, ___, ___ ___ 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 Q8H RX *acetaminophen 500 mg two tablet(s) by mouth every 8 hours as needed for pain Disp #*30 Tablet Refills:*0 2. Apixaban 5 mg PO BID Take 10mg twice daily for a total of 7 days (until ___, then 5mg twice daily thereafter. RX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice daily Disp #*30 Tablet Refills:*2 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX *ibuprofen 400 mg one tablet(s) by mouth every 8 hours as needed for pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pulmonary embolism Iron-deficiency Anemia Polysubstance use Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital for a blood clot in your lungs. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received blood for your anemia. - We gave you an IV blood thinner for your lung clot (called heparin). We switched this to oral tablets called Eliquis (apixaban). WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - You are now on a blood thinner that increases your risk of bleeding. Please go to your nearest Emergency Department if you experience any of the following: vaginal bleeding or bleeding elsewhere, chest pain, palpitations (rapid heart beats), shortness of breath, lightheadedness. - Please follow up with your primary care doctor within 5 days of being discharged. You will need to continue taking the Eliquis (apixaban) for your lung clot. - Take your Eliquis (apixaban) as directed: ___: Take 10mg in the morning + 10mg in the evening for a total of 7 days. ___: Take 5mg in the morning + 5mg in the evening. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10039708-DS-13

DS

2138-11-06 00:00:00

2138-11-13 21:38:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Ataxia/Altered Mental Status Major Surgical or Invasive Procedure: No major surgical or invasive procedures. History of Present Illness: ___ y/o F with HTN, hypothyroidism and alcoholism who presents with of ~1 week dizziness. Patient states has had unstable gait for several days causing her to fall on ___ in her bathroom She denies any head injury or LOC but does report that she bruised her right wrist. Dizziness is non-positional, does not feel like room is spinning and is not exacerbated with head movement. Denies changes in vision, headache, CP, SOB, n/v/d. Endorses smoking 5x cigarettes/day and drinking half a pint of EtOH daily. Denies drinking EtOH today, last drink was the day prior to admission. Per family, patient is significantly altered from her baseline over past week. Has also had some recent fecal incontinence. Unclear if related to dizziness hindering toileting or patient is unaware of incontinence. In the ED initial vitals were: 98.0, 71, 105/76, 16, 100% - Labs were significant for Mg 1.4, Cr 1.2 (baseline ). Serum tox screen was negative (including EtOH). - Patient was given thiamine 100mg x2, MVI, folate, magnesium oxide 400mg x1. Vitals prior to transfer were: 97.7, 65, 100/52, 18, 100% RA On the floor, patient reports that she feels well and has no complaints. History inconsistent, patient reports that her dizziness is positional and only associated with standing. She does not recall any episodes of fecal incontinence. Tried to contact both patient's mother and son by phone but no answer. Has trouble understanding some commands on examination. Past Medical History: ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: ___ Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals - 98.2, 90/56, 68, 16, 100% RA GENERAL: NAD, lying in bed HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, poor dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Soft, nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, moving all 4 extremities with purpose. Strength ___ for upper extremities, ___ for lower extremities. Patient seems to have some difficulty understanding instructions. Poor attention. Flat affect. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM ======================= Vitals - Temperature 98.0-98.3 84-97/48-58, 63-80, 18, 98-100% on RA GENERAL: Patient is laying in bed comfortably watching television. She appears more awake and oriented than yesterday. She is A+Ox3. CARDIAC: Regular rate and rhythm, normal S1 and S2, no m/r/g. LUNG: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. ABDOMEN: soft, non-tender, non-distended no rebound or guarding, no organomegaly. EXTREMITIES: Right ankle remains warm and tender to touch. Also swelling noted surrounding the right ankle. The swelling is decreased compared to yesterday. Dorsiflexion and plantarflexion is ___ strength of right. Inversion and eversion of the right foot is ___ although pain is noted on the lateral aspect of the right foot. No swelling or warmth of the left ankle noted. PULSES: 2+ DP pulses bilaterally. COGNITIVE: Alert and oriented x 3. Pertinent Results: ADMISSION LABS ============== ___ 06:39PM BLOOD WBC-7.6 RBC-3.15* Hgb-11.9* Hct-37.5 MCV-119* MCH-37.8* MCHC-31.7 RDW-17.5* Plt ___ ___ 06:39PM BLOOD Neuts-59.5 ___ Monos-5.5 Eos-2.0 Baso-0.3 ___ 06:39PM BLOOD Plt ___ ___ 06:39PM BLOOD Glucose-141* UreaN-16 Creat-1.2* Na-141 K-4.1 Cl-101 HCO3-26 AnGap-18 ___ 06:39PM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.2 Mg-1.4* ___ 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICROBIOLOGY ============ Blood Culture, Routine (Final ___: NO GROWTH. RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. IMAGING ======= ___ CHEST (PA & LAT) FINDINGS: PA 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. IMPRESSION: No acute intrathoracic process. ___ CT HEAD W/O CONTRAST FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Sulcal prominence especially within the cerebellum is age hands consistent with atrophy. The ventricles are normal in overall size and configuration. The basilar cisterns are widely patent. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial process. Age advanced atrophy. ___ LIVER OR GALLBLADDER US (SINGLE ORGAN) PRELIMINARY REPORT IMPRESSION: IMPRESSION: Normal exam. In particular, liver appears normal. OTHER NOTABLE LABS ================== ___ 06:39PM BLOOD ALT-18 AST-34 AlkPhos-102 TotBili-0.8 ___ 09:25PM BLOOD VitB12-216* ___ 09:25PM BLOOD TSH-1.3 ___ 05:40AM BLOOD Ret Aut-2.7 ___ 05:40AM BLOOD calTIBC-221* Ferritn-90 TRF-170* ___ 05:35AM BLOOD Folate-8.5 ___ 05:35AM BLOOD Cortsol-11.0 DISCHARGE LABS ============== ___ 05:50AM BLOOD WBC-4.9 RBC-2.39* Hgb-8.8* Hct-29.0* MCV-121* MCH-36.8* MCHC-30.3* RDW-17.3* Plt ___ ___ 05:50AM BLOOD Plt ___ ___ 05:50AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-141 K-4.6 Cl-109* HCO3-24 AnGap-13 ___ 05:50AM BLOOD Calcium-8.9 Phos-5.8* Mg-1.9 Brief Hospital Course: Ms. ___ is a ___ with PMH significant for HTN, hypothyroidism and alcoholism who presents with one-two weeks of ataxia and altered mental status per family. #___'S ENCEPHALOPATHY: Ms. ___ came in with change in mental status over the past two weeks. According to family, she was slow to respond to questions and had forgotten to do some of her daily activities. She has a history significant for chronic alcohol use. In addition to change in mental status, she also had ataxia with unbalance on feet. She did not have opthalmoplegia. Given the altered mental status and ataxia, she was treated for Wernicke's Encephalopathy. She was given thiamine 500 mg IV TID for 3 days, followed by thiamine 500 mg IV daily until she left against medical advice on ___. Prior to discharge recommendation was to take thiamine 100 mg PO daily. A CT of the head did show cerebellar atrophy which also likely played a role in her change in mental status. Vitamin B12 was found to be low at 216, therefore she was given B12 IM 1000 mcg daily was from ___. Recommendation for was vitamin B12 IM 1000 mcg daily for 10 days and then vitamin B12 IM 1000 mcg weekly for ___ weeks, then vitamin B12 IM 1000 mcg monthly. Since the patient left AMA, she was given cyanocbolamin 1000 mcg PO daily. Neurology was consulted. They believed the source of the altered mental status likely was multifactorial including vitamin deficiencies of thiamine, B12, as well as chronic sequelae of alcohol use, recommended neurology f/u. With supplementation with thiamine, vitamin B12, multivitamin and a balanced diet, her altered mental status improved and she was near baseline, however we advised that she stay in house for further rehabilitation given that she didn't pass ___ due to instability and did not qualify for rehab. She was advised of the risks of discharge including further instability leading to falls and at the extreme, death, however she elected to leave regardles. #GOUT: Ms. ___ has a history of gout. During hospitalization she developed swelling, erythema, and warmth of the right ankle. This was initially treated with naproxen 750 mg PO, followed by 250 mg PO Q8H with meals for five days (day 1: ___. The gout responded well to the naproxen. As she left AMA, we recommended she continue the naproxen for 2 additional days after the symptoms resolve. We also advised her to contact her PCP if the symptoms last more than one week. #HYPOTENSION: During hospitalization, Ms. ___ had systolic blood pressures ranging from the upper ___ to low 100s. She remained asymptomatic when her blood pressures were low. She did not feel chest pressure, tightness, shortness of breath, or lightheadedness/dizziness when standing. Initial thought was that it was due to poor nutrition/low volume satus. Fluid repletion and improved diet did improve blood pressure into the high ___. Even after IVFs and improved nutrition blood pressure still remained low. An AM cortisol was obtained to assess adrenal function and was normal at 11. She had no evidence of infection and remained asymptomatic. #ANEMIA: Patient presented with a macrocytic anemia. This was likely in the setting of chronic alcohol use as well as her previous bariatic surgery. B12 was low as noted above. To replete B12, we gave Vitamin B12 IM 1000 mcg daily. We also provided folic acid even though folate was within normal limits at 8. H/H remained relatively stable during hospitalization and was 8.8/29.2 at the time of discharge. She remained asymptomatic with no lightheadedness, dizziness, sob, or chest pain. She required no transfusions during hospitalization. #ALCOHOL DEPENDENCE: Ms. ___ has a significant history of alcohol consumption. She remained on CIWA protocol and did not score. She received multivitamin, folate, thimaine and B12 as noted above. Social work was consulted. Based on report from social work, she was willing to attend ___ Substance Abuse Program. Social work also provided a list of local AA meetings. Ms. ___ noted motivation in trying to become sober. Her main motivation is improving herself for her son. #HYPOTHYROIDISM: TSH was obtained during hospitalization was 1.3. Hypothyroidism stable. She was continued on her home dose of levothyroxine. #ASTHMA: Well controlled and without wheezing or dyspnea on exam during hospitalization. We continued home Advair and albuterol rescue inhaler prn. TRANSITIONAL ISSUES ==================== #ALTERED MENTAL STATUS/ATAXIA: Please follow-up in Neurology clinic for further management of the altered mental status/ataxia. #OCCUPATIONAL THERAPY: Will followup recommendations from occupational therapy: recommend intermittent supervision and assist with IADLs from family given cognitive decline. #HYPOTENSION: Blood pressures were low during hospitalization (SBP between high ___ and low 100s). Remained asymptomatic. ___ be due to autonomic dysfunction given chronic alcohol use. Consider tilt-table test and/or use of fludricortisone. #ALCOHOL USE: Please follow-up with goal towards sobriety. Patient willing to attend ___ Evening Substance Abuse Program. SW provided list of local AA meetings. #VITAMIN B12 REGIMEN for Vitamin B12 Deficiency: She was prescribed cyanocobolamin 1000 mcg PO daily. #GOUT: please follow-up with examination of the right ankle, as this is the site the gout developed. If not improving, consider use of colchicine. #CODE STATUS: FULL CODE #CONTACT: ___ (son); ___. ___ (mother); ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 2.5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheezing 7. Ascorbic Acid ___ mg PO DAILY 8. Calcium Carbonate 600 mg PO BID 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheezing 2. Ascorbic Acid ___ mg PO DAILY 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 4. FoLIC Acid 1 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Naproxen 250 mg PO Q8H RX *naproxen [Naprosyn] 250 mg 1 tablet(s) by mouth q8 hrs Disp #*21 Tablet Refills:*0 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID constipation 12. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 13. Cyanocobalamin 1000 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ___'s Encephalopathy SECONDARY: Alcohol use, anemia, vitamin B12 deficiency, gout, hypotension, hypothyroidism. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent but difficulty with stairs Discharge Instructions: Dear Ms. ___, You were admitted to ___ with ataxia (difficulty with your balance) as well as slowing of your thinking. You were initially evaluated with imaging of your head (head CT) which showed atrophy (weakening) of the cerebellum (part of the brain). This was likely due to chronic alcohol use in the past. The ataxia and slowing of your thinking was also likely due to the chronic alcohol use in the past. In order to help improve your thinking, we gave you a vitamin called thiamine which helped improve your thinking as well as your balance. We also continued you with other vitamins and minerals including Vitamin B12, folic acid, a multivitamin. We also had the neurologists (brain doctors) come and see you to evaluate your unsteadiness on your feet and slowed thinking. They also recommended continuing with the vitamins that we had been giving you. The neurologists would also like to have you seen as an outpatient with a neurologist within the At___ network. We also had social work come see you to discuss options regarding resources to help quit alcohol consumption. We recommended that you stay in the hospital given your ongoing difficulty with standing and climbing stairs, and need for physical therapy as well as ongoing IV thiamine. You elected to leave against medical advice. You were advised of the risks of leaving against medical advice, including falling with possibility of serious injury including death, worsening confusion, poor pain control and worsening of gout. You understood and accepted these risks and elected to leave against medical advice regardless. While in the hospital, you were also treated for a gout flare. You should continue to take naproxen for 2 days after your symptoms resolve and you should contact your PCP if your symptoms last for more than a week. We encourage you to continue taking these vitamins as they are helping improve your symptoms. It was a pleasure taking care of you in the hospital! Sincerely, Your ___ Care Team Followup Instructions: ___

10039708-DS-14

DS

2140-02-26 00:00:00

2140-02-27 19:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chief Complaint: Hypotension Reason for MICU transfer: Refractory hypotension, severe anemia Major Surgical or Invasive Procedure: Intubation: ___ Sigmoidoscopy ___ EGD ___ Tunneled hemodialysis line placement ___ Colonoscopy ___ History of Present Illness: ___ with a PMH of EtOH abuse, liver disease, hypothyroidism, and hypertension who presents with hypotension and severe anemia. The patient was seen at her PCPs office today for a a few days of fatigue and weakness. There she was found to be hypotensive to the 64/34, pulse 93. She was sent to ___ by ambulance. She has also been having diarrhea for the past few days with normal stool color. She denies CP, SOB, Abd pain, N/V, dysuria. No hx of GIB. No previous EGDs or colonoscopies. Of note, the patient had a recent admission to ___ ___ for dizziness and hypotension that responded to IVF. At that time her H/H was 9.9/29, cr 1.3. In the ED, initial vitals: 97.8 90 70/42 18 100% RA. She was hypothermic in the ED to 34 degrees C after getting 3L IVF; was given a bear hugger. Labs were notable for: H/H 4.3/14.4 with MCV 107, PTT 140 with INR 1.1, transaminitis with AST 168 and ALT 89, Tbili 0.7, alb 2.3, creatinine 2.9->2.5 (baseline 0.9), bicarb 8->11, VBG 7.25/33/40/15, lactate 2.1-> 1.5, neg UA. Exam was significant for normal mentation and brown, guaiac negative stool. CXR was without acute findings, and CTA abd/pelvis was without source of bleed, but showed hepatic steatosis, colitis versus portal colopathy, and heterogenous kidneys. A cordis was placed in the R femoral vein for resuscitation. The patient was given: ___ 13:12 IVF 1000 mL NS 1000 mL ___ 13:53 IVF 1000 mL NS 1000 mL ___ 15:23 IVF 1000 mL NS 1000 mL ___ 15:34 IV Piperacillin-Tazobactam 4.5 g ___ 15:34 PO Acetaminophen 1000 mg ___ 15:34 IV BOLUS Pantoprazole 80 mg ___ 16:16 IVF 1000 mL NS 1000 mL ___ 16:16 IV Vancomycin 1000 mg ___ 16:30 IV DRIP Pantoprazole Started 8 mg/hr 4 units pRBCs. On arrival to the MICU, the patient's vitals were 97.8 77 81/43 18 99% on RA. She was persistently hypotensive to ___. She was mentating well. She was given a total of 4L IVF and started on levophed without blood pressure response. A-line was placed. Past Medical History: ___'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: ___ Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.8 90 70/42 18 100% RA. GENERAL: Alert, oriented, no acute distress. HEENT: PERRL, MMM NECK: supple, JVP not elevated LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, mildly distended, no tenderness to palpation. EXT: Warm, no edema LINES: right femoral CVL, right PIV, foley in place DISCHARGE PHYSICAL EXAM: ======================== VS 98.3 124/84 66 18 100%RA FSBG 67 (getting juice) GENERAL: NAD, ill appearing, awake and interactive HEENT: AT/NC, MMM, NGT in place Chest: R anterior chest wall improved tenderness at tunneled HD site. without erythema or fluctance. CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA in anterior and axillary fields ABDOMEN: scaphoid. +BS, minimal tenderness diffusely EXTREMITIES: RLE edema present 1+ to around mid thigh asymmetrically w/ LLE with no edema. SKIN: warm, DP 2+ b/l Pertinent Results: ADMISSION LABS ============== ___ 01:40PM BLOOD WBC-7.5# RBC-1.35*# Hgb-4.3*# Hct-14.4*# MCV-107*# MCH-31.9# MCHC-29.9* RDW-19.8* RDWSD-74.3* Plt ___ ___ 01:40PM BLOOD Neuts-60.3 ___ Monos-11.2 Eos-0.8* Baso-0.0 Im ___ AbsNeut-4.54 AbsLymp-1.99 AbsMono-0.84* AbsEos-0.06 AbsBaso-0.00* ___ 01:40PM BLOOD ___ PTT-140.0* ___ ___ 02:39PM BLOOD ___ 01:40PM BLOOD Glucose-123* UreaN-62* Creat-2.9*# Na-140 K-5.4* Cl-123* HCO3-8* AnGap-14 ___ 01:40PM BLOOD ALT-89* AST-168* AlkPhos-259* TotBili-0.7 ___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 02:39PM BLOOD Albumin-2.1* ___ 07:14PM BLOOD Calcium-6.4* Phos-3.7# Mg-1.2* ___ 11:51PM BLOOD calTIBC-90* VitB12-GREATER TH Folate-GREATER TH ___ Ferritn-1085* TRF-69* ___ 07:30PM BLOOD Cortsol-7.4 ___ 07:30PM BLOOD ASA-NEG Acetmnp-9* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:43PM BLOOD ___ pO2-40* pCO2-33* pH-7.25* calTCO2-15* Base XS--11 ___ 01:43PM BLOOD Lactate-2.1* PERTINENT LABS: =============== Lactate trend: ___ 02:44PM BLOOD Lactate-1.5 ___ 07:48PM BLOOD Lactate-3.4* ___ 12:10AM BLOOD Lactate-3.9* ___ 12:49AM BLOOD Lactate-3.6* ___ 12:15PM BLOOD Lactate-6.7* ___ 05:30PM BLOOD Lactate-7.2* ___ 09:55PM BLOOD Glucose-187* Lactate-5.8* Na-133 K-3.3 Cl-112* ___ 01:49AM BLOOD Lactate-4.9* ___ 11:35AM BLOOD Lactate-3.4* ___ 03:54AM BLOOD Lactate-2.5* ___ 06:27PM BLOOD Lactate-1.7 Troponin trend: ___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 05:51AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 08:45AM BLOOD CK-MB-1 cTropnT-0.04* ___ 06:41PM BLOOD CK-MB-2 cTropnT-0.07* ___ 12:04AM BLOOD CK-MB-2 cTropnT-0.09* ___ 03:38AM BLOOD cTropnT-0.05* ___ 01:36AM BLOOD cTropnT-0.03* ___ 07:19AM BLOOD CK-MB-3 cTropnT-0.02* BNP: ___ 12:04AM BLOOD ___ ___ 05:32AM BLOOD Ret Aut-6.0* Abs Ret-0.16* ___ 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217* TotBili-1.0 ___ 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8* TRF-80* ___ 03:06AM BLOOD Ferritn-2632* ___ 11:10AM BLOOD %HbA1c-5.6 eAG-114 ___ 02:30PM BLOOD Triglyc-59 ___ 05:08PM BLOOD Osmolal-308 ___ 07:30PM BLOOD TSH-0.82 ___ 05:25AM BLOOD Cortsol-13.8 ___ 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE ___ 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 02:39PM BLOOD ANCA-NEGATIVE B ___ 05:41AM BLOOD AMA-NEGATIVE ___ 05:41AM BLOOD ___ ___ 05:45AM BLOOD C3-88* C4-27 ___ 07:30PM BLOOD HIV Ab-Negative ___ 05:27PM BLOOD ANTI-PLATELET ANTIBODY-Test Test Flag Result Unit Reference Value ---- ---- ------ ---- --------------- Platelet Ab, S Positive Not Applicable Comment Antibody reacts with glycoprotein to HLA Class I, probable alloimmunization due to pregnancy/transplant/transfusion. ___ 12:00AM BLOOD COPPER (SERUM)-Test Test Result Reference Range/Units COPPER 91 70-175 mcg/dL ___ 12:00AM BLOOD ZINC-Test Test Result Reference Range/Units ZINC 48 L 60-130 mcg/dL ___ 11:55PM BLOOD VITAMIN B1-WHOLE BLOOD-Test Test Result Reference Range/Units VITAMIN B1 (THIAMINE), 1118 H 78-185 nmol/L BLOOD, LC/MS/MS ___ 11:55PM BLOOD VITAMIN C-Test Test Result Reference Range/Units VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL ___ 09:10PM BLOOD SELENIUM-Test Test Result Reference Range/Units SELENIUM 29 L 63-160 mcg/L ___ 09:10PM BLOOD COPPER (SERUM)-Test Test Result Reference Range/Units COPPER 34 L 70-175 mcg/dL ___ 09:10PM BLOOD ZINC-Test Test Result Reference Range/Units ZINC 32 L 60-130 mcg/dL ZINC Test Result Reference Range/Units ZINC (repeat on ___ 27 L 60-130 mcg/dL ___ 09:10PM BLOOD VITAMIN C-Test Test Result Reference Range/Units VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL ___ 09:10PM BLOOD CERULOPLASMIN-Test Test Result Reference Range/Units CERULOPLASMIN 14 L ___ mg/dL ___ 06:35PM BLOOD VITAMIN B1-WHOLE BLOOD-Test Test Result Reference Range/Units VITAMIN B1 (THIAMINE), >1200 H 78-185 nmol/L BLOOD, LC/MS/MS ___ 01:17PM BLOOD HEPARIN DEPENDENT ANTIBODIES-TEST TEST RESULTS REFERENCE RANGE UNITS ____________________ _______ _______________ _____ PF4 Heparin Antibody .10 0.00 - 0.39 ___ 01:17PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL ___ 10:28AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-Test Test Result Reference Range/Units PARVOVIRUS B19 ANTIBODY 8.48 H (IGG) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive IgG persists for years and provides life-long immunity. To diagnose current infection, consider Parvovirus B19 DNA, PCR. Test Result Reference Range/Units PARVOVIRUS B19 ANTIBODY <0.9 (IGM) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive Results from any one IgM assay should not be used as a sole determinant of a current or recent infection. Because IgM tests can yield false positive results and low levels of IgM antibody may persist for months post infection, reliance on a single test result could be misleading. If an acute infection is suspected, consider obtaining a new specimen and submit for both IgG and IgM testing in two or more weeks. To diagnose current infection, consider parvovirus B19 DNA,PCR. ___ 11:56AM BLOOD T4, FREE, DIRECT DIALYSIS-Test Test Result Reference Range/Units T4, FREE, DIRECT DIALYSIS 3.3 H 0.8-2.7 ng/dL Urine studies: ___ 09:33AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 09:33AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 10:39PM URINE RBC-151* WBC->182* Bacteri-FEW Yeast-NONE Epi-2 TransE-1 ___ 01:20PM URINE AmorphX-FEW ___ 09:33AM URINE Hours-RANDOM UreaN-332 Creat-101 Na-41 K-43 Cl-12 TotProt-171 Prot/Cr-1.7* Albumin-36.1 Alb/Cre-357.4* DISCHARGE LABS: =============== ___ 04:57AM BLOOD WBC-9.6 RBC-2.84* Hgb-9.0* Hct-27.5* MCV-97 MCH-31.7 MCHC-32.7 RDW-19.0* RDWSD-67.4* Plt ___ ___ 12:30PM BLOOD ___ PTT-56.4* ___ ___ 04:57AM BLOOD Glucose-61* UreaN-33* Creat-2.9*# Na-137 K-4.6 Cl-100 HCO3-24 AnGap-18 ___ 05:45AM BLOOD Glucose-75 UreaN-59* Creat-4.1* Na-138 K-5.4* Cl-106 HCO3-20* AnGap-17 ___ 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217* TotBili-1.0 ___ 04:57AM BLOOD Calcium-8.7 Phos-5.8*# Mg-2.1 ___ 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8* TRF-80* ___ 03:06AM BLOOD Ferritn-2632* ___ 02:30PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE ___ 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 07:30PM BLOOD HIV Ab-Negative ___ 02:30PM BLOOD HCV Ab-PND ___ 03:29PM BLOOD HCV Ab-NEGATIVE ___ 06:27AM BLOOD freeCa-1.17 MICROBIOLOGY: ============= __________________________________________________________ ___ 11:53 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). __________________________________________________________ ___ 1:29 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 9:07 am BLOOD CULTURE Source: Line-hd line. Blood Culture, Routine (Pending): __________________________________________________________ ___ 9:07 am BLOOD CULTURE Source: Line-aline 1 OF 2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:39 pm Mini-BAL GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: YEAST. ~3000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. __________________________________________________________ ___ 1:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. ~3000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): Negative results: ___ URINE URINE CULTURE-FINAL INPATIENT ___ Immunology (CMV) CMV Viral Load-FINAL INPATIENT ___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT ___ SWAB Chlamydia trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT ___ URINE Chlamydia trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT ___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ STOOL C. difficile DNA amplification assay-FINAL INPATIENT ___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___- urine cultures x2 URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION ___ - blood cultures x2 - no growth PERTINENT STUDIES: ================== ___ CXR: FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. Chain sutures are noted in the left upper quadrant of the abdomen. IMPRESSION: No acute cardiopulmonary abnormality ___ CT abd/pelvis: IMPRESSION: 1. No active extravasation of contrast to suggest active GI bleeding at this time. 2. Profound hepatic steatosis. Enlarged periportal lymph nodes with hazy mesentery and retroperitoneum likely reflect underlying liver disease. 3. Colonic and rectal wall thickening which may reflect colitis versus portal colopathy. 4. Heterogeneous appearance of the kidneys with possible striated nephrograms. Correlate with urinalysis to exclude pyelonephritis. ___ TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are mildly myxomatous. Frank mitral valve prolapse is not seen but cannot be excluded with certainty. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. ___ ___ IMPRESSION: 1. Occlusive thrombus of all right lower extremity deep veins from the common femoral vein down to the calf veins. 2. Patent left lower extremity veins. ___ ECHO The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (LVEF = 40%) secondary to hypokinesis of the basal two-thirds of the left ventricle. The apical one-third of the left ventricle is hyperdynamic. 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 aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. The pulmonary artery is not well visualized. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, left ventricular systolic dysfunction is now present. Findings suggestive of stress cardiomyopathy with inverse Takotsubo pattern of left ventricular contractile dysfunction. ___ CTH: IMPRESSION: 1. There is mild progression of global cerebral atrophy since the prior examination of ___, greater than would be expected for the patient's age. 2. No intracranial hemorrhage or territorial infarct. ___ LIVER US: IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Trace ascites and small right pleural effusion. ___ IVC filter placement: FINDINGS: 1. Patent normal sized, non-duplicated IVC with no evidence of a IVC thrombus. A small circumaortic renal vein originating from the IVC just above the bifurcation was noted however is very small in caliber and likely of no clinical significance. 2. Successful deployment of an infra-renal retrievable IVC filter. IMPRESSION: Successful deployment of an infra-renal removable IVC filter. ___ ECHO: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and low normal global biventricular systolic function. No valvular pathology or pathologic flow identified. Trivial pericardial effusion. ___ Unilateral RLE veins IMPRESSION: Extensive deep venous thrombosis involving the wall of the right lower extremity veins, overall similar to ___, but now with perhaps minimal flow in the distal right SFV. ___ Video oropharyngeal swallow study Aspiration with thin liquid consistency. ___ Portable abdomen x-ray Patient is post gastric bypass surgery. The Dobbhoff tube ends in the proximal jejunum. ___ Renal ultrasound No evidence of hydronephrosis. Increased renal echogenicity consistent with diffuse parenchymal renal disease. Small bilateral effusions and small to moderate volume ascites. ___ - EGD Duodenum was not examined. Small gastric pouch consistent with Roux en y anatomy the blind limb and jejunal limb were both visualized. No varices. Otherwise normal EGD to the jejunum. Brief Hospital Course: ___ hx gastric bypass surgery, alcohol abuse complicated by Wernicke's encephalopathy, concern for autonomic insufficiency, presented originally with hypotension, anemia and academia. Her course in the MICU was complicated by severe nutritional deficiency, volume overload, renal failure, cardiomyopathy, hypoxemia and hypoxemic respiratory failure, and deep vein thrombosis. # Hypotension: # Cardiomyopathy: # Presumed alcoholic liver disease: Patient was given 4u PRBCs in the ED prior to FICU admission; her Hgb was stable for days afterward, and there was low suspicion for active GIB initially in her MICU course. She was empirically antiobiosed for concern of sepsis, but no source was found, and these antibiotics were held until a series of presumed aspiration events that will be discussed below. Morning cortisol was within normal limits twice; TSH was also within normal limits. She underwent several echocardiograms to explain her persistent hypotension with pressor requirement that showed in sequence: mitral regurgitation with eccentric jet; inverse Takutsubo's cardiomyopathy; and then resolution of these issues. Of note, the resolution occurred after initiation of high-dose thiamine repletion, which may suggest an element of wet beriberbi from severe nutritional deficiency in the setting of gastric bypass and alcoholism. There was also strong suspicion of cirrhosis given her imaging and alcohol abuse history, for which she was started on midodrine. With these measures, she was successfully weaned from pressors. Unresolved at the time of her MICU discharge was a question of autonomic insufficiency raised in her last Discharge Summary of ___ where it was thought her alcohol abuse could be contributing to baseline systolic pressures in the ___. This in part resolved on the floor as the patient was weaned off midodrine and maintained systolic blood pressure in the 100s. # Anemia: -Unexplained, possible GI source with lack of erythropoietin in the setting of subacute renal failure . Patient had decreasing pRBC transfusion requirements over the course of her stay, ultimately needing 1U pRBC every 4 days. She was evaluated by Hem/Onc who felt there was no evidence of significant hemolysis or malignancy and felt that there was an element of anemia of chronic inflammation, as well as decreased erythropoietin in the setting of subacute renal failure. She was evaluated by GI who found no source of bleed on sigmoidoscopy early in her course and no varices or bleeding on EGD. She had an episode of guaiac positive stool but had no significant bleeding on colonoscopy. Patient may benefit from outpatient capsule study if bleeding is ongoing. # Thrombocytopenia: There was no evidence of active bleed on presentation (stool normal color, not tachycardic, no clinical or radiographic evidence of extravasation into a compartment). Surgery and GI were consulted early in her MICU course for concern of ischemic gut in the setting of rising lactate, but flexible sigmoidoscopy was negative for this and lactate resolved with fluid resuscitation. ___ Hematology consulted, and believe her anemia and thrombocytopenia are likely a combination of alcoholic bone marrow suppression, malnutrition and critical illness. She may benefit from a bone marrow biopsy when more stable; additionally, given her renal failure, she may have a developing EPO deficiency. She was transfused by ED prior to MICU admission and did not require further blood products until ___ (gradually dropping Hct attributed to anemia of chronic illness/inflammation/underproduction; she held her Hct each time after transfusion). # Diarrhea: Negative c. diff, improved over the course of the hospital stay. Possibly related to tube feeding formulas as this improved with changing to a higher fiber formula and with the addition of banana flakes. Recommend continued loperamide as needed and optimization of tube feeds in patient s/p gastric bypass. # Renal Failure (Addressed Separately Below): Presented with serum bicarbonate of 8 of unclear etiology. She manifested diarrhea in the early part of her ICU stay (C diff assay negative, thought related to either alcohol abuse or early course of antibiotics administered empirically for presumed sepsis, resolved); her renal function markers may also have been under-estimates of her true GFR given her nutritionally deficient state. Acidemia corrected with bicarbonate drip, but recurrence remains in a concern in the setting of her renal failure with poor UOP. CRRT was started in the setting of volume overload in the ICU as described above, though she was noted to have ATN by muddy brown casts in her urine as well as persistently poor UOP. At time of FICU discharge she is being trialed off CRRT, though with her poor UOP she may need to be initiated on standing dialysis. Upon transfer to the floor, her renal function did not improve and she remained oliguric. She was evaluated by nephrology who felt that ATN without renal recovery was the most likely diagnosis based on her urine sediment and history. A renal biopsy was considered, but nephrology felt that the risks of the biopsy on a patient already requiring heparin for DVT would outweigh the benefits with the suspicion of ATN being high already. Urine output remained low prior to discharge, and tunneled HD line was placed for longer-term access. # Respiratory Failure: Patient developed progressive hypoxemia from volume overload eventually requiring CRRT with resolution of the same. However, on ___ she had an unexplained hypoxemic respiratory episode with persistent SpO2 measurements in the ___ despite NRB and NC; she was intubated with ___ of continued O2 saturations in the ___ before resolution not attributable to any particular intervention (nebs, suction, etc). This first hypoxemic episode was attributed to aspiration though subsequent CXR and bronchoscopy were not impressive for evidence of the same. She was extubated within 24hrs, but then reintubated in the setting of a break in her CRRT line that caused acute hypotension from blood loss (trapped in the CRRT circuit) and then hypoxemia. After restoration of hemodynamic stability and passing her RSBI, she was again extubated, but re-intubated for nearly the same exact sequence of events that evening(break in the CRRT circuit due to equipment failure; this has been reported and is being investigated). She was finally extubated on ___ and remains off supplemental O2 at time of MICU discharge. Antibiotics were empirically started in the setting of possible aspiration with leukocytosis (that could have been a stress reaction to aspiration pneumonitis or intubations/exbuations); these will finish on ___. She completed her course of antibiotics and remained afebrile and without respiratory distress the rest of her hospitalization. # Alcohol Abuse: Patient endorses heavy alcohol use. She was seen by social work who gave resources, though patient is not interested in counseling. # Severe Nutritional Deficiency: Nutritional deficiencies including zinc and selenium requiring significant repletion. Repeat testing of zinc showed continued need for repletion. Caloric needs and repletion addressed below. # Severe malnutrition: likely contributor to pancytopenia resulting from bone marrow suppression. Required tube feeding tube feed which was continued at discharge in order to meet her caloric needs. She was initially found to aspirate thin liquids by a speech and swallow evaluation, however on reevaluation after receiving tube feeds for some time, she was able to tolerate a regular diet and thin liquids. Her caloric intake by mouth was not sufficient to decrease tube feeds. # Hx Wernicke's Encephalopathy: Patient had waxing/waning mental status for much of her early hospital course which was initially attributed to delirium; however, for history of Wernicke's she was started on high-dose thiamine that seemed to improve her mental status. Nutrition was consulted, and nutrition labs were sent that were all markedly low. She was supplemented through her TFs and will need to remain on standing thiamine. # Deep Vein Thrombosis: Patient arrived to MICU with L femoral CVL; shortly thereafter, asymmetric R > L lower extremity swelling was noticed for which ___ was obtained - this showed extensive venous clot burden in the R lower extremity. IV heparin was started. Because of persistent thrombocytopenia, an IVC filter was placed, though because of her high clot risk IV heparin was continued. She should have interval follow-up of her DVTs after discharge, as well as scheduled follow-up with ___ for filter removal. She was maintained on a heparin drip and should be bridged to Coumadin to follow up with hematology/oncology as an outpatient. # Concern for Gastrointestinal Bleed: As described above, GI and Surgery were consulted early in her MICU stay for rising lactate and concern of gut ischemia in the setting of her hypotension; flexible sigmoidoscopy was unimpressive and lactate improved with pressors and IVF. Near the end of her FICU stay she had fresh blood coating a stool which raised concern for GIB; however, her Hct was stable, she was HD stable, and guaiacs of subsequent stools were negative prior to MICU discharge. She underwent evaluation by Hepatology and EGD which showed no varices, negative colonoscopy. Capsule study failed, but patient's H/H stabilized and hepatology felt the study could be done as an outpatient if necessary. **Transitional:** TRANSITIONAL ISSUES: -Patient will need daily assessment for hemodialysis needs, EPO with HD given renal failure -Reassess nutritional status and continued need for tube feeding, potential need for G-tube -Daily electrolytes and every other day CBC to evaluate need for blood transfusion -Patient on heparin gtt for DVT. Recommend bridge to coumadin -Needs appointment with OBGYN for Mirena IUD removal. Pt states this was places at least ___ years ago. -encourage smoking/alcohol cessation -f/u for potential IVC filter removal in the future -Outpatient hepatology f/u, consider outpatient capsule study -Outpatient Hematology f/u with Dr. ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 4. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Heparin IV per Weight-Based Dosing Guidelines Initial Bolus: 3900 units IVP Initial Infusion Rate: 850 units/hr Start: Today - ___, First Dose: 1600 Target PTT: 60 - 100 seconds 7. Nephrocaps 1 CAP PO DAILY 8. Warfarin 5 mg PO DAILY16 first dose ___ 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. LOPERamide 2 mg PO QID:PRN diarrhea 11. Sarna Lotion 1 Appl TP PRN itching Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: acute oliguric renal failure, deep vein thrombosis, anemia, thrombocytopenia, hypothyroidism 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 caring for you at the ___ ___. You were hospitalized with low blood pressure and low blood counts. You were treated with blood transfusions, kidney replacement therapy, and antibiotics. You were found to have a blood clot in your leg and are being treated with blood thinning medications. Your platelets were low but these recovered. Your kidney function has not recovered prior to leaving the hospital and you will be discharged with a hemodialysis line. You were evaluated for GI bleeds, and these studies were reassuring. If you continue to bleed, you may benefit from a capsule study as an outpatient. Best wishes, Your ___ Care Team Followup Instructions: ___

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2140-06-22 00:00:00

2140-06-24 20:24:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypotension, Abdominal Pain Major Surgical or Invasive Procedure: Right internal jugular line placement History of Present Illness: Ms. ___ is a ___ w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalopathy, hypotension likely due to autonomic neuropathy; hypothyroidism, hypertension, Hx of bariatric surgery, and other issues who was sent to the ED with hypotension. She was at a ___ appointment at her oncologist's office today where her SBP was noted to be in the ___. On review of systems, she endorsed nausea, vomiting, and diffuse abdominal pain. She also endorsed night sweats. She denied dysuria, cough, chest pain. Denied diarrhea, BPR, or melena. In the ED, initial vitals: 98.1 89 98/68 16 98% RA. Exam notable for suprapubic, periumbilical, epigastric, and RUQ TTP. Labs were notable for WBC 4.7 w/ 71% PMNs and 9% bands, Hgb 12.5, plts 232, BUN/Cr 94/3.3 (most recent Cr 2.9), HCO3 18, anion gap 27, ALT/AST 247/286, alk phos 590, T bili 3.2, Lactate 4.4. UA unremarkable. serum bHCG was 7 (equivocal). Stool was guiac negative. RUQ US notable for "Small amount of gallbladder sludge, without gallbladder distention or pericholecystic fluid., and Normal CBD caliber, without intrahepatic biliary dilatation." CT abdomen/pelvis was ordered, and BCx were collected. Patient received 2L NS, Zofran, and piperacillin/tazobactam and was admitted. On transfer, vitals were: 99.1 77 110/56 15 100% RA. On arrival to the MICU, the patient reported ongoing diffuse abdominal pain. Past Medical History: ___'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: ___ Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ================================== PHYSICAL EXAMINATION ON ADMISSION: ================================== Vitals: 99.1 77 110/56 15 100% RA. GENERAL: Alert, oriented, cachectic, ___ woman in mild distress HEENT: Sclera anicteric, MM dry, 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 ABD: soft, diffuse TTP worse in the RUQ, bowel sounds present EXT: Warm, well perfused, 2+ pulses, no edema SKIN: Dressing covering surgical site on R thigh NEURO: Moving all extremities ================================== PHYSICAL EXAMINATION ON DISCHARGE: ================================== Vitals: T 97.9 BP ___ HR ___ 96 RA GENERAL: Alert, oriented, cachectic, ___ woman in no acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: clean dressing over site of previous R IJ CVL LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs ABD: soft, mild diffuse TTP, no rebound, slight guarding EXT: Warm, well perfused. trace RLE edema SKIN: no rashes, lesions appreciated NEURO: Moving all extremities Pertinent Results: ====================== LABS ON ADMISSION ====================== ___ 10:03PM BLOOD ___ ___ Plt ___ ___ 10:03PM BLOOD ___ ___ ___ ___ 10:03PM BLOOD ___ ___ Tear ___ ___ 10:03PM BLOOD ___ ___ ___ 10:03PM BLOOD Plt ___ ___ 10:03PM BLOOD ___ ___ ___ 10:03PM BLOOD ___ ___ ___ 10:03PM BLOOD ___ ___ 10:03PM BLOOD ___ ___ 10:03PM BLOOD ___ ___ 10:08PM BLOOD ___ ___ 02:33AM BLOOD ___ ___ Base XS--1 ___ TOP ___ 12:19AM URINE ___ Sp ___ ___ 12:19AM URINE ___ ___ ___ 12:19AM URINE ___ Epi-<1 ___ 10:27AM URINE ___ ====================== PERTINENT INTERVAL LABS ====================== LFT TREND: ___ 10:03PM BLOOD ___ ___ ___ 02:17AM BLOOD ___ LD(LDH)-189 ___ ___ 09:35AM BLOOD ___ LD(LDH)-139 ___ ___ 12:06PM BLOOD ___ LD(LDH)-140 ___ ___ 05:37AM BLOOD ___ ___ ___ 09:53AM BLOOD ___ Lipase: ___ 10:03PM BLOOD ___ ___ 02:17AM BLOOD ___ Lactate: ___ 10:08PM BLOOD ___ ___ 02:33AM BLOOD ___ ___ 06:11AM BLOOD Ret ___ Abs ___ ====================== MICROBIOLGY ====================== ___ 9:15 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. 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 PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ ___ 11:10 ___. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ 11:10 ___. GRAM NEGATIVE ROD(S). ___ 10:18 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ 4:55 am URINE Site: CATHETER Source: Catheter. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. ___ - Blood Culture x 2 - Pending ___ - Blood Culture x 2 - Pending ___ - Blood Culture x 2 - Pending ====================== LABS ON DISCHARGE ====================== ___ 09:53AM BLOOD ___ ___ Plt ___ ___ 09:53AM BLOOD ___ ___ ___ 09:53AM BLOOD ___ ___ 09:53AM BLOOD ___ ====================== IMAGING/STUDIES ====================== Cardiovascular Report ECG Study Date of ___ 6:08:45 ___ Sinus rhythm. Compared to the previous tracing of ___ voltage has normalized. Cardiovascular Report ECG Study Date of ___ 9:26:38 ___ Baseline artifact. Probable sinus rhythm. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 1. Small amount of gallbladder sludge, without gallbladder distention or pericholecystic fluid. 2. Normal CBD caliber, without intrahepatic biliary dilatation. PELVIS LIMITED Study Date of ___ 5:51 ___ The uterus and ovaries are not visualized. The patient declined the transvaginal portion of the exam for further although evaluation CT ABD & PELVIS W/O CONTRAST Study Date of ___ 2:09 ___ 1. No etiology for the patient's pain identified. No evidence for infection in the abdomen and pelvis. No ovarian masses. 2. 0.9 cm opacity in the right lower lobe is new from ___ and may represent an infectious focus. Further evaluation with full chest CT is recommended 3. Significant improvement in hepatic steatosis. CT CHEST W/O CONTRAST Study Date of ___ Normal Chest CT. No evidence of active intrathoracic infection or malignancy. Right lower lobe opacity described on recent CT has almost completely resolved consistent with resolving atelectasis Brief Hospital Course: Ms. ___ is a ___ w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalopathy, hypotension likely due to autonomic neuropathy; hypothyroidism, hypertension, Hx of bariatric surgery, and other issues who was sent to the ED with hypotension and bandemia concerning for pancreatitis. #Septic shock: Patient presented with abdominal pain and fever, was found to have hypotension requiring IVF resuscitation and levophed for which she had a R IJ CVL placed. She was subsequently found to have GNR bacteremia which speciated to pan sensitive klebsiella in ___ bottles. She was initialy treated with broad spectrum antibiotics with IV Vancomycin/Zosyn which was narrowed to PO Ciprolfoxacin on discharge. Her blood pressure gradually increased and patient was off levophed with overall improvement of her symptoms. The etiology of the bacteremia as thought likely to be intrabdominal given pain and further findings described below in # abdominal pain. The differential also included pelvic process given adnexal tenderness on physical exam. Urinary etiologies were on the differential, though no urine culture prior to antibiosis obtained. The patient had previous hematoma evacuation of right thigh though wound appeared intact without evidence of infection. Of note the patient had a history of high risk HPV with ASCUS and there was concern that cervical etiologies could be the source of infection, particularly concerning for malignancy in the setting of her anemia and recent thrombosis as well. The patient understood the need for outpatient follow up with pap smear and IUD removal, and this was relayed to the patient's PCP as well. There were no other appreciate sources of infection on non contrast (in setting ___ on CKD) scans of the chest, abdomen and pelvis. The patient remained afebrile and hemodynamically stable after transfer to the medicine floor from the MICU. # Abdominal pain: Patient presented with abdominal pain and fever, was found to have GNR bacteremia speciated to pan sensitive klebsiella as above. In terms of source of infection, RUQ ultrasound was without evidence of cholecystitis or CBD dilatation and CT chest/abdomen was not notable for any abnormalities that could explain the symptoms. Elevated lipase with elevated LFTs was suggestive of pancreatitis; however, her pain was not entirely typical (not prominent in epigastrium) and CT abdomen did not show signs of pancrteatitis. Choledocholithiasis with a passed stone was thought to be a possibility as well given the downtrending LFTS. The differential also included pelvic etiology, though patient denied any urinary or vaginal symptoms. The patient's pain improved thoughout the admission and the patient was tolerating PO well on discharge. # Pancreatitis: Patient with lipase >3X ULN and abdominal pain (though somewhat atypical), however no evidence of pancreatitis on CT (though non contrast given ___ on CKD). Differential included EtOH given history of heavy drinking, biliary sources given elevated LFTs on admission as well. However lipase may also have been elevated for alternate etiologies in the setting of possible GI infection and may not have been representative of true pancreatitis. As above the patient's pain improved throughout the admission and was tolerating PO well on discharge. # Transaminitis: The differential included biliary infection, however RUQ US without cholecystitis or biliary dilatation, vs. choledochlithiasis with passed stone. Could consider contribution from heavy EtOH as well, though ration of ALT/AST less suggestive of this etiology. The patient's LFTs improved throughout the hospital course, and T bili normalized. # ___: Patient was recently discontinued from hemodialysis in the past month, as her renal function has recovered from a prior ATN. Cr was elevated on admission to 3.3. She received fluid and her creatinine gradually decreased. Creatinine on discharge was 1.8. # Anemia: Patient with chronic anemia extensively worked up in the past. No evidence of current hemolysis given normalized T bili. Likely component of hemoconcentration on admission in the setting of septic shock. Differential included infection and medication (Zosyn) causing bone marrow suppression, as well as heavy EtOh use. The patient did not require any blood transfusions during the admission. # EtOH abuse: Patient reported drinking ___ to 1 pint of hard liquor per day, with her last drink being the day before admission. She was placed on CIWA scale, and treated with multivitamins and thiamine. The patient attempted to leave AMA the day prior to discharge and was evaluated by psychiatry overnight who were concerned that the patient lacked capacity to at that time. The patient as re evaluated in the morning by psychiatry and after further discussion was deemed to have capacity regarding her plan of care. The patient was instructed regarding risks of alcohol withdrawal and referred to substance abuse treatment by psychiatry which she declined. # ___ metabolic acidosis: Resolved. Most likely due to lactic acidosis on presentation # Equivocal Serum HCG: Patient denied possibility of pregnancy. Urine hCG was negative. Patient with IUD in place with plans for outpatient removal. ==================== CHRONIC ISSUES ==================== # Hypothyroidism: Patient continued Levothyroxine Sodium 62.5 mcg PO DAILY. # Hx of wet beri beri: Furosemide was held in the setting of septic shock and held on discharge given no evidence of volume overload and soft pressures. # HTN: Home Hydrochlorothiazide held as well given infection and soft pressures as well. # Gout: Patient restarted on home allopurinol. ==================== TRANSITIONAL ISSUES ==================== - Please continue PO Ciprofloxacin through ___ (___) - Patient will need pap smear as outpatient for further evaluation of high risk HPV in setting of bacteremia, anemia, and thrombosis - Please discuss with PCP the need for restarting furosemide as an outpatient. - Patient will need removal of IUD - Patient will need removal of IVC filter in future - please discuss with PCP - ___ obtain CBC and Chem 10 at next PCP appointment for evaluation of anemia and Creatinine given ___ on CKD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Levothyroxine Sodium 62.5 mcg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Allopurinol ___ mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. Ascorbic Acid ___ mg PO BID 10. Ferrous Sulfate 325 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Acetaminophen 650 mg PO Q8H:PRN pain 13. Vitamin E 400 UNIT PO QD 14. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Levothyroxine Sodium 62.5 mcg PO DAILY 6. Multivitamins W/minerals 1 TAB PO BID 7. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*9 Tablet Refills:*0 8. Ascorbic Acid ___ mg PO BID 9. Cyanocobalamin 50 mcg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Vitamin D unknown PO DAILY 13. Vitamin E 400 UNIT PO QD Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses =================== Sepsis Klebsiella pneumoniae bacteremia Pancreatitis Transaminitis Abdominal Pain Acute on chronic kidney disease Anemia Anion gap metabolic acidosis Secondary Diagnoses =================== Hypothyroidism Alcohol use disorder Tobacco use disorder History of wet beri beri History of Wernicke's encephalopathy Gout Hypertension 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 stay at ___. You were admitted to the hospital with low blood pressure. You were treated with fluids and medications to increase your blood pressure. You were also found to have an infection in your blood stream. You will need to continue to take antibiotics for this infection for a total of 2 weeks. It is very important that you follow up with your primary care doctor. You will need to have a pap smear as an outpatient. You will also need to have your IUD removed. You should also discuss the optimal timing with your primary care doctor of removal of the IVC filter that was placed in your leg because of blood clots. Please take ciprofloxacin daily THROUGH ___ It was a pleasure to be a part of your care, Your ___ treatment team Followup Instructions: ___

10039708-DS-17

DS

2142-04-11 00:00:00

2142-04-12 02:16:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD (___) Paracentesis x3 (___) HD line placement (___) History of Present Illness: ___ with history of active alcohol abuse with cirrhosis, Wernicke encephalopathy, gastric bypass, severe anemia, stage IV CKD w/ history of temporary HD (last ___, HTN, DVT, p/w 2 weeks of abdominal distension and 2 days of abdominal pain. She reports worsening abdominal pain over the past 2 weeks, described as a constant dull pain diffusely through her abdomen. She has not been taking anything for pain, no Tylenol or NSAID use. She did try pepto-bismal, gas x without improvement She reports pain unchanged with position, hasn't been able to tolerating PO intake. She has noticed worsening abdominal distension. She reports nausea, dry heaves over the past few days and today had an episode of non-bloody emesis of clear fluid. She has been passing gas, denies diarrhea but has been having small non-bloody BMs. She has felt constipation and trialed Colace without improvement. She reports subjective fevers and chills over the past week, new palpitations over the past month, dyspnea with exertion and sometimes at rest. She reports chronic seasonal allergies with congestion and rhinorrhea. She reports chronic poor UOP, mild dysuria when starting stream. She denies any chest pain/pressure, confusion. She reports that she was seen at ___ about 2 weeks ago and treated with amoxicillin for a sinus infection. She had a blood transfusion a week ago. She is on pro-crit, increased to weekly recently. She reports that on day of presentation that she drank half a pint, usually drinks 1 pint daily but had been drinking less due to abdominal pain. At ___ had ethanol of 138, had diagnostic para done with 60 cc's removed results are pending, given IV CTX and IV thiamine. Past Medical History: EtOH Cirrhosis Stage IV CKD Wernicke's Encephalopathy Anemia Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT ___ s/p IVC filter (removed ___, with catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture. S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___ ___ History: ___ Family History: - T2DM - HTN - hypothyroidism - asthma - lung cancer (uncle) - ovarian cancer in ___ (MGM) Physical Exam: ADMISSION EXAM VS:98.7 PO 149 / 91 96 18 94 RA GENERAL: AOx3, mild distress HEENT: AT/NC, EOMI, PERRL, MM dry, icteric sclera HEART: RRR, S1/S2, ___ holosystolic murmur LUNGS: CTAB except crackles in bases (R>L), no wheezes, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, diffusely tender in all quadrants (L>R), no rebound/guarding, hepatomegaly EXTREMITIES: bilateral edema, R>L, 1+ non-pitting PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. Able to recount medical history and medications without difficulty. + asterixis SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM VS: 98.2 PO___ GENERAL: Cheerful, alert. HEENT: MMM. CV: RRR. RESP: CTAB without increased WOB ABDOMEN: Distended, soft, non-tender. EXTREMITIES: WWP. Bilateral ___ edema. NEURO: Alert, oriented, attentive. No asterixis. Pertinent Results: ADMISSION LABS ===================== ___ 12:30AM BLOOD WBC-10.4* RBC-2.47* Hgb-8.4* Hct-25.7* MCV-104* MCH-34.0* MCHC-32.7 RDW-21.2* RDWSD-79.6* Plt ___ ___ 12:30AM BLOOD Neuts-72.3* Lymphs-15.4* Monos-10.0 Eos-0.6* Baso-0.4 Im ___ AbsNeut-7.50* AbsLymp-1.60 AbsMono-1.04* AbsEos-0.06 AbsBaso-0.04 ___ 12:30AM BLOOD ___ PTT-29.9 ___ ___ 12:30AM BLOOD Glucose-67* UreaN-45* Creat-4.7* Na-140 K-3.5 Cl-100 HCO3-14* AnGap-26* ___ 12:30AM BLOOD ALT-32 AST-120* AlkPhos-239* TotBili-3.1* ___ 10:55AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.5* ___ 12:30AM BLOOD calTIBC-146* VitB12-868 Ferritn-560* TRF-112* ___ 11:46AM BLOOD ___ pO2-166* pCO2-35 pH-7.28* calTCO2-17* Base XS--9 Comment-GREEN TOP ___ 12:53AM BLOOD Lactate-3.7* MICRO ======================== __________________________________________________________ ___ 12:14 pm BLOOD CULTURE Source: Line-dialysis. Blood Culture, Routine (Pending): __________________________________________________________ ___ 10:53 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:47 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. __________________________________________________________ ___ 9:55 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. __________________________________________________________ ___ FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___. difficile DNA amplification assay- negartiv ___ CULTURE GRAM NEGATIVE ROD(S). ~1000 CFU/mL. ___ CULTUREnegative ___ CULTUREnegative IMAGING & STUDIES ====================== ___ CT Abdomen and Pelvis: Fatty liver with large volume ascites. No splenomegaly. Patient is status post gastric bypass with the excluded stomach appears severely edematous with thickened walls. Diffuse anasarca. ___ RUQ US: 1. Patent portal vasculature. Patent right and middle hepatic veins as well as the main hepatic artery. The left hepatic vein was not visualized. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Large volume ascites. ___ CXR Bilateral low lung volumes with moderate bibasilar atelectasis. No evidence of intraperitoneal free air. ___ TTE IMPRESSION: A left pleural effusion is present. Late bubbles seen in the left heart suggesting intrapulmonary shunting (bubbles appear at 8 beats). Normal biventricular size and systolic function. No pathologic valvular flow. Compared with the prior study (images reviewed) of ___ global biventricular systolic function is more vigorous. ___ EGD Findings: Esophagus: Protruding Lesions1-2 small varices were seen in the lower esophagus with no stigmata of bleeding. Stomach: Lumen:Evidence of a previous RNYGB was seen with a gastrojejunostomy. Duodenum: Flat LesionsA single small angioectasia was seen in the jejunal efferent limb. There was no evidence of bleeding. Otherduodenum not seen due to post surgical anatomy. Other findings:A jejunal feeding tube was placed into the small intestine endoscopically, however during oro-nasal conversion was noted to have become dislodged and was no longer as deep at the nares as when endoscopically placed. It was then advanced and bridled at 70 cm, however due to the fact it moved after endoscopic visualization it will require CXR prior to use. ___ CXR Increased opacities at the right lung base may reflect a combination of atelectasis and pneumonia. ___ Duplex Abdominal U/S 1. No evidence of portal vein thrombosis. Intermittent reversal flow within the left portal vein. Slow flow within the main portal, splenic, and superior mesenteric veins. 2. Cirrhotic liver without focal liver lesions. 3. Circumferential gallbladder wall edema, likely due to third spacing/underlying liver disease. 4. Small volume ascites. DISCHARGE LABS ====================== ___ 07:55AM BLOOD WBC-14.2* RBC-2.12* Hgb-7.1* Hct-21.1* MCV-100* MCH-33.5* MCHC-33.6 RDW-20.7* RDWSD-68.7* Plt ___ ___ 07:55AM BLOOD ___ PTT-35.3 ___ ___ 07:55AM BLOOD Glucose-121* UreaN-28* Creat-3.7* Na-136 K-4.3 Cl-95* HCO3-27 AnGap-14 ___ 07:55AM BLOOD ALT-20 AST-66* AlkPhos-219* TotBili-1.7* ___ 07:55AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.5 Brief Hospital Course: ================== BRIEF SUMMARY ================== ___ with active alcohol use, alcoholic cirrhosis, Stage IV CKD, admitted for alcoholic hepatitis, decompensated cirrhosis, and anuric ___ requiring initiation of HD. Patient was alert, oriented, and feeling well at discharge. Outpatient HD and Hepatology follow-up were arranged. ================== ACUTE ISSUES ================== # Decompensated alcoholic cirrhosis with ascites # Alcoholic hepatitis # Hepatic encephalopathy MELD Na 26 and Child C on presentation. LFTs and symptoms consistent with alcoholic hepatitis on cirrhosis; DF not high enough to warrant steroids. Had confusion and asterixis on admission consistent with HE. Had goals of care discussion with patient and family on ___ and confirmed she wants to pursue aggressive therapy, including EGD and HD; DNR/DNI in the event of arrest. She wants to be abstinent and eventually be placed on the transplant list. EGD showed ___ small varices with no stigmata of bleeding. She started lactulose and rifaximin for HE. Serial diagnostic paracentesis were negative for SBP. She had large-volume paracentesis on ___ for relief of tense ascites. ___ need outpatient LVP depending on whether she continues to be able to remove fluid via UF. She was maintained on high protein, ___ gm sodium diet and tube feeds. She will follow up with hepatology as an outpatient. # Anuric ___ on CKD Stage IV # ?Hepatorenal syndrome She did not respond to albumin challenge, nor to octreotide/midodrine for possible HRS. Octreotide was stopped but she was maintained on midodrine for soft BPs. Outpatient HD ___ arranged. PPD negative. # Abdominal pain Multifactorial - alcoholic hepatitis, tense ascites, and possible acute on chronic pancreatitis (lipase 190). Was initially treated empirically for possible SBP but cell counts were not consistent; prophylaxis not indicated per Hepatology. Pain much improved after LVP ___. Repeat diagnostic para ___ remained negative. # Severe protein calorie malnutrition Nutrition was consulted. Dobhoff was placed for ongoing tube feeds, and high-protein diet and supplements were prescribed. # Hypoxemia # Hepatic hydrothorax # ?Hepatopulmonary syndrome Patient had new 2L O2 requirement in setting of large R pleural effusion/hepatic hydrothorax, resolved after LVP. TTE did show evidence of pulmonary shunting which could represent HPS. # Leukocytosis Patient developed a new leukocytosis several days prior to discharge. Also had slight rise in bili and alk phos around this time. No fevers or localizing symptoms. Repeat infectious workup was unrevealing, including repeat diagnostic paracentesis, except for CXR equivocal for pneumonia. She was started on empiric oral levofloxacin for possible pneumonia, and leukocytosis stabilized for several days and LFTs improved somewhat prior to discharge. # Chronic macrocytic anemia Retics inappropriately low, consistent with marrow suppression. Likely multifactorial - EtOH, cirrhosis, splenomegaly, malnutrition, renal failure. No evidence of acute bleeding and not iron deficient on labs. B12 wnl. Hemolysis labs negative. EGD results as above. Will need continued attention as outpatient. # Chronic thrombocytopenia Likely multifactorial - EtOH, cirrhosis, splenomegaly, malnutrition. No evidence for DIC or other consumptive process. # Coagulopathy PTT was elevated due to SC heparin, normalized after this was held and dose decreased to 2500 units BID. ___ were elevated due to cirrhosis. No evidence of bleeding, DIC, or other acute pathology. # Alcohol use disorder Reports daily drinking prior to admission, about ___ pint qod to 1 pint/day. Last drink ___. Denies h/o withdrawal. She received IV thiamine x 3 days and maintained on oral thiamine, folate and MVI. We discussed the importance of abstinence and SW helped arrange outpatient supports. We also discussed pharmacological assistance to treat alcohol use disorder and depression, however patient deferred at this time. # Chronic RLE edema # History of RLE provoked DVT DVT occurred after left knee fracture. IVC filter was placed in ___. Course complicated by need for catheter lysis and extravasation into right thigh per patient. No longer on anticoagulation. Repeat Doppler this admission negative for persistent DVT. She continued on half-dose heparin SC. ===================== CHRONIC ISSUES ===================== # Hypothyroidism TSH 2.1 this admission. Continued home levothyroxine. # Gout Reduced home allopurinol from 100 mg daily to every other day due to renal failure. ================== TRANSITIONAL ISSUES =================== - WBC elevated to 14.0 on discharge. Please recheck at HD on ___ and evaluate for signs of infection. Discharged on empiric levofloxacin for possible pneumonia (500mg q48h, last day ___. - Other medications started: midodrine 20mg TID, lactulose titrated to ___ BM/day, rifaximin 550mg BID. - HD arranged ___ - ___ follow-up arranged - Discharged with tube feeds - ___ need intermittent LVP depending on whether she tolerates UF - Did not start beta blocker for varices b/c HR ___ - Patient should have CBC and MELD labs checked checked within 1 week of discharge. Script provided. # CODE: DNR/DNI # CONTACT: ___ (son, HCP) ___ > 30 minutes in patient care and coordination of discharge on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Levothyroxine Sodium 62.5 mcg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Thiamine 100 mg PO DAILY 5. Allopurinol ___ mg PO DAILY 6. Ascorbic Acid ___ mg PO BID 7. Cyanocobalamin 50 mcg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Pyridoxine 100 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Vitamin E 400 UNIT PO QD 12. Epoetin ___ ___ units SC EVERY 2 WEEKS (MO) Discharge Medications: 1. Lactulose 30 mL PO TID RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth ___ times per day Disp #*50 Package Refills:*0 2. Levofloxacin 500 mg PO Q48H Duration: 5 Days RX *levofloxacin 500 mg 1 tablet(s) by mouth every other day Disp #*3 Tablet Refills:*0 3. Midodrine 20 mg PO TID RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*3 4. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*5 5. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID RX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08 gram-1.8 kcal/mL 237 mL by mouth three times a day Refills:*0 6. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 7. Allopurinol ___ mg PO EVERY OTHER DAY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Levothyroxine Sodium 62.5 mcg PO DAILY 10.Outpatient Lab Work ICD-10 Code: ___ Please obtain by ___ and fax to: Dr. ___ ___ CBC; Chem-10 (Na, K, Bicarb, Cl, BUN, Cr, Ca, Mg, Phos); Hepatic Panel (AST, ALT, Alk Phos, Tbili, Albumin, INR) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Alcoholic hepatitis Decompensated alcoholic cirrhosis with ascites Acute on chronic renal failure Hepatic encephalopathy Severe protein calorie malnutrition Alcohol use disorder Thrombocytopenia Coagulopathy Anemia Community-acquired pneumonia Secondary Diagnoses ==================== Hypothyroidism Gout 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. WHY WAS I ADMITTED? You were admitted because alcohol damaged your liver and your kidneys. WHAT HAPPENED TO ME WHILE I WAS IN THE HOSPITAL? -You were followed closely by our liver and kidney experts. -You were started on dialysis for your kidneys. This helps remove fluid from your body since you are unable to urinate. -You had an endoscopy test which showed some dilated veins in your esophagus. -You had a tube placed from your nose into your intestine to give you more nutrition to help you recover. WHAT SHOULD I DO WHEN I GET HOME? -Follow up with your liver doctors, kidney doctors ___ see them at dialysis), and your primary care doctor. -___ will need to go to dialysis three times a week ___, ___. -You may need to have fluid drained from your abdomen from time to time. This can be arranged through your liver doctor. -___ all your medicines and continue your tube feeds. -Do not drink any alcohol. We strongly recommend you sign up for a program such as Alcoholic Anonymous to help you stay sober. We wish you all the best. Sincerely, Your ___ Care Team Followup Instructions: ___

10039708-DS-20

DS

2144-01-21 00:00:00

2144-01-23 14:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding (___), stomach ulcer, ESRD on HD, HTN, asthma who presents with altered mental status from dialysis. She had a recent admission (___) with a similar presentation, and was treated for hepatic encephalopathy with lactulose, alcoholic hallucinosis with lorazepam, and uremic encephalopathy with resumption HD. In the ED initial vitals: 96.6, 55, 159/80, 16, 99% RA - Exam notable for: Lethargic but arousable, Ox2-3, +asterixis - Labs notable for: CBC: ___ Chem7: lytes OK LFTs: AST/ALT: 73/33, ALP 429, Tbili 1.8, lip 50 Coags: INR 1.1 EtOH level: negative - Imaging notable for: Clean CTH, non-con RUQUS: 1. There is cholelithiasis without evidence of cholecystitis. 2. Echogenic kidneys which can be seen with chronic medical renal disease. - Patient was given: Home meds Ceftriaxone for SBP(?) iso HE On arrival to the floor the patient states that her confusion is starting to improve. Her son is at bedside and agrees. She describes being at dialysis and feeling more confused along with whole body cramping, with a single episode of non-bloody non-bilious emesis. Of note, she denies abdominal pain despite eliciting pain on exam. She stopped taking lactulose several months ago due to the diarrhea. Last drink was yesterday and she drinks around 5 shots of vodka/brandy a day. Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT ___ dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___ ___ Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: ___ Family History: Mother ASTHMA DIABETES ___ HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: ___ ___ Temp: 97.8 PO BP: 133/80 R Lying HR: 61 RR: 16 O2 sat: 99% O2 delivery: ra Dyspnea: 0 RASS: -1 Pain Score: ___ GENERAL: NAD, tired appearing HEENT: Sclera icteric CARDIAC: Regular rhythm, normal rate. LUNGS: Bilateral crackles, No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: mild non pitting edema to ankles SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 to person place and time. asked to say days of week backward and she answered days of week forward. asterixis on exam DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 812) Temp: 98.5 (Tm 98.9), BP: 101/63 (94-121/52-75), HR: 80 (77-92), RR: 18 (___), O2 sat: 95% (94-100), O2 delivery: Ra, Wt: 166.7 lb/75.62 kg (163.3-166.7) GENERAL: NAD, tired appearing HEENT: Sclera icteric CARDIAC: Regular rhythm, normal rate. LUNGS: Bilateral crackles, No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: mild non pitting edema to ankles SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 to person place and time. asterixis on exam. Days of week backwards Pertinent Results: ADMSSION LABS: ======================= ___ 01:15PM BLOOD WBC-5.5 RBC-3.09* Hgb-10.4* Hct-32.9* MCV-107* MCH-33.7* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt Ct-73* ___ 01:45PM BLOOD ___ PTT-32.1 ___ ___ 01:15PM BLOOD Glucose-85 UreaN-35* Creat-7.9*# Na-136 K-4.2 Cl-98 HCO3-22 AnGap-16 ___ 01:15PM BLOOD ALT-33 AST-73* AlkPhos-429* TotBili-1.8* ___ 01:15PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.4 Mg-2.3 ___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ======================== ___ 05:05AM BLOOD WBC-7.5 RBC-2.57* Hgb-8.5* Hct-28.0* MCV-109* MCH-33.1* MCHC-30.4* RDW-17.8* RDWSD-70.4* Plt Ct-92* ___ 05:05AM BLOOD ___ PTT-31.0 ___ ___ 05:05AM BLOOD Glucose-105* UreaN-18 Creat-5.3*# Na-138 K-3.6 Cl-98 HCO3-26 AnGap-14 ___ 05:05AM BLOOD ALT-26 AST-66* AlkPhos-365* TotBili-1.0 ___ 05:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1 PERTINENT IMAGING: ======================= CT HEAD IMPRESSION: 1. No acute intracranial findings. LIVER OR GALLBLADDER US IMPRESSION: 1. ThEre is cholelithiasis without evidence of cholecystitis. 2. Echogenic kidneys which can be seen with chronic medical renal disease. Brief Hospital Course: PATIENT SUMMARY =================== Ms. ___ is a ___ yo F with hx of EtOH cirrhosis complicated by esophageal varices s/p recent banding (___), stomach ulcer, ESRD on HD, HTN, asthma who presented with altered mental status from dialysis. The AMS is likely multi-factorial including lethargy from dialysis, recent excessive etoh intake, and non-compliance with lactulose. Specifically, she reports not taking lactulose for several months due to it causing diarrhea, therefore, she may only need 1x dosing a day. Her mental status completely improved the day after admission. The patient was encouraged to stop drinking and educated on the importance of taking lactulose and rifaximin. The patient is unaware of the medications she is taking and would benefit from close follow up. We discharged her with some medications to bedside. Please see below for more information TRANSITIONAL ISSUES: ==================== MED CHANGES [] Gave the patient four tiny bottles of lactulose and instructed her to use it if she or her son was concerned about confusion. Also filled rifaximin [] Filled Advair prescription for asthma. Unclear if she is using inhaler and would likely benefit from getting a rescue inhaler as well [] Filled baclofen that she takes for back pain (tiny dose) but this may be a deliriogenic that should be avoid in the future if she has recurrent confusion [] Gave the patient folic acid and thiamine given concern for malnutrition and Wernickes during previous hospitalization [] It was too soon to fill her levothyroxine. She states she has it at home. [] It was too soon to fill midodrine and dialysis vitamins [] Continued Alcohol Cessation Counseling [] Encourage cessation of tobacco --Discharge Hgb 8.5 --Discharge weight 166 lbs ACTIVE ISSUES ============= # Encephalopathy Multifactorial with most important factor likely hepatic encephalopathy. Patient and son confirm that she has not taken her lactulose for ~ 1 month, had drank a marked amount of alcohol the night prior. Has hx of concern for wernicke's encephalopathy and prior admissions for alcoholic hallucinosis but no signs of withdrawal this admission. Treated predominantly with lactulose with recovery of mental status and folate and thiamine by mouth. #Alcohol use disorder Patient met with social work on last hospitalization but stated she does not wish to stop drinking at this time. Was given resources for relapse prevention. This admission she states that she has a social worker already and not interested in another consultation. Patient received thiamine, MV, and folate. She was monitored for signs of withdrawal but did not require treatment. #Etoh Cirrhosis History of etoh cirrhosis with continued etoh intake. MELD score 21 Childs Class 6 on admission. Not a transplant candidate given continued etoh intake. Volume: no ascites on RUQUS, not discharged on diuretics and denies taking at home Infection: see above Bleed: Hgb 10.4 on admit and last was 7.3. history of anemia requiring transfusions, last EGD in ___ s/p banding of varices. Encephalopathy: on home rifaximin, but was not taking lactulose, discharged with lactulose PRN confusion CHRONIC ISSUES: ====================== #ESRD on iHD (___) Missed ___ dialysis as she was sent to ED. She received dialysis while in patient #asthma patient is taking advair at home twice a day. #hypothyroidism continued home levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Baclofen 2.5 mg PO BID 3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 7. Levothyroxine Sodium 62.5 mcg PO DAILY 8. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 9. Midodrine 20 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. rifAXIMin 550 mg PO BID 13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID Discharge Medications: 1. Lactulose 30 mL PO Q6H:PRN encephalopathy RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours Disp #*1 Bottle Refills:*1 2. Thiamine 100 mg PO DAILY Duration: 5 Days RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Allopurinol ___ mg PO EVERY OTHER DAY RX *allopurinol ___ mg 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*1 4. Baclofen 2.5 mg PO BID RX *baclofen 5 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 5. Dialyvite (B complex ___ complex-vitamin C-folic acid) ___ mg-mg-mcg-mg oral DAILY RX *B complex ___ [Dialyvite] 1 mg-100 mg-300 mcg-50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing RX *fluticasone propionate 50 mcg/actuation 1 spray intranasally each nostril, once a day Disp #*1 Spray Refills:*0 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID RX *fluticasone propion-salmeterol 100 mcg-50 mcg/dose 1 inhaled twice a day Disp #*1 Disk Refills:*1 8. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet by mouth once a day Disp #*30 Tablet Refills:*1 9. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 10. Levothyroxine Sodium 62.5 mcg PO DAILY RX *levothyroxine 125 mcg 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 15. rifAXIMin 550 mg PO BID RX *rifaximin [___] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Primary: Hepatic Encephalopathy Secondary: Alcohol Intoxication ESRD on Dialysis Cirrhosis 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 the ___ ___. You came to the hospital because you were confused and sleepy at dialysis. You were given lactulose to help with your confusion. This medicine works by helping you stool frequently. Please remember that if you do not take lactulose the confusion will return. We also encourage you to stop drinking alcohol. Your liver disease is worsening and you may die if you do not stop drinking. We wish you all the best, and once again it was a pleasure caring for you. Sincerely, Your ___ Team Followup Instructions: ___

10039709-DS-7

DS

2136-05-14 00:00:00

2136-05-14 17:50:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Pneumococcal Vaccine / nuts / treenuts Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ M with H/O pulmonary embolus, hypertension, and asthma presents with 2 days of right lower chest pain. The patient was on a boat 14 miles off shore on ___ when he felt nauseated, then developed right-sided lower chest discomfort, ___ in severity, with occasional spikes of sharp ___ pain that radiated to the back and shoulder. He presented initially to ___ where EKG showed "possible age indeterminate inferior MI", however the actual tracing was not available for review. Troponins negative, D-dimer normal, CXR normal. He was started on a heparin gtt and was loaded with clopidogrel. He was also given nitropaste and morphine with some improvement of his symptoms. He was then transferred to ___. At the ___ ED, initial vitals were T 97.4 HR 88 BP 158/87 RR 18 SaO2 96% on RA. Labs significant for normal troponins x2, bicarb 20, LDH 345. He was given heparin gtt, SL NTG, metoprolol 25 mg, ipratropium nebs, IV morphine x3, and ondasentron. He was also given his home medications: valsartan 160 mg, ranitidine 150 mgx2, atenolol 50 mg, Advair, tiotropium, aspirin 81 mg. Cardiology saw the patient and recommended stopping the heparin gtt, controlling chest pain with NTG, and trending cardiac biomarkers. On arrival to the cardiology floor, the patient reported persistent ___ right sided chest pain, unchanged from previous. The pain had been waxing and waning but mostly constant with bursts of sharp pain. It was non-pleuritic, non-exertional. No pain with palpation. Sharp pain radiated to his back with persistent associated nausea. He stated that morphine and NTG did not help much to relieve pain. He stated the discomfort felt different than at the time of his prior PE. He denied recent travel, however drives a lot for work. No recent surgeries, no H/O cancer. Past Medical History: - Asthma - Seasonal allergies - History of pulmonar embolus (thought to be provoked by flight from ___ ___, now s/p 6 months of warfarin - Hypertension - Previous knee surgery - Negative stress test several years ago Social History: ___ Family History: Father had CABG at age ___. No other family history of heart disease. Physical Exam: On Admission General: ___ middle aged Caucasian man in NAD, comfortable, pleasant VS: T 98.2 BP 150/93 HR 72 RR 24 SaO2 96% on RA HEENT: NCAT, PERRL, injected sclera bilaterally, mucous membranes moist Neck: supple, no JVD CV: regular rhythm; no murmurs, rubs or gallops; no pain with palpation of right lower chest Lungs: CTAB--no wheezing, rales or rhonchi Abdomen: soft, non-tender, not distended, BS+ Ext: no edema, no erythema, no pain with palpation of calves bilaterally Neuro: moving all extremities grossly, grossly intact At discharge General: NAD Neck: supple, no JVD CV: regular rhythm; no murmurs, rubs or gallops; no pain with palpation of right lower chest Lungs: CTAB--no wheezing, rales or rhonchi Abdomen: soft, non-tender, not distended, BS+ Ext: no edema Neuro: grossly intact Pertinent Results: ___ 02:30PM BLOOD WBC-8.3 RBC-4.44* Hgb-13.5* Hct-40.9 MCV-92 MCH-30.5 MCHC-33.1 RDW-13.2 Plt ___ ___ 02:30PM BLOOD ___ PTT-79.3* ___ ___ 02:30PM BLOOD Glucose-91 UreaN-11 Creat-0.9 Na-138 K-4.6 Cl-106 HCO3-20* AnGap-17 ___ 02:30PM BLOOD ALT-29 AST-32 LD(LDH)-345* AlkPhos-34* TotBili-0.6 ___ 02:30PM BLOOD Lipase-32 ___ 02:30PM BLOOD cTropnT-<0.01 ___ 08:24AM BLOOD cTropnT-<0.01 ___ 01:06PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 08:12AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 08:12AM BLOOD WBC-7.0 RBC-4.76 Hgb-14.7 Hct-44.9 MCV-94 MCH-30.9 MCHC-32.8 RDW-13.6 Plt ___ ___ 08:12AM BLOOD Glucose-106* UreaN-12 Creat-1.0 Na-141 K-4.4 Cl-106 HCO3-30 AnGap-9 ___ 08:12AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.5 EKG ___: NSR, HR 68, normal axis, normal intervals, q wave in lead III, T wave invesion in lead III, no ST segment changes CTA chest ___ Adequate opacification of the pulmonary arterial tree was noted. No filling defects are identified in the pulmonary arterial tree to the subsegmental level. No evidence of pulmonary embolus. The main pulmonary artery is normal in caliber. Respiratory motion artifact limits assessment of the ascending aorta, however no aneurysmal dilation of the thoracic aorta is identified. No intrathoracic or extrathoracic lymphadenopathy. Cardiac size is within normal limits. No pericardial or pleural effusions are identified. Minor bibasilar atelectasis is noted. No evidence of consolidation. No suspicious nodules are identified. Limited assessment of the subdiaphragmatic structures is unremarkable. OSSEOUS STRUCTURES: No suspicious focal osteolytic or osteoblastic lesions are identified. Mild multilevel degenerate changes of the thoracic spine are evident. IMPRESSION: No evidence of acute pulmonary embolus. No abnormality identified to explain patient's chest pain. Brief Hospital Course: ___ M with H/O pulmonary embolus in ___, hypertension, asthma presented with 2 days of right lower chest pain. ACUTE ISSUES: # Chest pain: Etiology unclear. The patient's cardiac biomarkers were negative x4, and there were no worrisome EKG changes despite prolonged pain. CXR and CTA chest were negative for pneumonia, pulmonary embolus or aortic dissection. LFTs and lipase were within normal limits. His pain was treated symptomatically with pain medications, and by discharge his pain had improved. He should follow up with his PCP for further management and evaluation. CHRONIC ISSUES: # Asthma: Continued home Advair, tiotropium. Gave prn nebs, cough medications. # GERD: Continued ranitidine # Hypertension: Continued home valsartan, atenolol TRANSITIONAL ISSUES: - PCP follow up for ongoing management Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 160 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Ranitidine 150 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Ranitidine 150 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Valsartan 160 mg PO DAILY 8. Ibuprofen 600 mg PO Q8H pain Take this medication with food. RX *ibuprofen 200 mg ___ tablet(s) by mouth q8h prn Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: -Chest pain, etiology uncertain, but without objective evidence of ischemia or myocardial infarction, pulmonary embolus, aortic pathology, or intrathoracic process -Asthma -Gastroesophageal reflux disease -Hypertension 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. You were admitted for chest pain. Your EKG and lab tests were reassuring that you did not have a heart attack. Imaging of your lungs did not reveal a pulmonary embolism or other concerning findings. Your pain was treated with pain medications and improved. Please follow up with your PCP for further management. If you symptoms worsen, please ___ medical attention. Best, Your ___ care team Followup Instructions: ___

10040025-DS-22

DS

2145-07-31 00:00:00

2145-08-01 14:24:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: allopurinol Attending: ___. Chief Complaint: "I had A-fib" Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a ___ year old female with a PMHx of paroxysmol afib on coumadin, CAD w/ MI ___ s/p PCI, CHF, IDDM2 who is presenting with palpitations and ___ edema. Patient started to have symptoms 5 days ago with worsening ankle swelling despite medication compliance. This morning she felt her heart pounding and palpitations similar to an episode ___ months ago when she was diagnosed with AFib, however it was worse then. She denies DOE, orthopnea, PND. Denies fevers, chills, chest pain, nausea, vomiting or diarrhea. Due to persistent symptoms this morning, patient presented to the ED for evaluation. Of note, patient was admitted at the end of ___ with ___ cellulitis, ___, HTN and hyperglycemia. In the ED intial vitals were: 98.5, 122, 182/78, 18, 98% RA. EKG showed afib with RVR to 124 without ischemic changes. Labs were notable for WBC 9.6K, Hct 35.5, INR 2.0, BNP of 2393, Cr 1.6 with K of 3.8. CXR showed hyperinflation without cardiopulmonary process. Patient was given: 40mg IV lasix, metoprolol 25mg PO followed by metoprolol IV 5mg x2. HR improved to ___ with metoprolol. Vitals on transfer: 97 158/88 16 99% RA. On the floor she is having mild chest discomfort but it is improved. She is very upset that she was not given insulin with dinner. ROS: Per HPI. Denies stroke/TIA/DVT/PE. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia + Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: Reportedly in ___. - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - HTN, labile - HLD - HYPOTHYROIDISM - RETINAL ARTERY OCCLUSION - BRANCH - MIGRAINE EQUIVALENT - CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) - CHF (EF 60-65% in ___ - OBESITY, - insulin-dependent DMII - Gout - Renal artery stenosis - CKDIII - Anemia - a-fib on anticoagulation - Depression Social History: ___ Family History: "Everybody's dead. I don't remember." Physical Exam: ADMISSION PHYSICAL: ============================= VS: 98.1, 168/110, 122, 20, 99/RA GENERAL: obese, well appearing female in NAD HEENT: Anicteric sclera, PERRL, MMM NECK: Mild JVD CARDIAC: Tachycardic, irregular, normal S1/S2, no m/r/g LUNGS: CTA b/l, non-labored ABDOMEN: Obese, +BS, soft, NT/ND EXTREMITIES: 1+ edema of the ankles. WWP. 2+ DP pulses bilaterally. DISCHARGE PHYSICAL: ============================== Vitals: 97.5, 141/71 (115-155 SBP), 40s-90s in AF, 18, 98 on RA Last 24 hours I/O: 1420/1400 Last 8 hours I/O: 60/500 Weight on admission: 103.8 kg DISCHARGE WEIGHT: 103 kg GENERAL: obese, well appearing female in NAD NECK: No appreciable JVD CARDIAC: irregular, normal S1/S2, no m/r/g LUNGS: very mild crackles at bases, non-labored ABDOMEN: Obese, +BS, soft, NT/ND EXTREMITIES: trace to 1+ edema of the ankles. WWP. Pertinent Results: ADMISSION LABS: ====================== ___ 11:45AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.8* Hct-35.5* MCV-96 MCH-31.9 MCHC-33.1 RDW-13.9 Plt ___ ___ 11:45AM BLOOD Neuts-72.6* ___ Monos-6.5 Eos-2.4 Baso-0.2 ___ 11:45AM BLOOD ___ PTT-42.0* ___ ___ 11:45AM BLOOD Glucose-187* UreaN-47* Creat-1.6* Na-136 K-7.2* Cl-98 HCO3-26 AnGap-19 ___ 11:45AM BLOOD proBNP-2393* ___ 01:17PM BLOOD CK-MB-2 cTropnT-0.02* ___ 05:35AM BLOOD CK-MB-2 cTropnT-0.01 ___ 05:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0 DISCHARGE LABS: ====================== ___ 05:55AM BLOOD WBC-5.7 RBC-3.20* Hgb-10.1* Hct-30.3* MCV-95 MCH-31.7 MCHC-33.5 RDW-14.3 Plt ___ ___ 05:55AM BLOOD ___ ___ 05:55AM BLOOD Glucose-219* UreaN-86* Creat-2.7* Na-133 K-3.8 Cl-93* HCO3-26 AnGap-18 ___ 05:55AM BLOOD Mg-2.3 STUDIES: ====================== CXR (___): FINDINGS: The lungs are hyperinflated but clear of focal consolidation, effusion, or vascular congestion. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities identified. IMPRESSION: Hyperinflation without acute cardiopulmonary process. Brief Hospital Course: Patient is a ___ with history of paroxysmal afib on coumadin, CAD w/ MI x4 and stents, CHF, and IDDM2 presenting with palpitations and ___ edema. # Atrial fibrillation: Patient with afib with RVR in ED possibly related to mild volume overload triggering worsening afib -Discharged on warfarin 5 mg daily, with instructions to have INR checked on ___ -Changed carvedilol to metoprolol succ 100 daily for rate control -Added diltiazem 30 mg Q6H, and transitioned to 180 ER daily on discharge # Hypertension: Hypertensive to 160s/100s on arrival to the floor. -Switched home carvedilol for metoprolol and diltiazem as above -Initially increased irbesartan to 150mg BID but discharged on 150 mg once daily given ___ -Held spironolactone on discharge for ___ # Acute on chronic diastolic heart failure: Last EF 60-65% in ___. Unclear cause for CHF exacerbation, though patient was recently on prednisone. Denies dietary or medication indiscretions. No recent illnesses. Leg swelling started before palpitations, so suspect CHF triggered AF with RVR and not the other way around. -Trops and CK-MB negative -Diuresis with 2.5 of metolazone and 120 IV lasix -Discharge with torsemide 40 mg daily for home diuretic, though this may need to be uptitrated as tolerated based on renal function -DISCHARGE WEIGHT HERE: 103 kg #Flu exposure from roommate -Received oseltamivir x1 for prophylaxis then refused. # CAD: -Continued asa 81mg -Metoprolol and irbesartan as above -Consider statin as outpatient # IDDM. -Continued home lantus 20u QHS -HISS with 10u with meals # CKD III: Baseline cr 1.6, likely related to DM and HTN. Increase in Cr to 2.7 in the setting of diuresis. -Patient given Rx to have Chem7 checked on ___, which should be followed up by PCP ___ ___ -Held home spironolactone, decreased home torsemide as above Other home medications were continued without changes. TRANSITIONAL ISSUES: [ ] continue to titrate rate control medications, antihypertensive, and diuretics per outpatient cardiology and primary care [ ] consider statin for history of CAD [ ] f/u lytes and INR from ___ at PCP appointment on ___ to ensure resolution/improvement ___ (secondary to diuresis) and adjust warfarin dose PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheezing 2. Aspirin 81 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Carvedilol 25 mg PO BID 5. Ezetimibe 10 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. irbesartan 150 mg oral Daily 8. Levothyroxine Sodium 112 mcg PO DAILY 9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 10. Spironolactone 25 mg PO DAILY 11. Torsemide 40 mg PO BID 12. Warfarin 2 mg PO 5X/WEEK (___) 13. Cyanocobalamin 1000 mcg IM/SC MONTHLY 14. Warfarin 2.5 mg PO 2X/WEEK (___) 15. Glargine 20 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheezing 2. Aspirin 81 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Ezetimibe 10 mg PO DAILY 5. Ferrous Sulfate 325 mg PO BID 6. Glargine 20 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner 7. Levothyroxine Sodium 112 mcg PO DAILY 8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 9. Cyanocobalamin 1000 mcg IM/SC MONTHLY 10. Outpatient Lab Work INR (ICD9 427.31) CHEM7 (ICD9 428.30) Please send results to ___. ___ 11. irbesartan 150 mg ORAL DAILY 12. Torsemide 40 mg PO DAILY 13. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 14. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Warfarin 5 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation with rapid ventricular response acute on chronic diastolic heart failure 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 palpitation and leg swelling. We think that your legs were swollen because your heart was not adequately circulating blood (heart failure). As a result, your heart also became stressed and started beating too fast (AFib with rapid ventricular response). We changed one of the medicines that control your heart rate in order to slow it down and added a new medicine to help control your heart rate and blood pressure. We also gave you medicine to remove fluid from your body (called a diuretic). Your heart rate came under control and your leg swelling improved. You also had an injury to your kidneys, likely from trying to remove fluid with diuretics. You will have your kidney function tests monitored closely after discharge and we have stopped or decreased medications that may be harmful to your kidneys. You should weigh yourself every day and call your PCP if your weight goes up by more than 3 lbs, as this could indicate that you are having more fluid build-up. Unfortunately, during your stay you were exposed to someone with the flu. We offered you medicine to prevent you from also getting the flu and monitored you for signs of illness. We have scheduled follow up appointments with cardiology and your primary care provider (detailed below). You should review your discharge medication list because it details the changes we made to your home medications. We are giving you a prescription to have your INR and electrolytes (including kidney function tests) checked on ___. It was a pleasure taking care of you. Sincerely, Your ___ Care Team Followup Instructions: ___

10040025-DS-24

DS

2147-06-22 00:00:00

2147-06-23 15:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___ Chief Complaint: Dyspnea and cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo with h/o CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, presented to ED w/3 days of productive cough and gradual onset dyspnea. Patient reports she developed URI symptoms soon after ___, including nasal congestion and cough. Over the past few days cough has worsened, productive of white/yellow sputum. She has also noted some SOB when lying flat and worsening dyspnea on exertion. She denies fevers, chest pain, abdominal pain, nausea, vomiting, diarrhea or urinary symptoms. She has been compliant with all of her medications, including her diuretics and denies worsening leg swelling or PND. Weight is down to 199lbs, from 210 in the past (intentional weight loss). No increase in her weight since she has been feeling unwell. Patient has been hospitalized in past w/HF exacerbation and states that her symptoms are not similar to those episodes. No history of asthma or COPD. In the ED, initial vitals were: 98.1, 71, 168/80, 16, 93% NC (improved to 95% on RA w/nebs). Exam notable for diffuse wheezes, no crackles. Labs revealed WBC 8.7, Hb 10.4 (baseline), BUN/CR 110/3.5 (unclear baseline-last measured ___ 93/2.41), trop 0.03, BNP ___. EKG NSR rate 70, no ischemic changes. UA negative, CXR showed "possible minimal pulmonary vascular congestion, no focal consolidation". Patient given duonebs with improvement in her respiratory status and transferred to medicine for further management. On the floor, patient complains of persistent productive cough. She is also requesting oxygen to be worn while she sleeps, for comfort (on no O2 at home). No additional acute complaints. Review of systems: (+) Per HPI (-) Otherwise 10 point ROS negative. Past Medical History: - HTN, labile - HLD - HYPOTHYROIDISM - RETINAL ARTERY OCCLUSION - BRANCH - MIGRAINE EQUIVALENT - CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) - CHF (EF 60-65% in ___ - OBESITY, - insulin-dependent DMII - Gout - Renal artery stenosis - CKDIII - Anemia - a-fib on anticoagulation - Depression Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION ========== Vital Signs: 97.9 PO 152 / 72 L Sitting 63 20 90 RA Weight: 90.58kg (199.7lbs) General: sitting up in bed, appears comfortable, NAD HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, JVP difficult to appreciate, given obese neck, but does not appear grossly elevated. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement throught, diffuse expiratory wheezes. No crackles. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding Ext: Warm, well perfused, trace edema midway up calves b/l Neuro: no focal deficits LABS: Reviewed, see below. DISCHARGE ========= Vitals: 98.4, HR 78, 93% RA, RR 20, BP ___ GENERAL: Alert, NAD, sitting up in bed HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVP difficult to appreciate due to habitus RESP: Kyphotic chest. Poor air movement but no wheezing or crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs ABD: +BS, soft, obese, nontender, nondistended. EXT: warm, well perfused. Trace edema bilaterally of medial ankles. NEURO: Grossly intact motor and sensory function. Pertinent Results: ADMISSION LABS ============== ___ 08:20PM BLOOD WBC-8.7 RBC-3.43* Hgb-10.4* Hct-33.6* MCV-98 MCH-30.3 MCHC-31.0* RDW-13.6 RDWSD-48.1* Plt ___ ___ 08:20PM BLOOD Neuts-72.5* Lymphs-18.4* Monos-6.7 Eos-1.2 Baso-0.2 Im ___ AbsNeut-6.27* AbsLymp-1.59 AbsMono-0.58 AbsEos-0.10 AbsBaso-0.02 ___ 08:20PM BLOOD ___ PTT-52.3* ___ ___ 08:20PM BLOOD Glucose-192* UreaN-110* Creat-3.5*# Na-135 K-4.4 Cl-91* HCO3-29 AnGap-19 ___ 08:20PM BLOOD ___ 08:20PM BLOOD cTropnT-0.03* ___ 08:20PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.7* ___ 08:20PM BLOOD Digoxin-0.9 ___ 08:20PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:20PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08:20PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 ___ 10:11AM URINE Hours-RANDOM UreaN-359 Creat-36 Na-87 TotProt-81 Prot/Cr-2.3* ___ 10:11AM URINE Osmolal-339 DISCHARGE LABS ============== ___ 07:35AM BLOOD WBC-12.4* RBC-3.66* Hgb-11.4 Hct-36.3 MCV-99* MCH-31.1 MCHC-31.4* RDW-13.6 RDWSD-49.7* Plt ___ ___ 07:35AM BLOOD ___ ___ 07:35AM BLOOD Glucose-168* UreaN-112* Creat-2.3* Na-141 K-4.0 Cl-95* HCO3-29 AnGap-21* ___ 07:35AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0 REPORTS ======== CT Chest ___. Bronchial wall thickening, endobronchial secretions, and peribronchial ground-glass and nodular opacities in the middle lobe and bilateral lower lobes, suspicious for aspiration pneumonia. 2. At least one pulmonary nodule measuring 10 mm in the middle lobe, possibly with a second 10 mm nodule in the right lower lobe. Recommend follow-up chest CT in 6 weeks, after appropriate treatment. 3. Probably reactive mediastinal and hilar lymphadenopathy. 4. Mild dilation of the ascending aorta, measuring 41 mm. Mild aortic valve calcifications. 5. Coronary calcifications. 6. Indeterminate 12 x 12 mm left adrenal nodule. Recommend further characterization with adrenal protocol CT or MRI. CXR PA-Lateral ___ COPD. Increasing left lower lobe opacities could be atelectasis or pneumonia in the appropriate clinical setting Renal US ___: Normal renal ultrasound. CXR ___ Possible minimal pulmonary vascular congestion. No focal consolidation. MICROBIOLOGY ============ Blood cultures - negative Urine culture - negative Brief Hospital Course: ___ y/o F with a h/o CAD, diastolic CHF, AFib, DM, CKD 4, Gout, who presented with hypoxic respiratory failure most consistent with a COPD exacerbation, and ___ on CKD. ACTIVE PROBLEMS =============== # Hypoxic Respiratory Failure # COPD Exacerbation # Aspiration PNA Her presenting symptoms included a preceding URI, which led to wheezing, cough, and dyspnea, in a patient with longstanding smoking history. She had a low peak flow. Thus, her diagnosis was most consistent with a COPD exacerbation, although there was no diagnosis of COPD prior to admission. She remained hypoxic when ambulatory on room air throughout her admission despite several days of high dose PO steroid (Methylpred 32mg daily - this chosen as opposed to Prednisone for simplicity's sake as she is chronically on low dose Methylpred), and scheduled/PRN nebulizers. Thus, due to continued hypoxia, repeat CXR was done on ___, which showed only radiographic evidence of COPD, as well as atelectasis. She was thus given Incentive Spirometry for atelectasis. As she remained hypoxic, CT chest was then done ___, showing likely consolidation due to aspiration in both lower lobes. She was thus started on Augmentin, and will complete ___s outpatient. There was no evidence of CHF exacerbation based on bedside eval or imaging. PE unlikely given she is chronically on Warfarin. Home O2 was arranged, but the patient declined this on day of discharge. Started inhaled fluticasone BID given clinical certainty of COPD. Outpatient PFT's recommended on discharge. # ___ on Stage 4 CKD: Presented with Cr 3.5, but quickly downtrended back to baseline mid-2's without any intervention. She appeared euvolemic, although volume status is certainly complex given CHF history. It is unclear what the acute insult was to cause worsening Cr of admission. FE-Urea was 28%, which is consistent with pre-renal azotemia, but not a fully reliable test. Renal US was unremarkable. Her home Torsemide was continued. Her home ___ (irbesartan) was replaced with Losartan while in house, as irbesartan is not formulary. CHRONIC PROBLEMS ================ # Chronic Diastolic CHF: No e/o exacerbation. She is below prior dry weight and had minimal edema and no significant rales. Continued home Torsemide, Carvedilol. Continued ___. Monitored volume status. Low salt diet # CAD: Stable. - Continue home ASA 81mg, Ezetimibe, Carvedilol - ___ as above # A-Fib on Warfarin: INR was supratherapeutic on admission, held Warfarin, and resumed once INR was therapeutic. There were no further INR issues. - Continued Warfarin - Daily INR, should recheck as outpatient with ___ Anticoag Team per their routine - Continue home digoxin (level checked, was 0.9) # Diabetes - Continue home Glargine/Humalog regimen, along with sliding scale # Gout - Continue home Febuxostat - Continue home Methylprednisolone 4mg (initially was on higher dose of 32mg daily to treat COPD exacerbation) # Hypothyroidism - Continue home Levothyroxine # Anxiety - Continue home Bupropion, Lorazepam # Incidental findings - Pulm nodules need f/u CT in 6 weeks - Adrenal nodule needs f/u CT or MRI with adrenal protocol as outpatient TRANSITIONAL ISSUES =================== - Augmentin 500mg BID x7 days for aspiration pneumonia, ___ - Started inhaled fluticasone BID given likely COPD - Arranged for home O2 and offered to the patient, but she declined it - Outpatient PFT's recommended - Needs f/u CT chest in 6 weeks to assess for resolution of x2 10mm pulmonary nodules seen on CT chest - Adrenal nodule noted on CT chest. Needs outpatient adrenal protocol CT or MRI for further characterization of left adrenal nodule Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Ezetimibe 10 mg PO DAILY 3. Methylprednisolone 4 mg PO DAILY 4. LORazepam 0.5 mg PO BID:PRN anxiety 5. Avapro (irbesartan) 150 mg oral DAILY 6. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Vitamin D ___ UNIT PO DAILY 8. Warfarin 6.25 mg PO 3X/WEEK (___) 9. Metolazone 2.5 mg PO DAILY 10. Febuxostat 40 mg PO DAILY 11. Torsemide 60 mg PO BID 12. nystatin 100,000 unit/gram topical ___ daily 13. BuPROPion (Sustained Release) 150 mg PO QAM 14. Digoxin 0.125 mg PO 4X/WEEK (___) 15. Carvedilol 37.5 mg PO BID 16. Levothyroxine Sodium 112 mcg PO DAILY 17. Miconazole Powder 2% 1 Appl TP BID 18. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 19. Ferrous Sulfate 325 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Warfarin 5 mg PO 4X/WEEK (___) 22. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 2. Fluticasone Propionate 110mcg 2 PUFF IH BID RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inhaled twice daily Disp #*1 Inhaler Refills:*2 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 4. Aspirin 81 mg PO DAILY 5. Avapro (irbesartan) 150 mg oral DAILY 6. BuPROPion (Sustained Release) 150 mg PO QAM 7. Carvedilol 37.5 mg PO BID 8. Digoxin 0.125 mg PO 3X/WEEK (___) 9. Ezetimibe 10 mg PO DAILY 10. Febuxostat 40 mg PO DAILY 11. Ferrous Sulfate 325 mg PO BID 12. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Levothyroxine Sodium 112 mcg PO DAILY 14. LORazepam 0.5 mg PO BID:PRN anxiety 15. Methylprednisolone 4 mg PO DAILY 16. Metolazone 2.5 mg PO DAILY as directed 17. Miconazole Powder 2% 1 Appl TP BID 18. nystatin 100,000 unit/gram topical ___ daily 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 21. Torsemide 60 mg PO BID 22. Vitamin D ___ UNIT PO DAILY 23. Warfarin 6.25 mg PO 3X/WEEK (___) 24. Warfarin 5 mg PO 4X/WEEK (___) 25.Home Oxygen ICD-10: J44.9, COPD 2 liters/minute flow rate Discharge Disposition: Home Discharge Diagnosis: Primary: COPD exacerbation ___ on CKD Aspiration pneumonia Secondary: CAD, diastolic CHF, AFib, DM, Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure caring for you at ___. You were admitted to our hospital because of trouble breathing. It was discovered that the most likely cause of this was an exacerbation/crisis of "COPD." You were treated with high dose steroids and nebulizers. The CT scan of your chest also showed evidence of a small pneumonia. We will prescribe you an antibiotic for this, to take twice per day for 1 week. You were also found to have worsening of your kidney function on arrival. However, this fortunately improved back to baseline during your stay. It was a pleasure caring for you, and we wish you the best. Please contact your PCP to get ___ follow up appointment. - ___ team Followup Instructions: ___

10040025-DS-27

DS

2147-12-18 00:00:00

2147-12-18 17:16:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: left foot ulcer Major Surgical or Invasive Procedure: ___: Excisional debridement down to tendon of left diabetic foot ulcer ___: diagnostic angiogram, left lower extremity History of Present Illness: Ms. ___ presents for evaluation of an infected left foot diabetic ulcer. She complains of severe pain and tenderness over the site. She tells me that approximately 7 weeks ago, she dropped a pacemaker cell onto her left foot while in the hospital. She developed a blister that broke down and became infected. She has received topical wound care but no vascular assessment as of yet. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) CHF (EF 60-65% in ___ OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: ___ Family History: Father died of colon cancer in ___. Physical Exam: At admission: VS: 96.6 78 126/87 16 98% RA General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, no LAD Lungs: CTAB anteriorly CV: ___ Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema ___ bilateral heel ulceration; dorsum of left foot with purulent, foul smelling defect with eschar edges and erythema extending from it. ulceration along posterior left leg 2x2cm Left: DP ___ none; Right: ___ doppler Neuro: CN2-12 intact, no focal deficits At discharge: GEN: NAD, annoyed--speaking in short, sarcastic, profranity-filled sentences HEENT: EOMI, MMM CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally, approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage, minimal surrounding erythema, L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer dressed with adaptic, Kerlix and ACE NEURO: A&Ox3 Pertinent Results: ABI/PVR (___): FINDINGS: TBIs obtained bilaterally and measuring 0.28 in the right lower extremity and 0.19 the left lower extremity. Wound Culture (L foot) ___: PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Brief Hospital Course: Ms. ___ was admitted to ___ On ___ with a non-healing left diabetic foot ulcer. She was started on IV antibiotics and taken to the Operating Room on ___ for debridement and application of VAC. For full details of the procedure, please refer to the separately dictated Operative Report. She was returned to the PACU in stable condition and after satisfactory recovery from anesthesia, she was transferred to the floor for further monitoring and wound care. ___ was consulted on ___ and recommended discharge to rehab. On ___, patient demanded that wound VAC be removed and refused replacement. Plastic surgery was consulted for wound care and also recommended VAC therapy. Patient was counseled that this was optimal medical care, yet she persisted in her refusal. Daily wet-to-dry dressings were initiated. ABI/PVRs were done on ___ and were consistent with severe peripheral vascular disease. Both Vascular Surgery and Plastics were in agreement that patient should have an angiogram. She was consented for procedure and taken to the Endovascular Suite on ___. She was on the table and Foley had been placed when she refused all procedures. She was returned to the floor where she continued to refused recommended treatment. She was transitioned to oral antibiotics on ___ when culture data resulted. She returned to the Operating Room on ___ for angiogram which showed long segment occlusion of the left SFA. Vein mapping studies were obtained for OR planning for a left femoral to AK-popliteal artery bypass. She was discharged to rehab on ___ with plan for antibiotics to continue through ___. She will follow up in clinic with Dr. ___ to discuss operative planning. At the time of discharge, she was tolerating a regular diet, ambulating independently to the rest room and with assistance in the hallways, voiding spontaneously and pain was well controlled. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Digoxin 0.125 mg PO 3X/WEEK (___) 4. Ezetimibe 10 mg PO DAILY 5. Febuxostat 40 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. HydrALAZINE 20 mg PO Q8H 8. Isosorbide Dinitrate 20 mg PO TID 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Methylprednisolone 4 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Miconazole Powder 2% 1 Appl TP BID 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 14. Prasugrel 10 mg PO DAILY 15. Simethicone 40-80 mg PO QID:PRN bloating 16. Torsemide 60 mg PO BID 17. Vitamin D ___ UNIT PO DAILY 18. Acetaminophen 650 mg PO Q8H 19. Bisacodyl ___AILY:PRN constipation 20. Docusate Sodium 100 mg PO BID constipation 21. FoLIC Acid 1 mg PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Polyethylene Glycol 17 g PO DAILY constipation 24. Senna 8.6 mg PO BID:PRN constipation 25. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 26. Fluticasone Propionate 110mcg 2 PUFF IH BID 27. Metolazone 2.5 mg PO PRN as directed by cardiologist 28. nystatin 100,000 unit/gram topical ___ daily 29. Spironolactone 12.5 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 3. Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*18 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q8H 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 8. Aspirin 81 mg PO DAILY 9. Bisacodyl ___AILY:PRN constipation 10. BuPROPion (Sustained Release) 150 mg PO QAM 11. Digoxin 0.125 mg PO 3X/WEEK (___) 12. Docusate Sodium 100 mg PO BID constipation 13. Ezetimibe 10 mg PO DAILY 14. Febuxostat 40 mg PO DAILY 15. Ferrous Sulfate 325 mg PO BID 16. Fluticasone Propionate 110mcg 2 PUFF IH BID 17. FoLIC Acid 1 mg PO DAILY 18. HydrALAZINE 20 mg PO Q8H 19. Isosorbide Dinitrate 20 mg PO TID 20. Levothyroxine Sodium 112 mcg PO DAILY 21. Methylprednisolone 4 mg PO DAILY 22. Metolazone 2.5 mg PO PRN as directed by cardiologist 23. Metoprolol Succinate XL 200 mg PO DAILY 24. Miconazole Powder 2% 1 Appl TP BID 25. nystatin 100,000 unit/gram topical ___ daily 26. Omeprazole 20 mg PO DAILY 27. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 28. Polyethylene Glycol 17 g PO DAILY constipation 29. Prasugrel 10 mg PO DAILY 30. Senna 8.6 mg PO BID:PRN constipation 31. Simethicone 40-80 mg PO QID:PRN bloating 32. Spironolactone 12.5 mg PO DAILY 33. Torsemide 60 mg PO BID 34. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: non-healing left lateral diabetic foot ulcer long segment left SFA occlusion 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 ___ with a non-healing left foot ulcer. You were taken to the Operating Room for debridement and a VAC was applied to the wound. You then refused replacement of the VAC and were started on wet-to-dry dressing changes. You were started on antibiotics (Augmentin) which you are being discharged with. Plastic Surgery was consulted and also recommended VAC treatment and angiogram. You were taken to the Operating Room for angiogram which showed blockage of arteries in your leg. You will need a bypass surgery at a later date. you are being discharged to rehab with follow up in 2 weeks with Dr. ___ to discuss the results of your vein mapping studies and to discuss the date of your operation. Thank you for allowing us to participate in your care. Sincerely, Your ___ Surgery Team Followup Instructions: ___

10040025-DS-29

DS

2148-02-04 00:00:00

2148-02-04 19:18:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Left lower extremity surgical site infection Major Surgical or Invasive Procedure: ___ Left lower extremity incision and drainage, debridement of left foot ulcer ___ Left lower extremity washout, wound vac placement ___ Left lower extremity wound vac change, debridement left lower extremity ulcers History of Present Illness: Ms. ___ is a ___ year old female recently admitted for management of a chronic, non-healing left foot ulcer who underwent a left femoral to above knee popliteal bypass with NRGSV and left foot ulcer debridement with wound vac placement. She was seen in clinic 3 days ago with left leg incision healing slowly and evidence of skin separation and wound infection in the left thigh. There was weeping fluid but not purulent and staples intact. There also was significant surrounding erythema and so she was sent to rehab with augmentin and was to follow-up in clinic in 2 weeks. She presents to the ED today with worsening pain and L groin to medial though wound dehiscence and purulent drainage. She is otherwise feeling well without fevers or chills, nausea or vomiting. She was admitted to the vascular surgery service for management of suspected left lower extremity surgical site infection. Past Medical History: PMH: -HTN, labile -HLD -HYPOTHYROIDISM -RETINAL ARTERY OCCLUSION -Migraine -CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) -CHF (EF 60-65% in ___ -OBESITY -insulin-dependent DMII -Gout -Renal artery stenosis -CKDIII -Anemia -afib -Depression PSH: -Debridement of L foot infected ulcer -LLE diagnostic angiogram -L fem-AK pop bypass Social History: ___ Family History: Father died of colon cancer in ___. Physical Exam: General: NAD CV: RRR Pulm: No respiratory distress Extremities: left groin wound with dressings in place. Bilateral chronic nonhealing ulcers of the lower extremities Pertinent Results: ADMISSION LABS: ___ 04:00PM BLOOD Neuts-86* Bands-1 Lymphs-3* Monos-9 Eos-1 Baso-0 ___ Myelos-0 AbsNeut-7.57* AbsLymp-0.26* AbsMono-0.78 AbsEos-0.09 AbsBaso-0.00* ___ 04:00PM BLOOD ___ PTT-53.7* ___ ___ 04:00PM BLOOD Glucose-118* UreaN-57* Creat-1.8* Na-139 K-4.8 Cl-97 HCO3-28 AnGap-14 DISCHARGE LABS: ___ 05:46AM BLOOD WBC-11.9* RBC-2.95* Hgb-8.7* Hct-27.5* MCV-93 MCH-29.5 MCHC-31.6* RDW-18.4* RDWSD-59.9* Plt ___ ___ 05:46AM BLOOD Plt ___ ___ 05:46AM BLOOD ___ PTT-28.0 ___ ___ 05:46AM BLOOD Glucose-79 UreaN-68* Creat-2.2* Na-136 K-3.7 Cl-96 HCO3-27 AnGap-13 ___ 05:46AM BLOOD Calcium-7.6* Phos-5.3* Mg-2.1 Brief Hospital Course: Ms. ___ presented on ___ to the emergency room with a concern for a surgical site infection and was given vanc/cipro/flagyl immediately. Her INR was also noted to be 5, so she received 10 of vitamin K in the emergency room. Her repeat INR was 2.3 preop. She was then taken to the operating room in the morning of ___ for a debridement and washout of the LLE. Please see OP note for more details regarding the procedure. Postoperatively, the LLE continued to exsanguinate. Cauterization and compression was done in the PACU and she was transferred to the wards. On ___ evening, she was noted to be hypotensive to SBP ___ and her Hct had drifted from 27 to 21. She was transferred to the SICU for monitoring. She received 2 units of pRBC and 1 unit of FFP along with 10 of vitamin K. Her INR was noted to be 1.7 with Hct stable at 28. Since her last echo was only done in ___, a repeat echo was done that revealed her EF to be 40%, and so she was carefully volume resuscitated in preparation for another debridement, washout and vac placement on ___. Please see op report for more details. Following her ___ postop course, her summary will be written by systems. #NEURO: Patient was kept intubated and sedated to help facilitate multiple evaluation of her wound, however she was extubated on HD4 due to hypotension. Her pain was controlled with oxycodone and dilaudid. #CV: Patient was noted to become transiently hypotensive to SBP ___ while she was sedated and so required levo on HD4. Her pressures improved once she was extubated. 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. She was extubated on HD4 without issues. #GI/GU/FEN: The patient had a foley placed intra-operatively for volume monitoring as well as to keep her incision clean. She was restarted on her home torsemide on ___. The patient was given oral diet once extubated, which she tolerated well. She was noted to have loose bowel movements and incontinent. Her C.diff was negative and so was given a flexiseal on HD3 to keep her wound clean. #ID: The patient's fever curves were closely watched for signs of infection. She was kept on vanc/cipro/flagyl as her initial wound cultures from her initial washout was noted to be 4+GNR, 2+ GPC in pairs and chains and 1+ GPRs. On HD4, her cultures showed enterococcus and acinetobacter that were resistant to cipro and so was transitioned to ___ on HD4. ID was consulted on HD5. Given that there were no cultures showing MRSA and her vanc trough continued to be high, they recommended holding off on vanc. Her VAC was changed q3d and on her second VAC change, tissue swabs and cultures were sent that showed GPC in chains and pairs and GNRs. Updated culture data suggested VRE and daptomycin was started per ID recs. At the time of her discharge, antibiotics were discontinued according to the patient and her daughter's wishes (see below). #HEME: Patient received several units of blood over her hospital course for low hematocrits related to bleeding from her left thigh wound. Her last transfusion was ___ and her hematocrits were stable the following two days. #WOUNDS: The patient's left thigh wound vac was changed every ___ days. She was also found to have bilateral lower extremity pressure ulcers, more extensive on the left than the right leg. The ulcers on the left leg were found to have purulent discharge, so she was taken to the operating room again on HD9 (___) for debridement of her left lower extremity pressure ulcers. Santyl was used on these ulcers for the first 3 days post operatively. At the time of discharge to hospice, the wound vac was removed and the thigh wound was redressed with wet to dry gauze and overlying curlex. On ___ a family meeting was held with the patient's daughter and healthcare proxy with a discussion about the lack of progression in her wounds. The following day a second meeting was held with the patient's daughter as well as representatives from palliative care, social work, case management, and vascular surgery. At that time the patient and her daughter elected to transfer the patient to a ___ facility and enact a DNR/DNI order. At the time of her discharge, the patient's vitals were stable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Aspirin 81 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. BuPROPion (Sustained Release) 150 mg PO QAM 6. Digoxin 0.125 mg PO 3X/WEEK (___) 7. Docusate Sodium 100 mg PO BID constipation 8. Ezetimibe 10 mg PO DAILY 9. Febuxostat 40 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. FoLIC Acid 1 mg PO DAILY 13. HydrALAZINE 20 mg PO Q8H 14. Isosorbide Dinitrate 20 mg PO TID 15. Levothyroxine Sodium 112 mcg PO DAILY 16. Methylprednisolone 4 mg PO DAILY 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. nystatin 100,000 unit/gram topical ___ daily 20. Omeprazole 20 mg PO DAILY 21. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 22. Polyethylene Glycol 17 g PO DAILY constipation 23. Prasugrel 10 mg PO DAILY 24. Senna 8.6 mg PO BID:PRN constipation 25. Vitamin D ___ UNIT PO DAILY 26. Metolazone 2.5 mg PO PRN as directed by cardiologist 27. Simethicone 40-80 mg PO QID:PRN bloating 28. Spironolactone 12.5 mg PO DAILY 29. Torsemide 60 mg PO BID 30. Levofloxacin 500 mg PO Q48H foot infection Discharge Medications: 1. Gabapentin 100 mg PO BID 2. Insulin SC Sliding Scale Fingerstick QACHS, HS Insulin SC Sliding Scale using REG Insulin 3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*4 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q8H 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 6. Aspirin 81 mg PO DAILY 7. Bisacodyl ___AILY:PRN constipation 8. BuPROPion (Sustained Release) 150 mg PO QAM 9. Docusate Sodium 100 mg PO BID constipation 10. Ezetimibe 10 mg PO DAILY 11. Febuxostat 40 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. FoLIC Acid 1 mg PO DAILY 15. HydrALAZINE 20 mg PO Q8H 16. Isosorbide Dinitrate 20 mg PO TID 17. Levofloxacin 500 mg PO Q48H foot infection 18. Levothyroxine Sodium 112 mcg PO DAILY 19. Methylprednisolone 4 mg PO DAILY 20. Metoprolol Succinate XL 200 mg PO DAILY 21. Miconazole Powder 2% 1 Appl TP BID 22. nystatin 100,000 unit/gram topical ___ daily 23. Omeprazole 20 mg PO DAILY 24. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 25. Polyethylene Glycol 17 g PO DAILY constipation 26. Prasugrel 10 mg PO DAILY 27. Senna 8.6 mg PO BID:PRN constipation 28. Simethicone 40-80 mg PO QID:PRN bloating 29. Spironolactone 12.5 mg PO DAILY 30. Torsemide 60 mg PO BID 31. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Surgical site infection of left thigh Infection of left lower extremity pressure ulcers Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: somnolent but arousable. Activity Status: Out of Bed with lift assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to ___ on ___ with a surgical site infection of your left thigh. You were started on antibiotics and taken to the operating room for left thigh debridement and subsequently for placement of a wound vac. You were also found to have left lower extremity pressure ulcers which appeared to be infected, so you were taken back to the operating room for debridement to ensure removal of any dead or infected tissue. At this time, you have elected to be transferred to a hospice facility. You ongoing care will be under the direction of the hospice team. Followup Instructions: ___

10040056-DS-13

DS

2145-07-24 00:00:00

2145-07-24 18:13:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abd pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with hx of htn, PE here with abd pain. Pt reports that ___ days ago he began to have a burning in the epigastric area. Over time, it increased to a "fire" with radiation to the back. He has also been having nausea and vomiting, has not been eating due to vomiting. He has had a few cold sweats, but no known fevers. He does not think that eating/drinking was making the pain worse. He denies diarrhea, hx of gallstones. He states that he usually drinks a "few gallons" of water a day because he likes to be always drinking something. He reports taking "anticoagulant" for PE for 90 days. He states that he hasn't taken his BP medications this week due to feeling weak and the pain. He states that he is not currently drinking alcohol, but sometimes does based on the client he is working with. States that he used to drink much more, but is not clear about how much. 10 systems reviewed and are otherwise negative. Past Medical History: longstanding HTN --states that he has multiple medications for it, but cannot tel me what they are, thinks that he goes to ___, but not sure --in atrius records I do not see refill of norvasc, meto, lisinpril recently DVT/PE ___ thinks that it was from going back and forth from ___ and ___ depression/anxiety-states no longer on zoloft, not taking gabapentin Social History: ___ Family History: sister with ___ htn in family Physical Exam: Admission physical exam: Afeb, ___ 97%RA Cons: NAD, lying in bed Eyes: EOMI, no scleral icterus ENT: MMM Cardiovasc: rrr, no murmur, no edema Resp: CTA B GI: +bs,soft, nd, +epigastric and RUQ ttp MSK: no significant kyphosis Skin: no rashes Neuro: no facial droop Psych: blunted affect Discharge physical exam tmax 99.2 167/100 97 18 100%RA Cons: NAD, lying in bed Eyes: EOMI, no scleral icterus ENT: MMM Cardiovasc: rrr, no murmur, no edema Resp: CTA B GI: +bs,soft, nt, nd MSK: no significant kyphosis Skin: no rashes Neuro: no facial droop Psych: blunted affect Pertinent Results: ___ 10:26PM LACTATE-2.5* ___ 10:20PM GLUCOSE-285* UREA N-10 CREAT-1.1 SODIUM-128* POTASSIUM-3.4 CHLORIDE-83* TOTAL CO2-19* ANION GAP-29* ___ 10:20PM ALT(SGPT)-49* AST(SGOT)-62* ALK PHOS-92 TOT BILI-1.0 ___ 10:20PM LIPASE-1342* ___ 10:20PM ALBUMIN-4.5 ___ 10:20PM WBC-17.7* RBC-4.66 HGB-12.1* HCT-36.4* MCV-78* MCH-26.0* MCHC-33.2 RDW-16.6* ___ 10:20PM PLT COUNT-319 US RUQ: 1. Sludge in the gallbladder, without evidence of cholelithiasis or cholecystitis. 2. Common bile duct measures 8 mm. Pancreatic duct is not seen. 3. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant fibrosis/cirrhosis cannot be excluded on this study. ___ MRCP -- IMPRESSION: 1. Acute necrotizing pancreatitis confined to the tail. No organized fluid collections. 2. Mild intrahepatic bile duct prominence, and 9 mm CBD, without evidence of stone or obstructing mass. 3. Gallbladder filled with sludge. No MR evidence for acute cholecystitis. 4. Severe hepatic steatosis. Brief Hospital Course: ___ man w/PMHx poorly controlled HTN admitted with pancreatitis, possibly due to biliary pathology (e.g. GB sludge). Stable w/conservative therapy, gradually improving. DETAILS BY PROBLEMS Pancreatitis of unclear etiology with tachycardia, leukocytosis - given the patient's labs and imaging, the ERCP team felt there was no need for ERCP but they do recommend elective cholecystectomy as an outpt -- will ask his PCP to refer him when he has insurance again - has a h/o of sig EtOH in the past, but denies recent -- steatosis is concerning, lipids unremark, viral hepatitis studies neg - pain control done with PO hydromorphone, pt will back down on the medication in the upcoming few days as an outpatient. Poorly controlled HTN, improved overall, suspect some elevation still due to pain - continue amlodipine, lisinopril, metoprolol - advised the pt that his BP is not yet at goal, but as he has not been on HTN medications since this ___ his baseline is likely even higher. OK to d/c to home and will have continued outpt BP medication titration. Microcytic anemia, stable - suspect ___ acute inflammation and hospital phlebotomy - markedly elevated ferritin suspected ___ inflammation but could be a sign of liver disease, may require more workup - don't suspect iron or B12 deficiency - can f/u as outpt about this Active smoking - recommend stopping smoking Proteinuria, urine protein/Cr ratio 0.5 - suspect related to HTN - plan further w/u as outpt PRN Hyperglycemic to 200s here but hemoglobin A1c normal -- sugars improved. - suspect ___ inflammation of pancreatitis - SSI for now -- hasn't need much and won't need to leave on insulin History of non-adherence - hospitalized recently for hypertensive urgency/emergency having seemingly not filled meds since ___ (according to a ___ where he'd been before) - needs more investigation Depression/anxiety - no longer on sertraline or gabapentin Insurance issues - spoke with SW and CM about this -- financial counseling spoke with him -- insurance ends on ___ Transitional issues: noted above OTHER INACTIVE PMHx History of DVT/PE ___ -- per pt he thinks that it was from going back and forth from ___ to ___ -- was tx'd for 90 days with an anticoagulant 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 Q4H:PRN Pain 2. Amlodipine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day as needed for constipation Disp #*60 Capsule Refills:*0 4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 3 hours as needed for pain Disp #*20 Tablet Refills:*0 5. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day as needed for constipation Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute pancreatitis of unclear etiology (possible due to gallstones, sludge) Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for pancreatitis (inflammation of your pancreas) that was of unclear cause. You were treated with IV fluids and your pain improved. You underwent a MRI of your liver and gallbladder which showed some fat in the liver (steatosis) -- it's possible this is due to alcohol and we recommend you cut down on alcohol. You were restarted on your blood pressure medications and need to follow closely with your primary care doctor. We also recommend you talk with your doctor about having your gallbladder removed in case gallstones or gallbladder sludge were the cause of your pancreatitis. We also noted that there is protein in the urine. this is not normal and needs to be checked again by your primary care doctor. It may be that your kidneys are being damaged by high blood pressure. Followup Instructions: ___

10040149-DS-13

DS

2181-09-23 00:00:00

2181-10-06 10:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female history of hypertension, cholecystectomy, hernia repair, hysterectomy, nephrectomy, transferred from ___ for bowel obstruction seen on CT scan. Patient has had a day of diffuse abdominal pain vomiting and diarrhea. No similar symptoms in past. No fever, chest pain, shortness of breath, cough. Past Medical History: PMH: Hypertension UTI Hypothyroidism CAD Pyelonephritis AAA PSH: CABG Cholecystectomy Hernia repair Hysterectomy L nephrectomy EVAR Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Examination Temp: 97.4 HR: 58 BP: 112/67 Resp: 20 O2 Sat: 94 Low Constitutional: Elderly woman seated in bed, awake and alert, speaking in full sentences, in no acute distress Head / Eyes: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact ENT / Neck: Moist mucous membranes. NG tube in place. Chest/Resp: Breathing comfortably on room air, speaking full sentences. Mild scattered rhonchi on auscultation without wheezes or crackles. Cardiovascular: Regular Rate and Rhythm GI / Abdominal: Soft, mildly distended, mild TTP throughout, worst on left side of abdomen. GU/Flank: No costovertebral angle tenderness Musc/Extr/Back: No peripheral edema. No midline spinal TTP. Skin: Warm and dry Neuro: Speech fluent. PERRL. EOMI. Facial movements symmetric. Moving all extremities Discharge Physical Exam: VS: 97.5, 156/92, 55, 18, 94 Ra Gen: A&O, intermittently confused Pulm: LS w/ faint expiratory wheeze CV: HRR Abd: softly distended. mildly TTP over left side of abdomen (has chronic pain here from ? hernia) Ext: WWP . no edema Pertinent Results: ___ 06:40AM BLOOD WBC-5.5 RBC-4.60 Hgb-12.6 Hct-40.4 MCV-88 MCH-27.4 MCHC-31.2* RDW-16.7* RDWSD-53.1* Plt ___ ___ 06:58AM BLOOD WBC-4.0 RBC-4.39 Hgb-11.9 Hct-38.6 MCV-88 MCH-27.1 MCHC-30.8* RDW-16.2* RDWSD-51.8* Plt ___ ___ 06:11AM BLOOD WBC-6.0 RBC-4.24 Hgb-11.4 Hct-37.7 MCV-89 MCH-26.9 MCHC-30.2* RDW-16.0* RDWSD-52.4* Plt ___ ___ 08:45AM BLOOD WBC-4.8 RBC-4.30 Hgb-11.7 Hct-38.8 MCV-90 MCH-27.2 MCHC-30.2* RDW-16.2* RDWSD-53.7* Plt ___ ___ 07:18AM BLOOD WBC-6.9 RBC-4.22 Hgb-11.4 Hct-37.5 MCV-89 MCH-27.0 MCHC-30.4* RDW-16.3* RDWSD-53.2* Plt ___ ___ 05:25PM BLOOD WBC-6.2 RBC-4.35 Hgb-11.8 Hct-38.3 MCV-88 MCH-27.1 MCHC-30.8* RDW-16.3* RDWSD-52.7* Plt ___ ___ 11:46AM BLOOD WBC-5.8 RBC-3.56* Hgb-9.6* Hct-32.5* MCV-91 MCH-27.0 MCHC-29.5* RDW-16.5* RDWSD-55.5* Plt ___ ___ 06:40AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-140 K-4.9 Cl-102 HCO3-29 AnGap-9* ___ 06:58AM BLOOD Glucose-79 UreaN-13 Creat-1.3* Na-140 K-4.8 Cl-101 HCO3-29 AnGap-10 ___ 06:11AM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-140 K-3.9 Cl-104 HCO3-26 AnGap-10 ___ 08:45AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-143 K-4.2 Cl-106 HCO3-25 AnGap-12 ___ 07:18AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-143 K-3.5 Cl-106 HCO3-28 AnGap-9* ___ 06:40AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 ___ 06:58AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 ___ 06:11AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.1 Imaging: OSH CT abdomen pelvis without contrast - 1. Distention of the stomach proximal and mid small bowel to the level of a lumbar abdominal wall hernia above the left iliac crest. 2. Status post endograft stenting of the infrarenal abdominal aorta and common iliac arteries ___ ECG - Baseline artifact but probable sinus bradycardia with atrio-ventricular conduction delay. Inferior infarction of indeterminate age. Intraventricular conduction delay. Delayed R wave transition. Non-specific ST segment changes. Left ventricular hypertrophy. Compared to the previous tracing of ___ the overall findings are similar. ___ Abdomen - 1. Mild pulmonary edema. 2. Oral contrast has progressed to the level of the proximal transverse colon excluding obstruction. There remains mild distension of the small and large bowel loops suggesting ileus. Brief Hospital Course: ___ with history of hypertension, prior UTI, hypothyroidism, cholecystectomy, hernia repair, hysterectomy, and left nephrectomy, who presents as a transfer from ___ with concern for small bowel obstruction and incidental finding of UTI. The patient was admitted for bowel rest, IV fluids, and close monitoring of her abdominal exam. She was hemodynamically stable. She was given antibiotics for the UTI. Nasogastric tube was inserted for stomach decompression. Oral contrast was given via the NGT. Eight hours after contrast had been given, an abdominal x-ray showed that oral contrast has progressed to the level of the proximal transverse colon, excluding obstruction. On HD2, the NGT was removed. 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. Because the patient was elderly and deconditioned, ___ evaluated the patient to determine the safest disposition. They recommended she be discharged to rehab. The patient was refusing rehab and currently lived with one of her sons who she stated provided assistance with her care. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with a walker, voiding without assistance, having bowel movements, and denied pain. The patient was discharged home with services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Levothyroxine Sodium 75 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Small bowel obstruction 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 abdominal pain and were found on CT scan to have a small bowel obstruction. You were managed non-operatively with a nasogastric tube for stomach decompression, bowel rest, IV fluids, and close monitoring of your abdominal exam. Once your obstruction resolved, your diet was advanced and you are now tolerating regular food and having bowel movements. You are ready for discharge home to continue your recovery. Please note the following: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 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. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids Followup Instructions: ___

10040284-DS-5

DS

2144-01-23 00:00:00

2144-01-23 16:22:00

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, foreign body ingestion Major Surgical or Invasive Procedure: ___: EGD with removal of foreign objects (magnets) and clipping/injection of gastric ulcerations History of Present Illness: ___ w PMH Schizophrenia, depression, PTSD and prior suicide attempts, presenting with abdominal pain following magnet ingestion. Pt recently discharged from ___ after presenting on ___ with ingestion of 4 magnets. The ingestion on ___ was with intent for self harm, so she was admitted to the psychiatric unit, started on SSRI and mood stabilizer and discharged on ___. She presents to ___ today after reportedly swallowing three magnets on ___. Says they were cylindrical, strong magnets taken from an office where she works in ___. She developed LUQ abdominal pain so she came to the ED. Patient reports swallowing magnets so as to come to the hospital and avoid her family, in a desire to save her family. She states that she heard voices telling her to hurt her family members, so she decided to swallow the magnets, in an attempt for help from the medical community. Denies SI or HI; endorses continued auditory hallucinations. She does not wish that her family know about this. Magnets were small, approx. 1x1cm; she swallowed them separately with 30 minute interval between them. Reports retrosternal pain initially after swallowing magnets. Today has developed epigastric and LLQ pain, worse with movement. No n/v/d. No bloody stool or melena In the ED, initial vitals: 98.0 69 120/56 18 100% RA. Physical exam significant for disorganized thought process epigastric and LLQ pain with involuntary guarding, no rebound tenderness. - Labs were significant for normal CBC, BMP, urine toxicology. UA + large blood, trace protein, trace ketones, 2 epithelial cells. - CXR significant for three connected oblong structures projecting over the expected area of stomach. - She received 2mg morphine and 1L NS. - She was taking emergently for EGD for attempted magnetic removal. Upon arrival to the floor, she endorsed sore throat and mild epigastric pain. Past Medical History: - PTSD - Depression - Dissociative Disorder - Schizophrenia - Multiple prior suicide attempts: clonazepam ingestion, magnet ingestion Social History: ___ Family History: + schizophrenia, alcoholism - father Physical ___: ADMISSION PHYSICAL: ===================== VS: T 98.1, BP 102/47, HR 68, R 18, SpO2 100%/RA 68.6 kg GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Clear bilaterally without wheeze or rhonchi COR: RRR (+)S1/S2 with faint grade I systolic murmur at bilateral upper sternal borders ABD: Soft, non-distended, mild TTP over epigastrium, normal bowel sounds EXTREM: Warm, well-perfused, no edema NEURO: face symmetric, moving all extremities well PSYCH: appropriate, denies SI, HI, AH, VH DISCHARGE PHYSICAL: =================== VITALS: 98 107/42 74 16 99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: +BS, soft, nondistended, ttp in LUQ without rebound GU: no foley EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: =================== ___ 03:01PM BLOOD WBC-5.4 RBC-3.82* Hgb-11.6 Hct-34.4 MCV-90 MCH-30.4 MCHC-33.7 RDW-11.9 RDWSD-38.4 Plt ___ ___ 03:01PM BLOOD Neuts-56.1 ___ Monos-4.8* Eos-0.4* Baso-0.7 Im ___ AbsNeut-3.04 AbsLymp-2.05 AbsMono-0.26 AbsEos-0.02* AbsBaso-0.04 ___ 03:01PM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-137 K-3.5 Cl-101 HCO3-27 AnGap-13 DISCHARGE LABS: ================= ___ 07:35AM BLOOD WBC-4.6 RBC-3.68* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.2 MCHC-32.8 RDW-11.9 RDWSD-39.7 Plt ___ IMAGING: ============= CXR ___ No acute cardiopulmonary process. Three connected oblong structures are seen projecting over the expected area of the stomach, likely representing ingested magnets. KUB ___ IMPRESSION: 3 cylindrical radiopaque densities vertically aligned end-to-end with each other likely reflective of ingested magnets in the left upper quadrant abdomen, possibly within the stomach. No free intraperitoneal gas. EGD ___: Foreign body in the stomach (foreign body removal) Ulcers in the stomach (injection, endoclip) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: ___ w PMH depression, ? schizophrenia, PTSD and prior suicide attempts, presenting with abdominal pain following magnet ingestion. # Magnet ingestion: Presented with abdominal pain following ingestion of 3 magnets which were seen on CXR and KUB. GI was consulted and patient underwent EGD on ___ with removal of magnets. Per patient, was not suicide attempt but rather was trying to get away from her family. While she has a history of prior episodes of magnet ingestion, psychiatric evaluation was unrevealing for true SI/HI and her attempt was felt to be related to an attempt to deal with ego dystonic thoughts related towards her anger towards her family. As such, she did not meet ___ criteria and the patient was felt to need assistance with housing outside of her current living situation. She was maintained on a 1:1 sitter prior to discharge to avoid further ingestions. Her abdominal pain was improved prior to discharge. Patient was discharged with cab voucher to take her to ___ ___ and was provided with clothes, a new cell phone, outpatient psych resources and T passes prior to discharge. # Gastric ulcers: Likely related to ingestion of magnets with pinching of gastric lining s/p clipping and epi injection. Patient was treated with 24 hours of IV pantoprazole BID and then transitioned to PO pantoprazole prior to discharge. Her diet was advanced to regular. # Anemia: Normocytic anemia in young female. Could be due to menstrual blood loss vs bleeding from gastric ulcers depending on duration (ie caused by prior magnet ingestion). Stable during this admission. Will require further work-up as outpatient if persists. # Depression: Patient with a history of ? schizophrenia, depression, and recent admission at ___ following intentional magnetic ingestion, representing with the same. As above, does not appear to be true voices suggesting psychosis but rather her own voice related to her anger at her current living situation. She had no active SI/HI and given that presentation was not felt to be true suicide attempt, she did not meet criteria for ___. She was started on aripiprazole (previously taking) per psychiatry recommendation and continued on home fluoxetine, trazodone and clonazepam. She had outpatient psychiatry ___ scheduled for ___ ___s access to the ___ women's program and was provided with the number for BEST on discharge. TRANSITIONAL ISSUES: ====================== [ ]Patient will benefit from ongoing psychiatric evaluation for depression and medication management [ ]Please have patient continue on BID PPI for at least one month (through ___ [ ]Please repeat Hemoglobin and hematocrit at PCP ___ on ___. If persistent anemia, consider further work-up for unexplained anemia Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. TraZODone 50 mg PO QHS 2. Fluoxetine 30 mg PO DAILY 3. ClonazePAM 1 mg PO BID:PRN anxiety Discharge Medications: 1. ClonazePAM 1 mg PO BID:PRN anxiety RX *clonazepam 1 mg 1 tablet by mouth twice a day Disp #*6 Tablet Refills:*0 2. Fluoxetine 30 mg PO DAILY RX *fluoxetine 10 mg 3 tablets by mouth daily Disp #*45 Tablet Refills:*0 3. TraZODone 50 mg PO QHS RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*15 Tablet Refills:*0 4. ARIPiprazole 10 mg PO DAILY RX *aripiprazole 10 mg 1 tablet(s) by mouth Daily Disp #*15 Tablet Refills:*0 5. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Foreign body (magnet) Ingestion Gastric Ulcers Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital after swallowing several magnets. You underwent a procedure called an endoscopy to remove the magnets. The endoscopy showed several ulcerations (cuts) from the magnets which were repaired. You were started on a new medication called pantoprazole to help your stomach heal. It is important that you take this medication as prescribed. You were seen by psychiatry in the hospital who felt that you were safe for discharge as you were not having thoughts of hurting yourself or others. You were restarted on abilify and continued on your other psychiatric medications. It is very important that you ___ with your psychiatrist as scheduled on ___ (see below). Additionally, please call the partial hospital program for women at ___ HRI at ___ to set up an intake appointment. Finally, you were seen by social work who helped to provide you with resources for when you leave the hospital. If you find that you need additional assistance when you leave the hospital, you have several options: 1. ___ CSA in ___ for care coordination at ___. 2. ___ Emergency Services Team (BEST) for emergency mental health concerns at ___ We wish you the best in your recovery. It was a pleasure taking care of you, Your ___ Care Team Followup Instructions: ___

10040602-DS-17

DS

2189-06-17 00:00:00

2189-06-17 23:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Amoxicillin Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right upper lobectomy, hypertension, and hyperlipidemia presented with chest pain. Patient reports acute onset of chest pain that woke him up from sleep the morning of presentation at about 3A. He described the pain as sharp and worse with inspiration. It had been constant throughout the course of the day and notably not worse with exertion. Pain was mainly across the ___ his chest, but he also has the sensation that it was "traveling down my esophagus and across the top of my back." There was no radiation down the arm or to the jaw. He reported some limitation in his ability to take a deep breath due to pain but no shortness of breath per se. He denied palpitations or diaphoresis. Patient has never had pain like this before. There was no significant improvement in pain by leaning forward. He denied any recent URI. He did recently travel to a resort in the ___. He denied fevers, chills, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. In the ED, initial vitals: HR 47 BP 112/54 RR 20 SaO2 99% on RA. EKG showed new inferior T waver inversions. Labs/studies notable for Hgb/Hct 12.7/38.0, WBC 9.3, plt 185, Na 140, K 4.5, BUN 36, Cr 1.8, Troponin-T negative x2, NT-pro-BNP 970. D-Dimer 1108. CXR showed that the heart size and mediastinum were stable with unchanged vascular enlargement in the hila, but no evidence of acute exacerbation of congestive heart failure. CTA showed no evidence of pulmonary embolism or acute aortic abnormality, no acute etiology identified for pleuritic chest pain, no focal consolidation concerning for underlying infection. There was enlargement of the pulmonary arterial system, consistent with pulmonary arterial hypertension. There was an unchanged soft tissue mass in the prevascular mediastinum, which has been slowly growing since ___ and appears stable since ___, probably an encapsulated thymoma. Thickening the mediastinal esophagus was unchanged compared ___ and may be sequela of chronic esophageal inflammation. Patient was given Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO, Donnatal 10 mL PO, Lidocaine Viscous 2% 10 mL PO, famotidine 20 mg IV, Nitroglycerin infusion starting at 0.35 mcg/kg/min. After arrival to the cardiology ward, the patient reported persistent, pleuritic chest pain. He said the nitroglycerin gtt might be helping marginally. He had been resting comfortably in bed prior to being woken up to give the above history. Past Medical History: 1. CAD RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY -Dilated cardiomyopathy attributed to PVC burden - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY -Lung cancer s/p lobectomy (no chemo/XRT) -Nephrolithiasis -Colonic polyps -High-grade prostatic intraepithelial neoplasia -Neuropathy Social History: ___ Family History: Mother with rheumatic heart disease, father with diabetes and required open heart surgery. Physical Exam: On admission GENERAL: Pleasant elderly white man in NAD VS: T 98 BP 112/66 HR 65 RR 20 SaO2 99% on RA HEENT: NCAT, mucous membranes moist CV: RRR; no murmurs, rubs or gallops PULM: CTAB GI: Soft, non-tender, not distended, BS+ EXTREMITIES: warm and well perfused; no clubbing, cyanosis or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric At discharge GENERAL: Pleasant elderly man in NAD VS: 24 HR Data (last updated ___ @ ___ Temp: 98.3 (Tm 99.5), BP: 99/62 (99-145/62-83), HR: 48 (48-58), RR: 20 (___), O2 sat: 96% (94-98), O2 delivery: RA HEENT: NCAT, mucous membranes moist CV: RRR; no murmurs, rubs or gallops PULM: CTAB GI: Soft, non-tender, not distended, BS+ EXTREMITIES: warm and well perfused; no clubbing, cyanosis or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric Pertinent Results: ___ 10:56AM BLOOD WBC-9.3 RBC-4.01* Hgb-12.7* Hct-38.0* MCV-95 MCH-31.7 MCHC-33.4 RDW-12.9 RDWSD-44.4 Plt ___ ___ 10:56AM BLOOD Neuts-74.1* Lymphs-12.9* Monos-11.6 Eos-0.9* Baso-0.3 Im ___ AbsNeut-6.88* AbsLymp-1.20 AbsMono-1.08* AbsEos-0.08 AbsBaso-0.03 ___ 10:56AM BLOOD Glucose-111* UreaN-36* Creat-1.8* Na-140 K-4.5 Cl-100 HCO3-26 AnGap-14 ___ 10:56AM BLOOD CRP-32.7* ___ 06:30AM BLOOD VitB12-691 Folate-19 Hapto-126 ___ 10:56AM BLOOD proBNP-970* ___ 10:56AM BLOOD cTropnT-<0.01 ___ 03:05PM BLOOD cTropnT-<0.01 ___ 06:30AM BLOOD cTropnT-<0.01 DISCHARGE LABS ___ 05:50AM BLOOD WBC-5.5 RBC-3.83* Hgb-12.1* Hct-36.6* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___ ___ 05:50AM BLOOD Glucose-129* UreaN-23* Creat-1.5* Na-138 K-4.3 Cl-101 HCO3-25 AnGap-12 ___ 05:50AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2 ___ ECGs ECG: stable anterior J point elevation, new inferior T wave inversions, with subsequent widening of the QRS duration into a not-quite-LBBB IVCD. ___ CXR Heart size and mediastinum are stable in appearance. Vascular enlargement in the hila is unchanged, with no evidence of acute exacerbation of congestive heart failure on the radiograph. Postsurgical changes in the right lung are stable. There is no pleural effusion. There is no pneumothorax. ___ CTA Chest HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. There is enlargement of the main, right main, and left main pulmonary arteries, measuring up to 3.8, 3.1, and 2.8 cm, respectively. These findings are likely suggestive of pulmonary arterial hypertension. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: Mediastinal esophagus appears thickened throughout its course (series 2; image 21), similar compared to prior and suggestive of underlying chronic esophageal inflammation. Again seen in the mediastinum, along the superior aspect of the left ventricle, adjacent to the main pulmonary artery, there is a lobulated, homogeneous 3.4 x 2.2 cm soft tissue density, which previously measured 3.5 x 2.0 cm. This mass is been slowly growing since ___ and likely represent an encapsulated thymoma. It appears to now abut the myocardium over a couple of cm. There is no axillary lymphadenopathy. There are prominent subcarinal and right hilar lymph nodes, which are nonspecific. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Changes seen after right upper lobectomy. There is bibasilar atelectasis, right greater than left, without focal consolidation concerning for infection. Incidentally noted is an azygos lobe. 4 mm nodule in the right upper lobe (series 3; image 84) is unchanged compared to ___ and now stable for 32 months. No additional concerning nodules are identified. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. No acute etiology identified for pleuritic chest pain. No focal consolidation concerning for underlying infection. 2. Enlargement of the pulmonary arterial system, consistent with pulmonary arterial hypertension. 3. Unchanged soft tissue mass in the prevascular mediastinum, which has been slowly growing since ___ and appears stable since ___. This is probably an encapsulated thymoma. 4. Thickening the mediastinal esophagus is unchanged compared ___ and may be sequela of chronic esophageal inflammation. EGD could be pursued on a nonurgent basis if clinically indicated. ___ Echocardiogram The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is mild-moderate global left ventricular hypokinesis. The visually estimated left ventricular ejection fraction is 35%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. 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 mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images not available for review) of ___, the estimated PA systolic pressure is now increased. Brief Hospital Course: ___ with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right upper lobectomy, hypertension, and hyperlipidemia presented with chest pain. He had negative troponin-T x3. He was also found to have esophagitis, with chest pain improved with initiation of PPI and Aluminum-Magnesium Hydrox-Simethicone. ACUTE ISSUES: # Chest pain, esophagitis: Patient was admitted with acute onset chest pain described as burning around esophagus, radiating across shoulders and to lesser degree across chest, not classic for ACS. ECG initially with some inferoapical T wave inversion (non-specific) though no other changes suggestive of acute ischemia, but troponin-T and CK-MB negative x3. Initial treatment with nitroglycerin gtt without obvious improvement in pain. CTA also negative after patient noted to recently have been on relatively long plane flight and with elevated D-Dimer. Patient reported no symptoms during recent trip to ___ ___ but a lot of stress during the flight home. Most likely etiologies of chest pain felt to be esophagitis (given thickened mediastinal esophagus on CTA) vs pericarditis with elevated CRP. Significant relief of chest pain with empiric treatment of esophagitis with GI cocktail and pantoprazole, therefore treatment of pericarditis not initiated. At time of discharge, chest pain was almost completely gone, and patient only reported faint sensation of burning around esophagus. # Non-conducted P waves, bradycardia. ___ telemetry pause with non-conducted P waves (2.5 sec longer QRS-free interval than expected if single non-conducted PAC with apparent AV block after a likely P wave vs artifact--failure of ventricular escape and/or AV block). Patient does not recall what he was doing at the time. Pause and tracing reviewed with several electrophysiologists. As sinus node dysfunction isolated and asymptomatic, no further intervention was felt warranted at present. Patient mentioned that Dr. ___ mentioned possibility of ICD (presumably primary prevention). Patient discharged with outpatient EP F/U with Dr. ___. We decreased home metoprolol succinate dose given occasional bradycardia (HR ___. # Dilated cardiomyopathy: LVEF 30% in ___ -> 44% on CMR in ___, presumed to be secondary to VEA burden. Per recent cardiology note, "Initially started on metoprolol and lisinopril with reduction in PVC burden to 15% and subsequently was initiated on amiodarone therapy in ___ with most recent Holter on ___ showing reduction VPC burden to 8% with multiple morphologies." Continued home amiodarone. Decreased dose of metoprolol, as above. CHRONIC ISSUES: # CKD stage 3 with ___: Cr on admission 1.8 (baseline 1.3-1.8) downtrended to 1.5 this admission. # Hypertension: Continued home hydralazine (once daily dosing confirmed by patient), HCTZ, metoprolol. # Hyperlipidemia: Continued home statin. # Lung CA s/p right upper lobectomy (no chemo/XRT): Surveillance imaging as outpatient. # Primary prevention against CAD: Continued home aspirin, statin, metoprolol. TRANSITIONAL ISSUES: ==================== [ ] Follow up resolution of chest pain with GI cocktail and pantoprazole. [ ] Further workup of esophagitis, would recommend endoscopy with Dr. ___. [ ] Follow up of non-conducted P waves in clinic with Dr. ___ ICD for primary prevention. [ ] He was noted to have left leg calf pain which is suspicious for claudication and PAD, would recommend an outpatient ABI and vascular medicine follow up to assess this. [ ] Consider ETT-MIBI or R-MIBI (develops claudication after walking 0.5 miles slowly, but useful to assess functional capacity) if symptoms not improve with aggressive GI regimen. [ ] Follow up of likely thymoma noted on CTA. - New Meds: GI cocktail QID, pantoprazole 40 mg daily - Stopped/Held Meds: None - Changed Meds: Metoprolol succinate XL 50 mg -> 25 mg daily - Follow-up appointments: PCP appointment with Dr. ___ appointment with Dr. ___ follow up with Dr. ___. - Post-Discharge Follow-up Labs Needed: None - Incidental Findings: Thymoma, left leg claudication - Discharge weight: 94.8kg - Discharge creatinine: 1.5 # CODE: full (presumed) # CONTACT: ___ (wife) - ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Gabapentin 100 mg PO BID 3. HydrALAZINE 25 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Simvastatin 10 mg PO QPM 7. Aspirin 81 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral DAILY 11. selenium 200 mcg oral DAILY 12. Florastor (Saccharomyces boulardii) 250 mg oral DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ mL by mouth four times a day Disp #*1680 Milliliter Refills:*0 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 20 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 3. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Florastor (Saccharomyces boulardii) 250 mg oral DAILY 8. Gabapentin 100 mg PO BID 9. HydrALAZINE 25 mg PO DAILY 10. Hydrochlorothiazide 12.5 mg PO DAILY 11. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral DAILY 12. selenium 200 mcg oral DAILY 13. Simvastatin 10 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Chest pain # Esophagitis # Dilated cardiomyopathy/chronic left ventricular systolic heart failure # Non-conducted P waves consistent with asymptomatic sinus node dysfunction # Bradycardia # Acute kidney injury on # Chronic kidney disease, stage 3 # Normocytic anemia # Left calf claudication consistent with peripheral arterial disease # Hypertension # Hyperlipidemia # Mediastinal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of chest pain. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had chest pain. - Lab tests of your blood found that your cardiac enzymes were normal (not elevated), and you had electrocardiograms (EKGs) that did not show a heart attack. - You had an imaging test called a CT angiogram of your chest. There was no sign of a blood clot in your lung (pulmonary embolus) and no signs of aortic dissection. However, the CT angiogram showed a mass in the mediastinum that is likely a thymoma that should be followed up as an outpatient. - The CTA showed thickening of your esophagus that could be a sign of esophagitis (inflammation of the esophagus), which was likely causing your chest pain. - You were treated with a GI cocktail medication and a proton pump inhibitor that helps to reduce acid in the stomach, and your pain improved. - You were noted to have slow heart rates and a pause on cardiac telemetry monitoring. You should see your cardiologist Dr. ___ in clinic for follow up. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Continue to take the GI cocktail and proton pump inhibitor. - Follow up with your gastroenterology doctor. We recommend getting an endoscopy to look at your esophagus. - You should get a test called an ankle-brachial index (ABI) as an outpatient to work up your left calf tightness. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___

10040721-DS-2

DS

2176-04-13 00:00:00

2176-04-19 11:30:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Amoxicillin Attending: ___ Chief Complaint: Trauma: motor vehicle collusion Major Surgical or Invasive Procedure: ___: s/p bilateral incision and drainage, arthrotomy, wound closure History of Present Illness: Ms. ___ is a ___ year old female with MVC vs pole. Patient brought in by medflight from scene. S/P car vs pole. Unknown of she was restrained or not. Found next to her car. Significant damage to vehicle. Steering wheel broken. As per medflight report initially unconscious. Regained consciousness but became agitated. Intubated by ALS prior to medflight arrival. Has multiple abrasions on extremities. Past Medical History: PMH: Obesity PSH: Gastric Bypass ___ Social History: ___ Family History: NC Physical Exam: Admission Physical Exam: Constitutional: intubated and sedated HEENT: Pupils equal, round and reactive to light, Normocephalic, atraumatic, Extraocular muscles intact C collar in place Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: no crepitus or stepoff Extremities: RUE/LUE with multiple superficial abrasions about elbows and ecchymosis about R humeral shaft. No palpable step-offs or crepitus is felt. No gross deformity. Able to range wrist, elbow and shoulder without resistance. LLE with 5cm laceration about lateral aspect of knee, penetrating deeply. Visible patellar tendon. Bleeding controlled. No gross crepitus about knee. Thigh compartment soft. Calf compartment soft. Unable to assess neuro exam ___ intubated. palpable dp/pt pulses. RLE with 7cm laceration about lateral aspect of knee, penetrating deeply. Visible muscle and tendons. Bleeding controlled. No gross fracture or anatomic abnormality. R medial calf wound approximately 2cm in length, with exposed fat. No gross crepitus or instability about tibia. Ankle range of motion without resistance. unable to assess neuro exam ___ intubated. palpable dp/pt pulses. Neuro: moving all extremities, intubated and sedated Psych: as above ___: No petechiae Physical examination upon discharge: ___: Vital signs: t=97.5, hr=84, rr=20, bp=140/78, 97% room air General: Tired appearing, ambulating with walker CV: Ns1, s2, -s3, -s4 LUNGS: Clear ABDOMEN: soft, non-tender EXT: sutured laceration left knee, clean and dry, right knee laceration mildly abraded with xeroform gauze and DSD, sutured laceration right lower leg, ecchymosis right lower leg, mild pedal edema bil. NEURO: oriented x 3, speech clear, no tremors Pertinent Results: ___ 06:15AM BLOOD WBC-5.8 RBC-3.35* Hgb-9.9* Hct-29.1* MCV-87 MCH-29.7 MCHC-34.1 RDW-12.4 Plt ___ ___ 12:00AM BLOOD Neuts-85.9* Lymphs-9.9* Monos-3.7 Eos-0.2 Baso-0.3 ___ 06:15AM BLOOD Plt ___ ___ 06:15AM BLOOD Glucose-121* UreaN-5* Creat-0.4 Na-131* K-3.9 Cl-96 HCO3-25 AnGap-14 ___ 12:00AM BLOOD ALT-40 AST-82* AlkPhos-46 Amylase-25 TotBili-0.7 ___ 12:00AM BLOOD Lipase-15 ___ 06:15AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9 ___ 03:32AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:19PM BLOOD Lactate-1.9 Imaging: CT ChestAbdomen/Pelvis: IMPRESSION: 1. Suboptimal exam due to extensive streak artifact generated by patient's arms by her side. Within this limitation, no acute intra-abdominal injury is identified. 2. Small consolidations in the lung bases bilaterally, may reflect aspiration, atelectasis or infection in the appropriate setting. Additionally, there are heterogeneous ground-glass opacities in right upper and middle lobes, which may reflect pulmonary contusions or aspiration. 3. Large amount of fluid in the excluded portion of the stomach, suggestive of gastrogastric fistula. 4. Locule of gas seen just anterior to left pericardium, may represent extrapleural air. Bilateral Tib/Fib Xrays IMPRESSION: 1. No fracture or dislocation of knee joints. Extensive soft tissue edema and linear lucencies surrounding knee joints, likely correspond to patient's known lacerations. 2. Limited views of the ankles are suggestive of ankle dislocation and/or ligamentous injury. Dedicated ankle views may be obtained when feasible. Bilateral ___ CT: CONCLUSION: Overall, there is little evidence to suggest significant bony trauma. Extensive soft tissue trauma as described. Fragmentation in the superolateral left patella. UGI SGL W/O KUB FINDINGS: This exam was limited due to poor patient mobility secondary to pain. Limited AP and RPO projections were obtained. There is no evidence of contrast extravasation after ingestion of water-soluble Optiray contrast. There is no obstruction. This study was not designed to evaluate for communication between the alimentary tract and excluded stomach as was suggested on the recent CT due to the large volume of fluid in the excluded stomach. IMPRESSION: No contrast leak ___: x-ray of right shoulder: Possible nondisplaced fracture of the distal acromion given history of trauma versus os acromiale. Limited assesment on current radiographs. Correlate with direct palpation or CT for definitive assesment. Brief Hospital Course: Patient presented to the emergency room via medflight after being involved in a MVC. She was intubated at the scene for a GCS of 3 and med-flighted here. Upon admission, she wa evaluated by the acute care service. The patient was reportedly intoxicated with a blood alcohol level of 261. Upon admission, she underwent radiographic imaging and was admitted to the intensive care unit for monitoring. Head and c-spine x-rays were reported as normal. Extensive x-rays and cat scans did not demonstrate any fractures or dislocations. She was reported to have sustained billateral pulmonary contusions. Her oxygen saturation was closely monitored. She was evaluated by the Orthopedic service who washed out the lower extremity lacerations and applied a wet to dry dressing. She was taken to the operating room on HD #1 for a bilateral knee arthrotomy, incision and drainage, and patella incision. Her operative course was stable with a 50cc blood loss. She remained intubated and returned to the intensive care unit for monitoring. She was extubated shortly after and started on clear liquids. She reported nausea with emesis after starting a diet. There was concern for an anastomotic leak related to her history of gastric bypass. An upper GI study was done which did not demonstrate any extrasavation of contrast. Her nausea was controlled with oral anti-emetics and slowly resolved. Patient was transfered to the floor and evaluated by physcical therapy. On HD #3, the patient reported right shoulder pain. Orthopedics was consulted and an x-ray of the shoulder was done which showed a possible non-displaced fracture of the distal acromion. A sling was recommended for comfort and no surgical intervention needed. Orthopedic reccomendations for full weight bearing bilateral lower extremities with knee immobilizer to right knee. Her vital signs have remained stable and she has been afebrile. Her appetite was slowly improving and she was ambulating with walker assistance. She has family support at home who will provide her with assistance in ADL's. She is preparing for discharge home with instructions to follow -up with orthopedics and with the acute care service. Medications on Admission: 1. OCP 2. MVI Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Ultram 50 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Trauma: MVC: bilateral knee lacerations pulmonary contusion R upper molar chipped possible non-displaced fracture right distal acromion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the ___ General Surgery service after a motor vehicle collision. You sustained bilateral lacerations to your lower extremities witout evidence of fracture. Your lacerations were closed and you were transfered to the floor for general care, ___ evaluation and recovery. Orthopaedics also evaluated you for your lower extremity injuries and will be following you after discharge. You will be discharged with the following instructions: Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *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 an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue activity as tolerated per physical therapy reccomendations and orthopaedic restrictions, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. As per previous instruction do not take NSAIDS given your history of gastric bypass and continue any nutritional supplements as instructed by your bariatric physican. Followup Instructions: ___

10040884-DS-13

DS

2162-07-21 00:00:00

2162-07-23 02:33:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Cough, dyspnea, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of metastatic melanoma (on Ipilimumab, last dose 2 days ago) comes to the ED with cough and dyspnea on ambulation. Patient had onset of symptoms after his infusion 2 days ago. Denies any fever, chills, chest pain or dyspnea at rest. Endorses dyspnea with ambulation. Noted at clinic to have ambulatory O2 sat drop to 87 %. In the ED: initial vitals: 97.6 63 99/53 18 99%. CXR: No acute process. Concern for PE, but given renal insufficiency, CT not done. But likelihood very high, D ___ ___, so heparin drip started in ED. On the floor, patient endorses SOB on ambulation. Otherwise, no fever, chills, nausea, vomiting. No palpitations. he reports that for the last 2 days, he had loose Bms twice daily, which has now resolved. No PMH of DVT or PE. Past Medical History: Past Medical History: Hypertension, hyperlipidemia, myocardial infarction in ___ status post angioplasty, aortic stenosis. . Past Surgical History: Status post appendectomy at age ___, two TURP, Prior history of SCC and BCC with surgical removal Oncologic history: ___: biopsy of right lower back skin lesion showed invasive malignant melanoma, superficial spreading type, with a Breslow thickness of 0.95 mm, ___ level IV with ulceration present. Mitotic activity less than one per mm sq. He went on to have an excisional biopsy of that area as well as a right iliac sentinel lymph node biopsy. Margins were free of melanoma and Breslow thickness was 1.1 mm. Four out of four lymph nodes were negative for melanoma. - ___ noticed a right groin mass thought to be a hernia - ___: excisional biopsy was consistent with malignant melanoma. Immunohistochemical stains showed expression of MART-1 and was S100 negative. - ___: CT scan of his abdomen and pelvis showed right inguinal iliac and retroperitoneal lymphadenopathy as well as numerous metastatic disease in his liver. - ___: Brain MRI negative for metastatic disease. - BRAF wild-type - ___: Week 1 Ipilimumab 3 mg/kg - ___: Week 4 Ipilimumab 3 mg/kg - ___: Week 7 Ipilimumab 3 mg/kg - ___: developed a new rash, treated with prednisone 40 mg daily, ___ with creatinine 2.1 - ___: Week 10 Ipilimumab delayed due to ___ and K+ 6.2; prednisone decreased to 20 mg. - ___: prednisone decreased to 10 mg x 4 days, then stop Social History: ___ Family History: He reports a sister with some type of cancer in her ___. Otherwise, no family history of melanoma. Physical Exam: 97.6 64 98/54 16 99% RA GENERAL: Alert, oriented, ashen color. HEENT: Anicteric, MMM, oropharynx is clear NECK: No cervical, supraclavicular, or axillary LAD, no thyromegaly CV: Regular rate and rhythm, nl S1/S2, no murmurs, rubs or gallops PULM: Clear to auscultation bilaterally ABD: Normoactive bowel sounds, soft, non-tender, non-distended, no masses or hepatosplenomegaly INGUINAL LYMPH NODES: Firm, fixed nodal mass on the right side, appears unchanged without evidence of infection. LIMBS: Trace peripheral edema of the lower extremities bilaterally Discharge exam: VSS, O2 sat 98-100% on RA at rest and with ambulation Skin: gray/bluish tinge on face, scalp Pulm: clear lungs bilaterally Pertinent Results: ___ 05:32PM ___ ___ 05:05PM GLUCOSE-121* UREA N-24* CREAT-1.8* SODIUM-140 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16 ___ 05:05PM WBC-5.4 RBC-4.38* HGB-12.2* HCT-37.6* MCV-86 MCH-27.8 MCHC-32.3 RDW-14.3 ___ 05:05PM NEUTS-60.9 ___ MONOS-9.4 EOS-4.1* BASOS-0.6 ___ 05:05PM PLT COUNT-134* ___ 05:05PM ___ PTT-24.4* ___ Labs at discharge: ___ RDW Plt Ct ___ 14.2 128 GlucoseUreaN Creat Na KCl HCO3AnGap 114 30 1.7 138 ___ 13 TypeArterial: pO2pCO2 pH ___ 7.47 22 O2 SatMetHgb 97 0 FINDINGS: The heart size is normal. The aorta is mildly tortuous and demonstrates diffuse atherosclerotic calcifications. Mediastinal and hilar contours otherwise are unremarkable. Previously noted nodular opacity within the lingula on CT is not clearly demonstrated on the current study. The lungs are clear. No pleural effusion or pneumothorax is present. The pulmonary vascularity is normal. No acute osseous abnormalities are seen. IMPRESSION: No acute cardiopulmonary abnormality. CT head: FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect or recent infarction. Prominence of the ventricles and sulci is consistent with age-related global atrophy. A hypodensity in the region of the right basal ganglia (2:9) is consistent with a prominent perivascular space. No concerning osseous lesion is seen. The mastoid air cells are clear. There is mucosal thickening of the left frontal sinus, right frontoethmoidal recess, left ethmoid air cells and sphenoid sinuses bilaterally. IMPRESSION: No evidence of acute intracranial process. No evidence of mass or mass effect. V/Q Scan: INTERPRETATION: Ventilation images obtained with Tc-99m aerosol in 8 views demonstrate no significant defects Perfusion images in the same 8 views show no segmental defects Chest x-ray shows no acute cardiopulmonary process The above findings are consistent with a very low probability of pulmonary embolus. IMPRESSION: Very low probability for acute pulmonary embolus. Brief Hospital Course: ___ with history of metastatic melanoma (on Ipilimumab, last dose 2 days ago) comes to the ED with cough and possible hypoxia. # Hypoxia: The acuity of symptoms, d Dimer of ___, pulmonary embolism is highly likely. Given renal insufficiency, CTA would not be a reasonable study. Continued heparin gtt until V/Q scan returned very low probability for PE. Given bluish/gray discoloration of skin, ruled out methemoglobinemia with ABG. There was no evidence of hypoxia at rest or with ambulation. Patient noted to have significant nasal congestion, and Flonase was started empirically for symptomatic relief of cough. # Metastatic melanoma- pt will follow up with his oncologists as previously scheduled # Diarrhea: ikely secondary to side effect from Ipilimumab. Latter can cause diarrhea in around 30 % cases. Will watch for now. Did not recur, did not check C diff PCR. # HTN: Continued home dose Metoprolol. # Hyperlipidemia: Continue Crestor. # CAD: Stable. Continue Aspirin and Metoprolol. ACEI was stopped recently due to history of hyperkalemia and low blood pressure. # CKD: Likely secondary to HTN. Cr. remained at baseline. # Full code Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Aspirin 81 mg PO 2 tabs DAILY 2. Rosuvastatin Calcium 40 mg PO DAILY 3. Metoprolol Tartrate 25 mg PO BID Discharge Medications: 1. Aspirin 162 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO BID 3. Rosuvastatin Calcium 40 mg PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY RX *Flonase 50 mcg 1 spray NU daily Disp #*1 Unit Refills:*0 5. Lisinopril 10 mg PO DAILY not taking as prescribed. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: possible hypoxia, eval for pulmonary embolus metastatic melanoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after noted to have a low oxygen level at your doctors ___. You presented to the hospital, and there was concern for a possible blood clot in your lungs, and you received a blood thinner. You underwent a lung scan that did not show any evidence of blood clots, which is good news. Your oxygen level was normal at rest and with walking, and your blood oxygen level, determined with a blood test, was also normal. The only medication change is the addition of Flonase, one spray per nostril daily. This may help with your cough. Please see below for your follow up appointments. Followup Instructions: ___

10040984-DS-9

DS

2179-03-16 00:00:00

2179-03-16 15:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Incarcerated inguinal hernia and perforation of incarcerated sigmoid colon with foreign body (toothpick). Major Surgical or Invasive Procedure: ___ 1. Exploratory laparotomy with sigmoid colectomy and ___ procedure. 2. Abdominal washout. 3. Reduction of incarcerated left inguinal hernia with Bassini-type repair. History of Present Illness: Per Dr. ___ note as follows: ___ man with known cirrhosis who presents with a two-day history of incarceration of a known left inguinal hernia. He also has not passed any flatus and is quite sick with an elevated white count and redness over the hernia. He is brought urgently to the operating room. Past Medical History: - prostate CA s/p prostatectomy in ___ - Saw a hematologist (Dr. ___ in ___ for a "blood disorder" a few years ago, might have been related to his liver disease - GERD - ETOH Abuse (per pt and wife quit ___ years ago) - s/p L hip ORIF (pt fell and broke right hip while withdrawing from EtOH a number of years ago) - "liver disease," unclear if pt had actually been diagnosed with cirrhosis Social History: ___ Family History: No FH of CAD or CA. A grandparent had DM. Physical Exam: ___ 80 HR 136/81 RR18 98% RA Gen: affable, elderly appearing gentleman CV: RRR no obvious MRG Pulm: post CTAB, anterior minor wheezes Abd: soft, non tender non distend no guarding or rebound, infra umbilical midline incision well healed no obvious facial defects Left scrotm large, tender, non reducible with erythematous skin. No ___ edema b/l Labs: 141 ___ 4.4 21 1.3 estGFR: 53 ALT: 42 AP: 136 Tbili: 1.4 Alb: 3.5 AST: 32 Lip: 19 11.0 23.1 500 32.3 Coags: pending CXR: outside facility ___ without evidence of acute process EKG: pending OSH ___: WBC 27k Plts 644k Cr 1.44 Tb 1.7 lactic acid ___ Pertinent Results: Admission labs: ___ 04:07PM BLOOD WBC-23.1*# RBC-3.49* Hgb-11.0*# Hct-32.3* MCV-93 MCH-31.5 MCHC-34.1 RDW-13.9 RDWSD-47.1* Plt ___ ___ 04:07PM BLOOD Glucose-106* UreaN-30* Creat-1.3* Na-141 K-4.4 Cl-107 HCO3-21* AnGap-17 ___ 04:07PM BLOOD ALT-42* AST-32 AlkPhos-136* TotBili-1.4 ___ 11:59PM BLOOD Calcium-7.6* Phos-4.7* Mg-1.7 ___ 04:07PM BLOOD Albumin-3.5 Discharge labs: ___ 06:14AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.0* Hct-30.8* MCV-91 MCH-29.7 MCHC-32.5 RDW-14.4 RDWSD-47.3* Plt ___ ___ 04:53AM BLOOD ___ PTT-27.8 ___ ___ 06:14AM BLOOD Glucose-130* UreaN-43* Creat-1.8* Na-135 K-4.8 Cl-100 HCO3-22 AnGap-18 ___ 06:14AM BLOOD ALT-60* AST-50* AlkPhos-368* TotBili-0.5 ___ 06:14AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.3 Brief Hospital Course: On ___, he underwent exploratory laparotomy with sigmoid colectomy and ___ procedure for perforation of incarcerated sigmoid colon with foreign body (tooth pick), abdominal washout and reduction of incarcerated left inguinal hernia with Bassini-type repair. Other finders were peritonitis and cirrhosis. Surgeon was Dr. ___. Please refer to operative note for complete details. Postop,urine output was low and IV fluid bolus was given with improvement. He had a short run of VTach with normal EKG. Metoprolol was given for tachycardia on ___. Overnnight on ___, he had several rhythms (Tachy w/ new LBBB, inverted T waves). Cardiology was consulted. Cardiology was consulted and recommended ???? Cardiac enzymes were normal and lytes were repleted. The NG was removed on ___. He was started on sips and was passing gas and stool thru ostomy on ___. Diet was advanced to a regular diet. Dilaudid PCA was changed to oral dilaudid. On ___, O2 desaturated to 80%. CXR was done showing stable left opacity and right upper opacity. Lasix was started for pulmonary edema. Heart rate was tachy with a new LBBB, inverted T waves. Cardiology was consulted, troponin/ck cycled (wnl),and lytes replaced. Metoprolol was started for rate control. TTE was grossly unremarkable. On ___, he had ascites leaking through the incision as well as parastomal. Albumin and Lasix doses were given. Zosyn was started while ascites leaking. On ___, Liver U/S demonstrated cirrhosis, secondary evidence of portal HTN, and no thrombus. LFTs increased mildly from admission and remained in the same range. Cardiac enzymes were cycled and negative. Metoprolol was given with better control of heart rate. He had some SVT initermittently on walks down hallway without symptoms. Lasix and Spironolactone were decreased a couple times for creatinine increase to 1.8 on ___ from 1.3-1.5. Creatinine remained at 1.8 Weight was 64kg (admission 74kg). A Prevena wound vac was applied to the incision to control the ascites leak with good response. Prevena vac was removed on ___. Incision remained clean and dry. Staples were left in place to be removed by Dr. ___ in follow up appointment. Zosyn was changed to Augmenting on ___ then discontinued on ___ when he was discharged to rehab ___). He remained afebrile. Nutritional intake was poor despite nutritional supplements. Kcal count was low (325) and a feeding tube was placed. Osmolite 1.5 was started and rate increased to goal of 60ml/hour continuous. He tolerated this just fine. ___ evaluated and worked with him noting deconditioning and weakness. Rehab was recommended. ___ in ___ offered a bed and he was discharged in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. LevETIRAcetam 250 mg PO BID 3. Omeprazole Dose is Unknown PO DAILY 4. Aspirin Dose is Unknown PO Frequency is Unknown 5. Vitamin D 800 UNIT PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Ranitidine 150 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN thick secretions 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. Furosemide 10 mg PO DAILY 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Glucose Gel 15 g PO PRN hypoglycemia protocol 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing 10. Metoprolol Tartrate 12.5 mg PO Q6H Hold for SBP <95 Hold for HR <60 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Senna 8.6 mg PO BID:PRN constipation 13. Spironolactone 25 mg PO DAILY 14. TraMADol 25 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 15. Aspirin 81 mg PO DAILY 16. Docusate Sodium 100 mg PO BID hold for loose stool 17. LevETIRAcetam 250 mg PO BID 18. Ranitidine 150 mg PO QHS 19. HELD- Vitamin D 800 UNIT PO DAILY This medication was held. Do not restart Vitamin D until discussed with PCP ___: Extended Care Facility: ___ Discharge Diagnosis: Incarcerated inguinal hernia. Perforation of incarcerated sigmoid colon with foreign body (toothpick) Peritonitis Cirrhosis ETOH Cirrhosis SVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will be transferring to ___ Rehab in ___ Please call Dr. ___ office at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, discoloration of stoma, constipation, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, or any other concerning symptoms. You may shower, but no tub baths No heavy lifting/straining (nothing heavier than 10 pounds) Tube feedings have been started for malnutrition. Followup Instructions: ___

10041312-DS-20

DS

2169-10-30 00:00:00

2169-10-30 10:06:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: codeine / erythromycin base / cephalasporin / Motrin Attending: ___. Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: ___: ___ aspiration of perihepatic fluid collection ___: ___ drainage of perihepatic fluid collection, drain placement ___: ___ drainage of perihepatic fluid collection, replacement of drain; percutaneous cholecystostomy tube History of Present Illness: ___ COPD, CHF (EF 40%) was recently treated for acute cholecystitis with a cholecystostomy at beginning of ___ at ___ here with recurrent right upper quadrant pain. She was transferred to ___ from ___ after being found hypotensive and hypoxic at rehab. She responded to 1L of fluid and was started on levaquin and flagyl. She reports having right upper quadrant pain that has been on going but progressive in nature. Her percutaneous cholecystostomy was accidentally removed over the weekend and she saw Dr. ___ in clinic on the ___ who wanted to discuss an interval cholecystectomy with the family. Of note she was discharged from rehab yesterday and last night she felt weak and slid to the floor. She denies any LOC, or head strike. The fire department did come and help her back to bed. The following morning she was taken to the rehab who found her to be hypotensive which prompted the transfer. She reports some nausea and has a decreased appetite. She denies any post prandial pain, diarrhea, vomiting, constipation, back pain, headaches, dysuria, cough, chest pain, shortness of breath, rashes. She is reporting some left foot pain that seems to be chronic and was evaluated by her PCP. Past Medical History: MHx: COPD- not on home O2, CHF/CMO, CKDIII, CAD, HTN, HLD, Cognitive dysfunction, Obesity, GERD Hypercoagulable state-family unsure-no history of clots, OA, asthma, gastric polyps, diverticulosis history of falls, SHx: ___ Family History: Non-contributory Physical Exam: At admission: 97.2 86 105/55 16 96% General: Comfortable, obsese HEENT: anicteric sclera ___: regular rhythm Pulm: clear bilaterally Abdomen: soft, TTP RUQ Ext: WWP, moves all extremities At discharge: 97.9 82 128/81 20 92RA General: NAD HEENT: EOMI, MMM, anicteric sclera Cardiac: RRR Pulm: non-labored breathing, on room air Abdomen: soft, NT, ND, RUQ ___ drains x2 with bilious fluid in bag Ext: no edema Neuro: A&Ox2 Psych: appropriate mood, appropriate affect Pertinent Results: -Ultrasound guided drainage of perihepatic collection (___): IMPRESSION: 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 0.45 L of fluid were removed. -Abdominal Ultrasound (___): IMPRESSION: 1. Reaccumulation of perihepatic ascites appears overall similar to the images obtained prior to ultrasound-guided paracentesis 1 day prior. There is a more loculated portion measuring 5.6 x 2.0 x 5.0 cm in the midline upper abdomen which appears to be connected to the perihepatic ascites 2. Cholelithiasis. -Ultrasound guided drainage of perihepatic collection (___): IMPRESSION: 1. Technically successful US-guided placement of ___ pigtail catheter into the right upper quadrant fluid collection. 2. 160 cc of dark green bilious fluid was removed. -Abdominal Ultrasound (___): IMPRESSION: Perihepatic fluid again identified and a small right pleural effusion is noted. Despite effort the right upper quadrant drain could not be identified with ultrasound. The CT is recommended for further evaluation. CT INTERVENTIONAL PROCEDURE (___): IMPRESSION: 1. Successful CT-guided placement of ___ pigtail catheter into the perihepatic collection. Samples were sent for microbiology evaluation. 2. Successful CT-guided ___ percutaneous cholecystostomy tube placement. ___ Drainage (___): -Tbili 55 -Gram stain: no organisms, no PMNs -Culture: rare GPCs Urine Culture (___): -Preliminary: gram negative rods (>100k CFU), speciation/sensitivity pending Brief Hospital Course: Ms. ___ presented to the ___ ED from ___ on ___ after CT scan showed a perihepatic abscess following accidental removal of her percutaneous cholecystostomy tube 1 week ago. She was admitted and started on IV antibiotics (Cipro/Flagyl). She was kept NPO and ___ was consulted. INR was 1.7 and she was given 1 unit of FFP prior to ___ procedure. She underwent US-guided drainage of a perihepatic fluid collection on ___. Fluid drained was non-purulent and bilious, concerning for a bile leak. She underwent repeat abdominal ultrasound on ___ that showed reaccumulation and she returned to ___ on ___ for placement of an ___ drain. Drain output was initially good, but became minimal on ___. She underwent another ultrasound on ___ which again showed unchanged perihepatic fluid collection with drain unable to be visualized in the collection. She returned to ___ on ___ for replacement of the perihepatic ___ drain and was as placement of percutaneous cholecystostomy tube. Diet was advanced to regular on ___ and she was transitioned to oral antibiotics which she tolerated well. Foley was removed on ___ and patient voided spontaneously without issue. Urine was noted to be concentrated and foul smelling on ___ and a sample was sent for UA and culture. At time of discharge, preliminary culture data showed >100k CFU of gram negative rods. She was already on ciprofloxacin for bile leak and continues on this at the time of discharge for a total 5 day course (stop date ___. Speciation and sensitivity were pending at time of discharge, and the rehab facility will be contacted to make appropriate changes if final culture data shows resistance to ciprofloxacin. She was discharged to rehab on ___. At the time of discharge she ambulating with assistance, voiding spontaneously, tolerating a regular diet, and pain was well controlled with oral medications. She was discharged with instructions to follow up in the ___ with Dr. ___ on ___ at 10:30 am. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. amLODIPine 2.5 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Simvastatin 20 mg PO QPM 11. TraZODone 50 mg PO QHS 12. Acetaminophen 650 mg PO BID:PRN Pain - Mild Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*5 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*7 Tablet Refills:*0 3. Acetaminophen 650 mg PO BID:PRN Pain - Mild 4. amLODIPine 2.5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. Lisinopril 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Simvastatin 20 mg PO QPM 13. TraZODone 50 mg PO QHS 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: perihepatic fluid collection bile leak s/p cholecystostomy tube Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___ or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ for drainage of a perihepatic fluid collection that developed after your percutaneous cholecystostomy tube fell out. You were also noted to have a urinary tract infection while you were here, for which you have been prescribed antibiotics. You have recovered well and are now ready for discharge. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may start some light exercise when you feel comfortable. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Thank you for allowing us to participate in your medical care. Sincerely, Your ___ Surgery Team Followup Instructions: ___

10041429-DS-8

DS

2114-03-12 00:00:00

2114-03-12 12:35:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Vicodin Attending: ___. Chief Complaint: recurrent low back pain post mvc and right foot paresthesias and weakness Major Surgical or Invasive Procedure: L4-S1 Decompression/Fusion History of Present Illness: ___ female PMHx lumbar spinal stenosis, chronic low back pain s/p multiple surgeries on her lumbar spine including several microdiscectomies (___ @ ___, ___ @___) s/p L4,L5 laminectomies ___ ___ @ ___ who had been doing relatively well over the past ___ years until she was involved in a high energy MVC ___ following which she had recurrent severe low back pain and also esophageal injury currently being worked up. Since this past ___ she noted that her right foot was unable to dorsiflex and had decreased sensation and paresthesias - this has resulted in several falls over the past week. She had planned follow-up with Dr. ___ ___ this upcoming ___ but became concerned due to these falls and did not feel safe to wait any longer for evaluation. Went to ___, transferred to ___ due to lack of spine consult availability at ___. Denies saddle anesthesia, denies bowel/bladder changes. IMAGING:MRI of the lumbar spine demonstrates diffuse post-surgical changes including superficial seroma. Multiple lumbar disc herniations most prominent at L4/5-right lateral disc. Past Medical History: PMH/PSH: Multiple lumbar spine surgeries s/p MVC ___ Social History: ___ Family History: Single mother, works but not currently working after MVC. Physical Exam: PHYSICAL EXAMINATION: Vitals: AVSS General: Well-appearing female in no acute distress. Spine exam: Surgical wounds well healed over lumbar spine, no erythema. Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 2 3 -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 decreased sensation, L nl L5 (Grt Toe): R decreased sensation, L nl S1 (Sm toe): R decreased sensation, L nl S2 (Post Thigh): R nl, L nl -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 0 ___: neg Babinski: downgoing Clonus: none Perianal sensation: intact Rectal tone: intact LABS: Pending Pertinent Results: ___ 11:03AM BLOOD WBC-7.3 RBC-3.01* Hgb-8.3* Hct-26.9* MCV-89 MCH-27.6 MCHC-30.9* RDW-15.6* RDWSD-50.6* Plt ___ ___ 10:33AM BLOOD WBC-6.6 RBC-3.09* Hgb-8.7* Hct-27.3* MCV-88 MCH-28.2 MCHC-31.9* RDW-15.0 RDWSD-48.6* Plt ___ ___ 07:30AM BLOOD WBC-7.0# RBC-3.33* Hgb-9.2* Hct-29.4* MCV-88 MCH-27.6 MCHC-31.3* RDW-15.2 RDWSD-48.9* Plt ___ ___ 01:35PM BLOOD Neuts-81.9* Lymphs-13.5* Monos-3.6* Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.82# AbsLymp-0.63* AbsMono-0.17* AbsEos-0.01* AbsBaso-0.03 ___ 08:00AM BLOOD Neuts-54.5 ___ Monos-6.5 Eos-3.5 Baso-0.8 Im ___ AbsNeut-2.17 AbsLymp-1.37 AbsMono-0.26 AbsEos-0.14 AbsBaso-0.03 ___ 11:03AM BLOOD Plt ___ ___ 10:33AM BLOOD Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 01:35PM BLOOD ___ PTT-27.5 ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD ___ PTT-27.8 ___ ___ 11:03AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-22 AnGap-15 ___ 10:33AM BLOOD Glucose-153* UreaN-7 Creat-0.4 Na-137 K-4.3 Cl-104 HCO3-22 AnGap-15 ___ 07:30AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-25 AnGap-12 ___ 10:33AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 ___ 07:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 ___ 03:01PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8 Brief Hospital Course: Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable ___ were used for postoperative DVT prophylaxis.Intravenous antibiotics were continued for 24hrs postop per standard protocol.Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD#2. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's.Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Clonazepam Gabapentin Mirtazapine Omeprazole Sertraline Discharge Medications: 1. Diazepam 5 mg PO Q6H:PRN muscle spasms may cause drowsiness RX *diazepam 5 mg 1 tab by mouth every eight (8) hours Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID please take with narcotic pain medications RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate please do not operate heavy machinery, drink alcohol or drive RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*90 Tablet Refills:*0 4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*90 Tablet Refills:*0 5. ClonazePAM 1 mg PO QID 6. Gabapentin 300 mg PO TID 7. Mirtazapine 7.5 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Lumbar spondylosis and stenosis and scoliosis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With Fusion Immediately after the operation: • Activity:You should not lift anything greater than 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 ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. • Diet: Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. • Brace:You may have been given a brace.If you have been given a brace,this brace is to be worn when you are walking.You may take it off when sitting in a chair or while lying in bed. • Wound Care: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. • 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. • 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.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: 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. Followup Instructions: ___

10041429-DS-9

DS

2114-04-05 00:00:00

2114-04-05 16:01:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Vicodin Attending: ___. Chief Complaint: Abdominal pain, fever Major Surgical or Invasive Procedure: Laparoscopic adjustable gastric band and port removal. History of Present Illness: Ms. ___ is a ___ s/p laparoscopic gastric band at ___ in ___ who presented with LLQ abdominal pain. She has a recent history of a motor vehicle accident on ___ with exacerbation in lumbar pain, and underwent L4-S1 3 part laminectomy and instrumented fusion ___ and was discharged from the hospital on ___. She was recovering well after her procedure, but presented to the ED on ___ for fever up to 103 at home. She has been having LLQ pain since her spinal surgery. She reports that she has been having occasional food intolerance and difficult swallowing for the past 5 months, with occasional heartburn but no regurgitation. Her symptoms have gradually worsened during the past 5 months. She reports occasional nausea, no vomiting, no constipation or diarrhea. She has lost 200 pounds after the lap band procedure, her preop weight was 365 and now it is 165lbs. Upon arrival to the ED they performed a CT scan, which demonstrated a large fluid collection in the soft tissues posterior to the lumbar fusion (?seroma/ abscess) and a moderate hiatal hernia and slipped lap band. Past Medical History: PMH/PSH: Multiple lumbar spine surgeries s/p MVC ___ Social History: ___ Family History: Single mother, works but not currently working after ___. Physical Exam: Vitals: T=98.2F; BP=96/60mmHg; HR=76x'; RR=18x'; O2 Sat=98% Ra GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. CARDIAC: Regular rate and rhythm, no murmurs/rubs/gallops. LUNGS: No respiratory distress. Clear to auscultation bilaterally. No wheezes, rhonchi or rales. ABDOMEN: Decreased bowel sounds, non distended, expectedly tender diffusely. No peritoneal signs. Dressings appear clean, dry, and intact EXTREMITIES: No clubbing, cyanosis, or edema. Pertinent Results: ___ 05:08AM BLOOD Hct-30.3* ___ 12:30AM BLOOD WBC-5.1 RBC-3.19* Hgb-8.2* Hct-26.7* MCV-84 MCH-25.7* MCHC-30.7* RDW-15.1 RDWSD-46.1 Plt ___ ___ 12:30AM BLOOD Neuts-71.1* Lymphs-18.9* Monos-8.4 Eos-0.6* Baso-0.8 Im ___ AbsNeut-3.65 AbsLymp-0.97* AbsMono-0.43 AbsEos-0.03* AbsBaso-0.04 ___ 12:30AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-138 K-3.8 Cl-102 HCO3-24 AnGap-16 ___ 12:30AM BLOOD CRP-38.0* CT abdomen/pelvis w/contrast ___ 1. Large fluid collection in the soft tissues posterior to the lumbar fusion surgical bed could represent abscess or post operative seroma. 2. Moderate hiatal hernia and increased stomach above the band consistent with slipped lap band. Brief Hospital Course: Ms. ___ is a ___ who is status post laparoscopic gastric band placed at an outside hospital (___). She presented to the ED on ___ with a history of many months of dysphagia to solids, progressive to liquids over the last day or so. We removed all the fluid from her band with no improvement of symptoms. Her CT scan, demonstrated prolapse. We discussed risks, benefits, alternatives. She understood and consented to have the band removed. She underwent laparoscopic gastric band removal on ___ without complications. Her postoperative hematocrit was stable. Of note, she underwent L4-S1 3 partial laminectomy and instrumented fusion recently and is currently followed by her spine surgeon, who is managing her pain medications. We have given her a prescription for Dilaudid tablets (#10) that should suffice until her next appointment with Dr. ___ spinal surgeon) on ___ at 9:30AM. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ClonazePAM 1 mg PO QID 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO TID 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate 5. Omeprazole 20 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Diazepam 5 mg PO Q6H:PRN muscle spasms 8. Mirtazapine 7.5 mg PO QHS 9. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Diazepam 5 mg PO Q6H:PRN muscle spasms 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN 5. ClonazePAM 1 mg PO QID 6. Gabapentin 300 mg PO TID 7. Mirtazapine 7.5 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Laparoscopic adjustable gastric band prolapse. 2. Dysphagia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You have undergone removal of your adjustable gastric band, recovered in the hospital and are now preparing for discharge to home with the following instructions: Discharge Instructions: Please call your surgeon or return to the Emergency Department if you develop a fever greater than 101 F, shaking chills, chest pain, difficulty breathing, pain with breathing, cough, a rapid heartbeat, dizziness, severe abdominal pain, pain unrelieved by your pain medication, a change in the nature or severity of your pain, severe nausea, vomiting, abdominal bloating, severe diarrhea, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness, swelling from your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage IV diet until your follow up appointment; please refer to your work book for detailed instructions. Do not self- advance your diet and avoid drinking with a straw or chewing gum. To avoid dehydration, remember to sip small amounts of fluid frequently throughout the day to reach a goal of approximately ___ mL per day. Please note the following signs of dehydration: dry mouth, rapid heartbeat, feeling dizzy or faint, dark colored urine, infrequent urination. Medication Instructions: Please refer to the medication list provided with your discharge paperwork for detailed instruction regarding your home and newly prescribed medications. Some of the new medications you will be taking include: Pain medication: You will receive a prescription for Dilaudid tablets that should last you until your appointment with Dr. ___. Constipation: This is a common side effect of opioid pain medication. If you experience constipation, please reduce or eliminate opioid pain medication. You may trial 2 ounces of light prune juice and/or a stool softener (i.e. crushed docusate sodium tablets), twice daily until you resume a normal bowel pattern. Please stop taking this medication if you develop loose stools. Please do not begin taking laxatives including until you have discussed it with your nurse or surgeon. You must not use NSAIDS (non-steroidal anti-inflammatory drugs). Examples include, but are not limited to Aleve, Arthrotec, aspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen, Indocin, indomethacin, Feldene, ketorolac, meclofenamate, meloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen, Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren. These agents may cause bleeding and ulcers in your digestive system. If you are unclear whether a medication is considered an NSAID, please ask call your nurse or ask your pharmacist. Activity: You should continue walking frequently throughout the day right after surgery; you may climb stairs. You may resume moderate exercise at your discretion, but avoid performing abdominal exercises or lifting items greater than10 to 15 pounds for six weeks. Wound Care: You may remove any remaining gauze from over your incisions. You will have thin paper strips (Steri-Strips) over your incision; please, remove any remaining Steri-Strip seven to 10 days after surgery. You may shower 48 hours following your surgery; avoid scrubbing your incisions and gently pat them dry. Avoid tub baths or swimming until cleared by your surgeon. If there is clear drainage from your incisions, cover with clean, dry gauze. Please call the doctor if you have increased pain, swelling, redness, cloudy, bloody or foul smelling drainage from the incision sites. Avoid direct sun exposure to the incision area for up to 24 months. Do not use any ointments on the incision unless you were told otherwise. Followup Instructions: ___

10041690-DS-8

DS

2139-11-24 00:00:00

2139-11-26 10:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / escitalopram / lisinopril / aspirin / latex / hydrochlorothiazide Attending: ___. Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with hypertension, hypothyroidism and anxiety presenting with hyponatremia found on outside labs. For approximately the past 10 days she has not been feeling herself. Over this time frame she has had a headache, dizziness, general weakness and bilateral tinnitus. Notably in the end of ___ she has a diarrheal illness, which her son had at the same time. She recovered from this spontaneously. She went to an urgent care on ___ and was given HCTZ 25mg BID for hypertension. She took a single dose of this medication on ___ in the evening. She then presented to her primary care physician ___ ___ for hypertension and had a chem panel drawn in this setting. Her sodium resulted as 118 and she was called to come to the ED. Her last sodium check prior to this was about 3 months prior and was normal at 135. Of note, she describes an incident about ___ years ago when she was very weak after a diarrheal illness and collapsed. She was admitted to the hospital at that time reportedly because of severe hyponatremia. Ms. ___ reports she typically has about 4 cups of tea every morning and then ___ bottles of water later in the day. Overall she eats a fairly mixed diet. She has not had chest pain, vomiting, diarrhea, fevers, chills. She endorses some anorexia. In the ED, - Initial Vitals: T97.8, HR 75, BP 178/89, RR 16, O2 100% RA - Exam: Physical General: well-appearing HEENT: MMM, neck supple Lungs: CTAB, normal work of breathing Heart: RRR, normal S1/S2, no murmurs Abd: soft, nontener, nondistended Skin: WWP, cap refill <2 sec Ext: no edema, ecchymosis Neuro: CN II-XII grossly intact, ___ strength and sensation to light touch throughout Her initial sodium was 121 on presentation. She received 1L NS for this and overcorrected to 130. She then received DDAVP 2mcg and her sodium dropped to 126 before coming to the floor. ROS: Positives as per HPI; otherwise negative. Past Medical History: - Osteoporosis - Anxiety - HTN - Hypothyroidism - Sciatica Social History: ___ Family History: No known family history of electrolyte derangement Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ VS: T98.7, HR 81, BP 142/87, RR 16, ___ 98% RA GEN: Sitting up in bed and speaking with me. Somewhat anxious. EYES: Pupils equal and reactive. No icterus or injection HENNT: Moist mucous membranes. CV: S1/S2 regular with no murmurs, rubs or S3/S4. RESP: Clear bilaterally, no respiratory distress. GI: Soft, non-tender, non-distended. EXT: Warm extremities, no lower extremity edema. SKIN: Warm, dry. Bruising on L dorsum of hand. NEURO: CN II-XII normal, ___ strength in upper and lower extremities. PSYCH: Anxious appearing. ============================ DISCHARGE PHYSICAL EXAMINATION VS: 24 HR Data (last updated ___ @ 749) Temp: 98.1 (Tm 98.3), BP: 155/87 (132-155/83-87), HR: 70 (67-70), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra\ GEN: Ambulating around room/hall, NAD EYES: Pupils equal and reactive. No icterus or injection HENNT: Moist mucous membranes. No CLAD CV: S1/S2 regular with no murmurs, rubs or S3/S4. RESP: Clear bilaterally, no respiratory distress. GI: Soft, non-tender, non-distended. EXT: Warm extremities, no lower extremity edema. SKIN: Warm, dry. NEURO: CN II-XII normal, ___ strength in upper and lower extremities. PSYCH: Mildly anxious appearing. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 04:30PM BLOOD WBC-6.7 RBC-4.31 Hgb-13.6 Hct-37.8 MCV-88 MCH-31.6 MCHC-36.0 RDW-11.1 RDWSD-35.6 Plt ___ ___ 04:30PM BLOOD UreaN-8 Creat-0.4 Na-118* K-3.6 Cl-81* HCO3-24 AnGap-13 ___ 12:59AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== ___ 10:26AM BLOOD Na-122* K-3.2* ___ 02:12PM BLOOD Na-127* ___ 04:22PM BLOOD Na-130* ___ 04:48PM BLOOD Na-126* ___ 06:28PM BLOOD Na-125* K-3.8 ___ 09:27PM BLOOD Na-127* ___ 01:12AM BLOOD Na-126* ___ 04:36AM BLOOD Na-126* ___ 08:29AM BLOOD Na-124* ___ 01:08PM BLOOD Na-125* ___ 04:35PM BLOOD Na-130* ___ 11:52PM BLOOD Na-126* ___ 07:07AM BLOOD Na-127* =========================== REPORTS AND IMAGING STUDIES =========================== ___ CXR FINDINGS: The lungs are hyperexpanded. There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. The bony thorax is grossly intact. IMPRESSION: No acute cardiopulmonary abnormality. ============ MICROBIOLOGY ============ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: ASSESSMENT/PLAN: ___ w/ HTN, hypothyroidism, and anxiety p/w hyponatremia that is likely multifactorial iso recent HCTZ use and excessive water intake in relation to solute intake. #Hyponatremia: 10 days of constitutional symptoms prompting PCP visit and lab testing revealing hyponatremia to 118. Likely multifactorial in the setting of poor solute intake, high water intake, recent HCTZ use. ___ have been precipitated by diarrheal illness 3 weeks ago. She seems prone to this with a similar episode about ___ years ago. Received a total of 2 doses of DDAVP while in the ICU. Sodium improved with 1L/day fluid restriction; however, by day of discharge it had not fully normalized and urine osms had increased to 458 from 121, raising the possibility of an additional underlying process such as SIADH. Discharged home on fluid restriction per renal recommendation with PCP ___ in two days for sodium check. HCTZ added to allergy list. Discharge Na 131 by serum, 129 by whole blood. Plan for repeat labs on ___ with results faxed to PCP and nephrology. PCP received ___ warm hand off on patient. #HTN: On metop XL 25 TID at home, which is an unusual regimen. Appears that patient feels some sense of reassurance by taking this medication more frequently. We therefore changed her metoprolol succ to metop tartrate 25 tid. Added amlodipine 5mg daily for blood pressure control. Chronic Issues #Anxiety: Continued home alprazolam #GERD: Continued Maalox, ranitidine Transitional Issues: [] ___ blood sodium, consider SIADH if not normalized [] Patient was taking metoprolol XL 25 TID at home. We changed this to metop tartrate 25 tid. [] HCTZ added to allergy list, would use caution with diuretics in this patient given 2x episodes of hyponatremia [] ___ blood pressures on amlodipine 5mg initiated on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Metoprolol Succinate XL 25 mg PO TID 3. ALPRAZolam 0.25 mg PO TID:PRN anxiety 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. ALPRAZolam 0.25 mg PO TID:PRN anxiety 5. Levothyroxine Sodium 50 mcg PO DAILY 6.Outpatient Lab Work E87.1 Please obtain chem 7, fax results to ___ attention ___ ___ MD Discharge Disposition: Home Discharge Diagnosis: hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted because you had a low sodium level in your blood. The medical term for this condition is 'hyponatremia'. What was done for me while I was in the hospital? Your blood's sodium level was increased to a near-normal level by managing your body's fluid level. Your blood sodium level did not completely normalize, and we made an appointment for you with your PCP to follow up on this issue as an outpatient in the next ___ days. What should I do when I leave the hospital? Limit your fluid intake to no more than 1 liter per day, until you see your PCP. Make sure to attend your scheduled PCP appointment, which should be scheduled for ___ days from your discharge from the hospital. Please make sure to get labs drawn on ___. The results will be faxed to your doctors. We started you on amlodipine which is blood pressure medication in place of HCTZ. Please take all of your medications as prescribed. Sincerely, Your ___ Care Team Followup Instructions: ___

10041894-DS-9

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2140-12-09 00:00:00

2140-12-12 14:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back Pain Major Surgical or Invasive Procedure: TEE History of Present Illness: Mr. ___ is a ___ y/o man with a PMH of AFib on warfarin, bioprosthetic AVR/MVR, gout, HTN, and HLD, who was transferred from ___ for ___ and anemia. He has been having fatigue, back pain and intermittent fevers for the past five weeks up to ___ (most recently AM of ___. Notes a 10 lb weight loss over this time. 2 weeks ago he saw his PCP for these fevers as well as cough, who felt that his presentation was consistent with community-acquired pneumonia, for which he received a five-day course of azithromycin with some relief. He subsequently received a one week course of levofloxacin. Yesterday, he returned to his PCP because he was having sacral pain for the past three weeks. This sacral pain was previously treated with cyclobenzaprine and orphenadrine. Denied any trauma. In conjunction with these fevers, his PCP was concerned for pyelonephritis, and he was sent to the ED at ___. There, a CT chest/abd/pelvis was performed. CT chest had no acute abnormality. The abdomen and pelvis scan showed cardiomegaly, mild splenomegaly, degenerative spine changes, and severe prostate enlargement. Labs at ___ were notable for: WBC 22, H/H 10.1/29, plt 116, bands 4, Na 128, K 4.5, BUN 41, Cr 2.08, trop .08, lactate 1.1, CRP 21, INR 4.35. EKG: AFib 91, LAD, QTc 471, TWI III Blood cultures grew GPC in pairs and chains. He received IV fluids, vancomycin, and Zosyn, and he was transferred to ___. In the ___ ED, initial vitals: T 99.6 P 80 BP 116/74 RR 16 O2 96% RA - Exam notable for PE: dry mucous membranes, CTAB, ___, abdomen soft, NT, ND, no CVAT, no midline spine tenderness. Brown, weakly positive guaiac stool. - Labs were notable for: Chemistries: 132 100 44 -------------< 115 4.7 20 1.8 CBC: 8.5 16.0 >---< 96 25.1 DIFF: N:84 Band:7 ___ M:7 E:0 Bas:0 Nrbc: 1 Absneut: 14.56 Abslymp: 0.32 Absmono: 1.12 Abseos: 0.00 Absbaso: 0.00 Coags: ___: 78.3 PTT: 46.1 INR: 6.9 Trop-T: <0.01 Lactate:1.2 UA: WBC 68, many bacteria, large leuks, negative nitrites, large blood, trace ketones - Patient was given: ___ 00:56 IVF 1000 mL NS 500 mL ___ 02:19 IV Pantoprazole Started 8 mg/hr ___ 02:19 IV Phytonadione 2.5 mg ___ 02:39 IV Gentamicin 350 mg ___ 02:39 IVF 1000 mL NS 1000 mL - Consults: none On arrival to the MICU, he reported L flank pain and sacral pain. He denied chest pain, shortness of breath. He has previously had fevers and chills, which had subsequently resolved. Denied nausea, vomiting, lightheadedness, dizziness, dysuria, hematuria, melena, or hematochezia. Denied sick contacts. Review of systems: - as above, otherwise a 10 point review of systems was negative Past Medical History: atrial fibrillation on warfarin - severe aortic stenosis s/p #23 ___ pericardial valve (___) - severe mitral regurgitation s/p #33 ___ porcine valve (___) - gout - hypertension - hyperlipidemia Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 97.6F BP 106/51 mmHg P 70 RR 22 O2 97% 2L O2 General: Pleasant, elderly man appearing his stated age in NAD. HEENT: PERRL; EOMs intact. Dry mucous membranes. OP clear. Neck: Supple, neck veins flat. No JVD. CV: Irregularly irregular. III/VI systolic murmur; no rubs or gallops. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Back: Point tenderness to palpation over sacrum. Ext: Warm and well-perfused. Lone splinter hemorrhage on L thumb. No ___ nodes. 2+ DP pulses. No edema. Neuro: A&Ox3; CNs II-XII grossly intact. Distal sensation intact to light touch. DISCHARGE PHYSICAL EXAM: ========================= Vital Signs: 99.0 121/64 74 18 94%RA GEN: Alert, NAD HEENT: NC/AT CV: irreg, ___ systolic murmur PULM: CTA B, bilateral rales in the lower lung fields GI: S/NT/ND, BS present EXT: no calf tenderness ___ edema NEURO: A&Ox3 Pertinent Results: Admission Labs: ___ 12:15AM BLOOD WBC-16.0* RBC-2.73* Hgb-8.5* Hct-25.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.2 RDWSD-47.6* Plt Ct-96* ___ 12:15AM BLOOD Neuts-84* Bands-7* Lymphs-2* Monos-7 Eos-0 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-14.56* AbsLymp-0.32* AbsMono-1.12* AbsEos-0.00* AbsBaso-0.00* ___ 12:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL ___ 12:15AM BLOOD ___ PTT-46.1* ___ ___ 06:12AM BLOOD ___ ___ 06:12AM BLOOD Ret Aut-1.1 Abs Ret-0.03 ___ 12:15AM BLOOD Glucose-115* UreaN-44* Creat-1.8* Na-132* K-4.7 Cl-100 HCO3-20* AnGap-17 ___ 06:12AM BLOOD ALT-31 AST-40 LD(LDH)-356* AlkPhos-135* TotBili-0.6 ___ 12:15AM BLOOD cTropnT-<0.01 ___ 06:12AM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.4 Mg-2.0 Iron-14* ___ 06:12AM BLOOD calTIBC-146* Hapto-278* Ferritn-1144* TRF-112* ___ 12:18AM BLOOD Lactate-1.2 Discharge Labs: ___ 05:42AM BLOOD WBC-14.1* RBC-2.79* Hgb-8.7* Hct-26.0* MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 RDWSD-48.4* Plt ___ ___ 05:42AM BLOOD ___ PTT-40.6* ___ ___ 05:42AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-133 K-3.9 Cl-100 HCO3-23 AnGap-14 ___ 05:42AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 ___ 01:00AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01:00AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 01:00AM URINE RBC-131* WBC-68* Bacteri-MANY Yeast-NONE Epi-<1 TransE-<1 Blood Cx x 4 negative, OSH blood cx growing strep pneuma URINE CULTURE (Final ___: NO GROWTH. IMAGING: ========== ___ EKG: Probable atrial fibrillation. Compared to the previous tracing no change. ___ TTE: The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets appear thickened in some views. The gradients across the prosthesis are likley mildly elevated (not knowing what type of prosthesis this is). No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Marked biatrial enlargement. Normal left ventricular systolic function. Moderately dilated right ventricle with borderline normal free wall motion (intrinsically depressed due to volume of tricuspid regurgitation). Well seated aortic valve bioprosthesis with normal gradients and no evidence of endocarditis. Mildly increased gradients across the mitral valve bioprosthesis without definitive vegetation. Moderate to severe tricuspid regurgitation with at least mild pulmonary hypertension (likely higher given increased RA pressures). No mobile masses on the tricuspid valve. No prior echos for comparison. If there is a high clinical suspicion for endocarditis, TTE cannot exclude with two bioprosthetic valves. ___ TEE: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and the descending thoracic aorta to 38 cm from the incisors. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. There is a highly mobile echodensity on the anterior leaflet of the bioprosthetic mitral valve, measuring 0.5 cm x 0.4 cm, most consistent with a small vegetation. No mitral valve abscess is seen. Trivial mitral regurgitation is seen. There is no abscess of the tricuspid valve. The tricuspid regurgitation jet is eccentric and may be underestimated. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Well-seated mitral valve bioprosthesis with small vegetation on the anterior leaflet and trivial mitral regurgitation. Well-seated aortic valve bioprosthesis with no vegetation and no aortic regurgitation. Normal global biventricular systolic function. CXR - IMPRESSION: No previous images. There is been placement of a left subclavian PICC line that extends to the lower portion of the SVC. There is substantial enlargement of the cardiac silhouette in a patient with intact midline sternal wires. No definite vascular congestion. Mild blunting of the left costophrenic angle with opacification at the left base suggests small pleural effusion and atelectatic changes. MRI L Spine (___) - IMPRESSION: 1. Due to patient discomfort postcontrast imaging and multiplanar, multisequence imaging of the sacrum were not performed. 2. L2-L3 and L3-L4 severe spinal canal stenosis which crowds the central nerve roots and compresses the traversing L3 and L4 nerve roots in the subarticular zones. 3. L5-S1 subarticular zone stenosis which contacts the traversing S1 nerve roots. 4. Edema at L3-L4 articulating endplates with fluid signal within the intervertebral disc space, likely representing degenerative type ___ ___ change. No specific findings for infection, without cortical dehiscence, epidural fluid, or paraspinal soft tissue edema. Recommend clinical correlation. If there is high suspicion for infection, consider follow-up postcontrast imaging to assess for interval change. MRI Pelvis (___) - IMPRESSION: 1. Punctate foci of high T2 signal are seen along the inferior edge of both SI joints. The appearance is not typical for infectious or inflammatory sacroiliitis. Otherwise, the sacroiliac joints are within normal limits. 2. No evidence of osteomyelitis or abscess formation. 3. Diffuse soft tissue edema including small amount of pelvic free fluid, an atypical finding in a male. 4. Focal edema and enhancement in the left gluteus muscle near the coccyx could represent a focal area of phlegmon. The differential diagnosis could include an site of prior intramuscular injection. 5. Please see separate report of L-spine MRI performed on ___. MRI L Spine (___) - IMPRESSION: No enhancement to support discitis, osteomyelitis. No epidural or prevertebral fluid collection. Brief Hospital Course: Mr. ___ is a ___ y/o man with a PMH of AFib on warfarin, AVR/MVR, gout, HTN, and HLD, who was transferred from ___ for ___ and anemia, found to have strep pneumo bacteremia / endocarditis. #Strep pneumococcus bacteremia / endocarditis: Strep pneumo in ___ bottles from ___. TEE showed small mitral valve veg. Now narrowed to CTX with ID input. No further positive blood cultures on labs here. Will continue CTX for total of 6-week course. Discharged home with services for home infusion via ___. # Lower back pain: Initial concern for epidural abscess v. osteomyelitis in light of bacteremia. CT torso at ___ negative for fluid collection. MRI performed here without evidence of infection. #Coagulopathy. INR of 6.9 on admission; most likely appears to have been ___ concomitant usage of azithromycin, levofloxacin, and warfarin. He received 2.5 mg Vitamin Kx1 in ED, with INR downtrended to 2 and warfarin was resumed. However, INR trended back up, once again likely ___ abx. Coumadin was held at discharged with plans for INR recheck on Modnay ___. This was communicated with pt's PCP's office. #Thrombocytopenia: His platelets were at nadir of 77-97, and may have been acute response to infection vs. medication side-effect. There were no signs of bleeding. Plts were trending back up at discharge. #Acute Kidney Injury: Patient's creatinine initially was 2.1, likely pre-renal injury improved with fluid resuscitation. #Atrial Fibrillation: Goal INR 2.0-3.0, warfarin held on discharge as above. #Concern for GI bleeding: Patient's hemoglobin was 8.5 on admission from 10.2 at OSH. His serial H/H remained stable since his transfer to ___. He had a weakly guaiac positive, stool but was at high risk of bleeding given coagulopathy with elevated INR. Patient's initial hypotension appeared to be likely hypovolemic and vasodilatory from infection, with no evidence of an active bleed. He was initially on an IV proton pump inhibitor transitioned to oral form. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Warfarin 4 mg PO DAILY16 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Simvastatin 40 mg PO QPM 5. Allopurinol ___ mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. CefTRIAXone 2 gm IV Q 24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV q 24 hours Disp #*38 Intravenous Bag Refills:*0 8. Outpatient Lab Work Weekly labs: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, ESR/CRP. RESULTS SHOULD BE SENT TO ___ CLINIC - FAX: ___ 9. Outpatient Lab Work Please check INR on ___. Results should be faxed to Dr. ___ (Fax: ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Endocarditis Bacteremia Acute Kidney Injury Coagulopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred here with an fevers, an infection in your heart valve, as well as a blood stream infection. You were seen by our infectious diseases team, and you were started on antibiotics. You will continue the IV antibiotics for 6 weeks total. Of note, you also underwent an MRI of your lower back given your back pain. This did not show any evidence of infection. As we discussed on ___, your INR (Coumadin level) is very high. Please hold your Coumadin on ___ and ___. Please call your PCP's office on ___ morning to have your INR checked and Coumadin dose adjusted accordingly. Followup Instructions: ___