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10042037-DS-5

DS

2165-10-04 00:00:00

2165-10-05 17:40:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Heroin withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with a h/o heroin and barbiturate use who presents with heroin withdrawal. He reports that he has been using oral heroin for the last 7 months and stopped two days ago. Since then he has been experiencing vomiting, diarrhea, abdominal pain, and diffuse muscle aches. He was previously admitted in ___ for an opiate and barbiturate overdose (somnolence) requiring naloxone and charcoal. He apparently has access to barbiturates in his lab at ___. . In the ED initial VS were 97.4, 84, 114/79, 18, 100% RA. Labs notable for neg tox screen, WBC 20.2 (91% PMN), K 3.0, Phos 6.9, AG 21, UA neg. CXR neg for acute process. EKG showed SR w/o ischemic changes. Patient was given diazepam 10mg. . 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: - H/o heroin and barbiturate overdose - H/o diverticulitis (___) Social History: ___ Family History: Mother with HTN. Father died at ___ of heart problems. Three children are healthy. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.6, 68, 126/77, 18, 97% on RA GENERAL: NAD, comfortable, appropriate HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK: supple, no thyromegaly, no JVD HEART: PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: no rashes or lesions NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . DISCHARGE PHYSICAL EXAM: VS: Tm 99.6, 101/63 (101-138/63-78), 55 (55-69), 18, 96-100% RA GENERAL: NAD, somewhat uncomfortable, appropriate HEENT: NC/AT, pupils dilated bilaterally, EOMI, sclerae anicteric, MMM, OP clear NECK: supple, no thyromegaly, no JVD HEART: PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN: NABS, diffusely tender, soft/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: no rashes or lesions NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: LABS ON ADMISSION: ___ 11:30AM BLOOD Glucose-149* UreaN-27* Creat-1.1 Na-139 K-3.0* Cl-91* HCO3-27 AnGap-24* ___ 11:30AM BLOOD Calcium-9.9 Phos-6.9*# Mg-2.2 ___ 11:30AM BLOOD WBC-20.2*# RBC-5.70# Hgb-17.6# Hct-51.1 MCV-90 MCH-30.8 MCHC-34.3 RDW-12.8 Plt ___ ___ 11:30AM BLOOD Neuts-91.7* Lymphs-3.7* Monos-3.6 Eos-0.9 Baso-0.1 ___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:30AM BLOOD cTropnT-<0.01 ___ 01:10PM BLOOD Lactate-1.8 ___ 01:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-SM Urobiln-2* pH-5.0 Leuks-NEG ___ 01:30PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-3 ___ 01:30PM URINE CastHy-419* . LABS ON DISCHARGE: ___ 04:30AM BLOOD Glucose-140* UreaN-18 Creat-0.7 Na-136 K-3.6 Cl-99 HCO3-26 AnGap-15 ___ 04:30AM BLOOD Calcium-8.4 Phos-2.4*# Mg-2.0 ___ 04:30AM BLOOD WBC-11.9* RBC-4.42* Hgb-13.7*# Hct-40.6# MCV-92 MCH-30.9 MCHC-33.7 RDW-12.9 Plt ___ . MICRO: Blood culture (___): pending . IMAGING: CXR PA/LAT (___): PA and lateral chest radiographs demonstrate no focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Brief Hospital Course: ___ year old man with a history of heroin and barbiturate use who presented with heroin withdrawal, leukocytosis, and an anion gap. . # Heroin withdrawal: Patient presented after last taking oral heroin 2 days ago. He denied any recent use of any IV drugs and had no signs of this on his skin exam. His symptoms were controlled with the following: - Ondansetron 8mg IV Q8h prn nausea - Acetaminophen 1g PO Q8h - Lorazepam 1mg PO HS prn insomnia - Loperamide 2mg PO QID prn diarrhea - Clonidine patch 0.1mg, monitor BP and HR - Methocarbamol 750mg PO Q6h prn muscle pain/cramps - Dicyclomine 20mg PO Q4h prn stomach pain/cramps The patient was able to tolerate small amounts of food and fluids. He is being discharged to the ___ for further treatment. . # Leukocytosis: Initial blood work showed a leukocytosis of 20.2 suspected to be a leukamoid reaction to catecholamine release secondary to heroin withdrawal. Patient was afebrile with unremarkable UA and normal CXR. No signs of cellulitis. No cardiac murmurs and no history of recent IV drug use to suggest endocarditis. By the following day the leukocytosis had resolved to 11.9. Blood cultures are pending at the time of discharge. . # Anion gap: Initial blood work revealed an anion gap suspected to be starvation ketoacidosis in the setting of poor PO intake for the 2 days prior to admission. Dextrose was given via IV fluids and the anion gap resolved by the following morning. . # Transitional Issues: - Blood cultures pending at time of discharge, we will contact the patient and the ___ facility should these return positive. Medications on Admission: 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bismuth Subsalicylate 30 mL PO TID:PRN diarrhea 3. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED 4. DiCYCLOmine 20 mg PO Q4H:PRN stomach pain/cramps 5. Loperamide 2 mg PO QID:PRN diarrhea 6. Lorazepam 1 mg PO HS:PRN insomnia 7. Methocarbamol 750 mg PO Q6H:PRN muscle pain/cramps 8. Nicotine Patch 14 mg TD DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Heroin withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital for heroin withdrawal. Your symptoms were treated with anti-emetics, Tylenol every 8 hours for pain, anti-diarrheals, and intravenous fluids. You are being discharged to the ___ for continued treatment. Followup Instructions: ___

10042350-DS-2

DS

2118-06-01 00:00:00

2118-06-04 12:35:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: cephalexin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Percutaneous drainage of right lower quadrant abscess History of Present Illness: Mr. ___ is a ___ year-old male with a 1 week history of RLQ pain, fevers (___), nausea, and decreased appetite. He reports that he has had intermittent fevers for the last week. He also reports that the abdominal discomfort is mostly in the RLQ for the last week associated with a decreased appetite. His last colonoscopy was in ___ where they saw a hyperplastic polyp and recommended a repeat colonoscopy in ___ years. Past Medical History: panic disorder, mitral valve prolapse, psoriasis, osteoarthritis Past Surgical History: R arm nerve decompression Medications: alprazolam 1mg TID, ASA 81 daily Allergies: cephalexin: rash Social History: ___ Family History: Non-contributory Physical Exam: Vitals: 98.9 73 132/77 18 100%RA GEN: A&O3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, tender in the RLQ, no rebound or guarding. Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 09:30PM BLOOD WBC-10.9* RBC-3.92* Hgb-11.5* Hct-33.0* MCV-84 MCH-29.3 MCHC-34.8 RDW-13.6 RDWSD-42.1 Plt ___ ___ 09:30PM BLOOD Glucose-122* UreaN-15 Creat-1.1 Na-128* K-4.0 Cl-90* HCO3-24 AnGap-18 ___ 06:05AM BLOOD WBC-10.8* RBC-3.44* Hgb-10.1* Hct-29.6* MCV-86 MCH-29.4 MCHC-34.1 RDW-14.5 RDWSD-45.4 Plt ___ ___ 06:05AM BLOOD Glucose-85 UreaN-15 Creat-0.9 Na-131* K-3.7 Cl-93* HCO3-27 AnGap-15 ___ 09:30PM BLOOD ALT-17 AST-23 AlkPhos-85 TotBili-0.4 Micro: ABSCESS RLCE ABSCESS FROM APPENDICEAL RUPTURE. ANAEROBIC CULTURE (Final ___: BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH. BETA LACTAMASE POSITIVE. Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: NO GROWTH. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. Radiology: CT ABD & PELVIS WITH CONTRAST Study Date of ___ 4:52 ___ 8.5 cm walled off abscess in right lower quadrant consistent with perforated appendicitis. IMAGE CATH FLUID ___ Study Date of ___ 4:00 ___ Successful CT-guided placement of an ___ pigtail catheter into the right lower quadrant collection with removal of 60 cc purulent fluid. Culture and sensitivity sent. CXR ___ The lungs are clear of interstitial or airspace opacity. No pleural effusions or pneumothorax. The cardiomediastinal silhouette is not enlarged. Multiple distended loops of colon are visualized in the upper abdomen. Brief Hospital Course: Mr. ___ is a ___ year-old male who presented to the ED on ___ with a on week history of RLQ pain and fevers. A CT scan demonstrated concern for perforated appendicits. The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. The patient was made NPO and started on IVF and cipro/flagyl. After review the CT scan with a GI radiologist the patient was determined to have 8.5 cm walled off abscess in right lower quadrant consistent with perforated appendicitis and was scheduled for ___ guided drainage. Intereventional radiology placed a drain on ___ and aspirated 60cc of purulent material which was sent for culture. The procedure went well and without complication (reader referred to ___ note for details). On ___ the patients WBC had increased from 12 the prior day to 17. The patients antiobiotic regimen was thus changed from cipro/flagl to unasyn. Blood and urine cultures and a chest film were obtained, all of which resulted negative for evidence of infection. By the ___ the patients WBC had downtrended to 12.1. On ___ the patient had a WBC of 12 and had experienced no further fevers in 24 hours. During this hospitalization, the patient ambulated frequently and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with his drain in place. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: alprazolam 1mg TID, ASA 81 daily Discharge Medications: 1. ALPRAZolam 1 mg PO TID:PRN anxiety 2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 2 Weeks RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*20 Capsule Refills:*0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: appendicits Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ and underwent percutaneous drainage of your ___ abscess. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: 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. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___

10042769-DS-20

DS

2154-03-10 00:00:00

2154-03-10 15:46:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Morphine Attending: ___. Chief Complaint: right groin cyst pain, and RLE edema Major Surgical or Invasive Procedure: ___ aspiration and drainage of right groin cyst fluid collection. History of Present Illness: This is ___ with history significant for chronic right hip/groin cyst s/p multiple ___ drainage procedures. The patient presented to the OSH with compaints of right groin pain and right lower extremity edema. The patient's sister reports that this has been a recurrent problem which began approximately ___ years ago following the patient's second hip replacement. His cyst has now reoccurred and it is very painful. This is associated with right thigh pain.The patient underwent an ultrasound at OSH which showed extensive right femoral DVT. He was transferred to ___ for further evaluation and treatment. The patient is well known to Dr. ___ on the surgical service and was admitted for ___ drainage of right groin cyst and treatment of DVT. Past Medical History: CAD thalassemia vertigo gout mild dementia gout chronic RLE edema PSH: right hip replacement and revision ___ Social History: ___ Family History: There is no other family history of known coronary artery disease or cancer. Physical Exam: VS: Tm 97.1, Tm 97.1, HR 59, BP 110/62, RR 19, 98% RA General: NAD, AAOx3 Cardiac: RRR, faint heart sounds Respiratory: CTA Abdomen: Soft, NTND, normoactive bowel sounds Extremities: right lower abdomen/groin site c/d/i, no hematoma, no erythema right lower extremity +2 edema, no erythema Pertinent Results: Admission Labs: ___ 06:40PM BLOOD WBC-4.2 RBC-4.67 Hgb-10.4* Hct-33.4* MCV-72* ___.3* MCHC-31.1 RDW-16.7* Plt ___ ___ 06:40PM BLOOD Neuts-61.4 ___ Monos-11.1* Eos-6.8* Baso-2.6* ___ 04:50AM BLOOD ___ ___ 06:40PM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-144 K-4.2 Cl-109* HCO3-26 AnGap-13 Coagulation Trend: ___ 06:40PM BLOOD ___ PTT-33.4 ___ ___ 08:40AM BLOOD ___ PTT-69.4* ___ ___ 11:00AM BLOOD ___ PTT-38.6* ___ ___ 12:05PM BLOOD ___ PTT-69.8* ___ ___ 05:20AM BLOOD ___ PTT-85.9* ___ ___ 05:00AM BLOOD ___ PTT-44.9* ___ ___ 04:50AM BLOOD ___ Brief Hospital Course: Mr. ___ is a ___ year old male who presented to OSH an accumulation of a chronic right groin cyst, as well as a new right lower extremity DVT. The patient was admitted to the inpatient general surgery unit under the care of Dr. ___ further evaluation and treatment. The patient went to the ___ suite and underwent an aspiration of the right groin cyst. The patient did not require placement of a drain. The right groin site was monitored closely for signs and symptoms of seroma and hematoma of which there were none. He remained afebrile without leukocytosis. For treatment of his DVT, Mr. ___ was started on anticoagulation therapy and was maintained on a heparin gtt during his hospitalization and bridged to Coumadin. His INR levels were monitored closely and he was dosed appropriately. Mr. ___ need to continue on long term anticoagulation therapy and will be followed by his PCP for monitoring of his INR and for Coumadin dosing. He was set up with home ___ who will check his INR on ___ and fax the results to his PCP. During this admission the patients pain was treated with Oxycodone and Tylenol and he had adequate pain control. He was ambulating plentifully throughout the admission and tolerating a regular diet. The patient was discharged home in good condition with follow-up instructions. Medications on Admission: sotalol 60 mg Po BID aricept 10 mg PO QD ASA 81 mg PO QD tylenol prn indomethacin 25 mg PO prn imdur 30 qhs antivert 25 prn iron folic acid Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)). 4. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. meclizine 25 mg Tablet Oral 6. indomethacin 25 mg Capsule Oral 7. folic acid Oral 8. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. sotalol 120 mg Tablet Sig: ___ Tablet PO twice a day. 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other day. 11. potassium Oral Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1.Right groin cyst 2.Right femoral DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to take care of you during this hospitalization. You were hospitalized for continued management of a right groin cyst and underwent ___ drainage. You also presented with right leg swelling and were found to have a blood clot also known as DVT (Deep vein thrombosis). During your hospitilization you were treated on a Heparin drip and Coumadin (blood thinners). Once your blood level was stable the heparin drip was discontinued and you were started on Coumadin. You will need to continue on Coumadin and have your blood level monitored closely. We have arranged for your primary care provider to monitor your blood level and dose your Coumadin. Starting today you should start taking your coumadin (2 mg) at night. Your visiting nurse ___ draw your blood to check your INR ___ and fax the results to your primary Physician. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. If you have any questions or concerns please contact the office. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: ___

10042793-DS-7

DS

2141-05-02 00:00:00

2141-05-02 15:41:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: shellfish derived Attending: ___ Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: Patient is ___ with PMH of PE/DVT on warfarin, Alzheimer's (nonverbal at baseline) who presents as a transfer from ___ ___ after evaluation of witnessed fall from her nursing home today. History and exam limited as patient has dementia and is nonverbal at baseline. Per ___ notes: ___ year old female with Alzheimer's, nonverbal, presenting after a witnessed fall at her facility. She struck her head and was transferred here. She is not endorsing any pain or changes from her baseline. She has a 2cm laceration on her right forehead and significant swelling and bruising around her right eye. She takes warfarin." At ___, Vitals: T100.6R 63 20 96% RA 133/60. Patient's PE was significant for "tenderness to palpation and pain with movement of the right wrist. Remainder of the exam was unremarkable." Labs were notable for INR of 2.1. CT head wo contrast showed acute SAH along the frontal and temporal lobes bilaterally with no midline shift. CT cervical spine wo contrast showed no fracture or traumatic malalignment. She received K Centra, splint was applied to right wrist, and her laceration over her right eye was treated with dermabond prior to transfer. At ___, vitals were 98.8 64 143/60 19 98%RA At the bedside, patient endorses pain in right wrist. Denies HA, chest pain, or abdominal pain. Past Medical History: PMH: -DVT/PE -Alzheimers Dementia -Volvulus Social History: ___ Family History: ___: non-contributory Physical Exam: Physical: General: NAD Vitals: 101.0 70 139/69 16 96%RA HEENT: PERRLA, 2cm laceration to right forehead with swelling and ecchymosis around right eye Cardio: RRR, II/VI systolic murmur Pulm: breathing comfortably on RA Abdomen: soft, NT, ND, no rebound or guarding Neuro: AOx1 to self, believes she is at home; Responds to name; intermittently follows commands; moving extremities spontaneously; denies sensory deficits Extremities: warm, well-perfused, trace peripheral edema; ace wrap over right wrist Skin: Grade 1 pressure ulcer to left of coccyx Physical Exam At Discharge: VS: 98.4, 132/68, 56, 18 95%Ra HEENT: PERRLA, 2cm laceration R supraorbital healing, R infraobrital hematoma healing Cardio: RRR, soft II systolic murmur Pulm: clear to auscultation bl Abdomen: soft, NT, ND, no rebound or guarding Neuro: AOx1 to self, not place or time, moving extremities spontaneously with slow to respond on right lower extrem Extremities: warm, well-perfused, trace peripheral edema; R arm in cast Pertinent Results: Wrist XRay ___: IMPRESSION: Overlying cast material obscures fine bony detail. Similar appearance of slightly impacted, dorsally angulated distal intra-articular fracture of the radius. CT Head wo Con ___: IMPRESSION: Slight increase in the volume of subarachnoid hemorrhage, particularly in the right sylvian fissure, since the prior study. Otherwise unchanged examination. CXR ___: IMPRESSION: No focal consolidation. Stable small hiatal hernia and mild cardiomegaly. Pelvis ___: IMPRESSION: No evidence of acute fracture or dislocation with limited evaluation of the sacrum due to overlying bowel gas. LABS: ___ 04:10AM cTropnT-0.01 ___ 11:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:40PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD* ___ 11:40PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:40PM URINE HYALINE-7* ___ 11:40PM URINE MUCOUS-RARE* ___ 11:07PM LACTATE-1.8 K+-4.0 ___ 11:00PM GLUCOSE-132* UREA N-24* CREAT-1.0 SODIUM-137 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13 ___ 11:00PM cTropnT-0.03* ___ 11:00PM WBC-12.4* RBC-4.00 HGB-11.8 HCT-36.6 MCV-92 MCH-29.5 MCHC-32.2 RDW-13.6 RDWSD-45.7 ___ 11:00PM NEUTS-83.7* LYMPHS-7.9* MONOS-7.3 EOS-0.4* BASOS-0.2 IM ___ AbsNeut-10.33* AbsLymp-0.98* AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 ___ 11:00PM PLT COUNT-228 ___ 11:00PM ___ PTT-29.5 ___ Brief Hospital Course: Ms. ___ was transferred to ___ from ___ after a witnessed fall at her facility with a right radius fracture, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital she received K Centra, splint was applied to right wrist, and dermabond over her right eye laceration prior to transfer. When she presented to ___ ___ she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone. Her coumadin was held while in the hospital. On HD2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae. On HD2 she was monitored for cardiac ectopy to further work up her fall, none was reported by nursing as visualized by the monitor. She was on telemetry and will discharge you with a holter monitor for further cardiac workup. She was seen by orthopedics who placed a brace on her right wrist. She was seen by neurosurgery who determined no surgery was necessary. Tertiary trauma survey was complete without new findings. She was discharged on HD3 to a rehabilitation facility to continue physical therapy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 1 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Donepezil 10 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID Please do not exceed 4000mg in 24 hours 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO HS 4. Vitamin D unknown PO DAILY 5. Donepezil 10 mg PO QHS 6. Furosemide 20 mg PO DAILY 7. Levothyroxine Sodium 150 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. HELD- Warfarin 1 mg PO DAILY This medication was held. Do not restart Warfarin until ___ and after you talk to your PCP about the risks and benefits of this drug. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: mechanical fall subarachnoid hemorrhage radius fracture R 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: Dear Ms. ___, You were transferred to ___ from ___ after a witnessed fall at her facility with a radius fracture on the r, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital you received K Centra, splint was applied to right wrist, and dermabond over your right eye laceration prior to transfer. When you got to ___ you were noted to have a urinary tract infection which we treated with antibiotics. We placed you on telemetry and will discharge you with a holter monitor for further cardiac workup. You were seen by orthopedics who placed a brace on your right wrist. You were seen by neurosurgery who determined no surgery was necessary. You are doing well and are ready for discharge. General Surgery: 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 new onset burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Holter: *There was concern that your heart may be the case for your falls. *You were placed on a holter monitor at the time of discharge. *Your cardiac monitor will be evaluated after 30 days. *If you have any questions please call the office ___. Medications: *Please resume all regular home medications. *Please hold Coumadin for total of 7days until at least ___ and you talk to your PCP about the risks and benefits with restarting this medication. *Also, please take any new medications as prescribed. General Care: *Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. *Avoid lifting with your right arm until you are cleared by physical therapy or your orthopedic surgeon as an outpatient. *Avoid driving or operating heavy machinery while taking pain medications. Thank you for letting us participate in your care! Followup Instructions: ___

10042896-DS-16

DS

2147-11-03 00:00:00

2147-11-05 18:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUQ abdominal/flank pain, R pleuritic chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with GERD, hiatal hernia, h/o thyroid Ca s/p thyroidectomy ___ years ago who presents with RUQ/lower R chest pain since ___. Patient reports pain started suddenly and was initially concerned that it was muscle pull or reflux. She took pepcid without benefit. Unable to sleep given pain. Took 6 tabs ibuprofen without relief. Pain was worse with inspiration, worse when lying on affected side. Denies chest pain, denies SOB, denies lightheadedness, denies ___ edema. Not affected by eating (pt does have a h/o gallstones). No f/c, N/V/D. In the ED, initial vitals were: 97.9 111 139/60 8 97% RA - Exam notable for: Tachy to 111, otherwise VSS Gen: well-appearing CV: RRR, no M/R/G Resp: unable to take deep breath, CTAB Chest wall: no TTP Abd: non-distended, soft, non-tender. Neg ___ sign Ext: no swelling, no calf tenderness - Labs notable for: DDimer 770 - Imaging was notable for: CTA chest: 1. Segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. No CT evidence for right heart strain. 2. Small right pleural effusion. CXR: Wedge-shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest CTA is recommended to evaluate for pulmonary embolism. No pneumothorax. - Patient was given: lovenox 70 mg SQ - Vitals prior to transfer: 98.1 97 116/67 14 98% RA Upon arrival to the floor, patient reports pain is persistent, worse with inspiration, worse when lying on affected side. Denies palpitations, lightheadedness, chest tightness, chest pain. Notably, denies long plane ___ car rides, recent surgery or immobility. Last ___ within the year, had breast bx that was negative for malignancy per pt report. Last pap smear ___ years ago, wnl per pt. No prior cervical bx. No weight loss, fevers, chills, night sweats. Follows with endocrinologist at ___ for her hypothyroidism (s/p thyroidectomy), had bone scan notable for osteoporosis. Does not have routine imaging for thyroid malignancy follow up. No hormonal use. Never smoker REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: - GERD, hiatal hernia -macular degeneration -papillary thyroid Ca s/p partial thyroidectomy ___ -Hypothyroidism -high cholesterol Social History: ___ Family History: father had ___ disease. Mother had breast cancer (___) and dementia. One daughter has primary biliary cholangitis. No ___ blood clots, PE, DVT. Father was on ___ for unknown indication Physical Exam: ADMISSION EXAM: Vital Signs: 99.8 103/59 109 20 94 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. No chest wall tenderness Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE EXAM: Vital Signs: T98.1 BP 102 / 55 73 18 96 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Decreased breath sounds in RLL, otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi. Posterior chest wall tender to palpation Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS ============== ___ 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt ___ ___ 03:15PM BLOOD Neuts-59.3 ___ Monos-11.9 Eos-0.1* Baso-0.4 Im ___ AbsNeut-5.55 AbsLymp-2.61 AbsMono-1.12* AbsEos-0.01* AbsBaso-0.04 ___ 03:15PM BLOOD ___ PTT-26.6 ___ ___ 03:15PM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-139 K-4.1 Cl-101 HCO3-22 AnGap-20 ___ 03:15PM BLOOD ALT-32 AST-40 AlkPhos-64 TotBili-0.6 ___ 03:15PM BLOOD Lipase-24 ___ 03:15PM BLOOD cTropnT-<0.01 proBNP-111 ___ 03:30PM BLOOD D-Dimer-740* IMAGING ========= CTA chest ___: 1. Segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. No CT evidence for right heart strain. 2. Small right pleural effusion. CXR ___: Wedge-shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest CTA is recommended to evaluate for pulmonary embolism. No pneumothorax. DISCHARGE LABS ============= ___ 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt ___ ___ 06:10AM BLOOD ___ PTT-29.0 ___ ___ 06:10AM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-139 K-3.5 Cl-101 HCO3-26 AnGap-16 ___ 06:10AM BLOOD ALT-26 AST-24 LD(LDH)-179 AlkPhos-59 TotBili-0.8 ___ 06:10AM BLOOD cTropnT-<0.01 ___ 06:10AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-2.2 ___ 06:10AM BLOOD TSH-1.5 Brief Hospital Course: Mrs. ___ is a ___ year old female with a history of papillary thyroid carcinoma s/p partial thyroidectomy in ___, GERD and hiatal hernia who presented to the ___ ED with RUQ abdominal/flank and right-sided posterior chest wall pleuritic pain, found to have RLL segmental and subsegmental PEs, with associated RLL pulmonary infarction. ACTIVE ISSUES: # Segmental and subsegmental PEs: Patient presented with RUQ and right posterior chest wall pain, which was noted to be pleuritic in nature and worsened with inspiration. Initial CXR was concerning for a wedge like opacity within the periphery of the right lower lobe concerning for pulmonary infarction. CTA chest revealed segmental and subsegmental PEs in the right lower lobe, accompanied with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. Patient had no evidence of right heart strain and cardiac markers (troponin and BNP) were negative. Underlying etiology of forming a VTE is unclear at this time. Patient does not endorse recent history of being immobile, and further denies any medications associated with formation of PE. She has a history of papillary thyroid cancer ___ years prior) but is s/p thyroidectomy. Her age-appropriate cancer screening includes regular colonoscopies with a known history of polyps, but last colonoscopy in ___ was within normal (pt was recommended f/u in ___ years), also up to date on mammography and pap smears. Patient was treated as an unprovoked PE, and was initiated on lovenox therapy, and transitioned to Rivaroxaban for 6 month course for unprovoked PE. She will be seen as an outpatient by hematology/oncology to assess etiology of PE and complete a hypercoagulable workup. TRANSITIONAL ISSUES: ==================== [] Pt was started on a 6 month course of Rivaroxaban for unprovoked segmental and subsegmental PE, with associated pulmonary infarct. Patient will take Rivaroxaban 15mg BID for 21 days (start date ___, end date ___, and then transition to Rivaroxaban 20mg once daily for 6 months (end date ___. She will further followup with her PCP and outpatient hematologist for further hypercoagulable workup to guide length of therapy. [] Please readdress the length of anticoagulation required with Rivaroxaban pending outpatient workup with hem/onc. [] Please ensure patient is compliant with taking Rivaroxaban daily to prevent future blood clots [] Pt will benefit from f/u with endocrinologist to consider repeat thyroid imaging including thyroid U/S as well as TSH/FT4 to ensure no evidence of recurrence of her thyroid ca, and to determine if patients thyroid cancer history is related to development of a PE . [] Pt had incidentally found cholelithiasis noted on CT imaging, however had normal LFTs on this admission. Pt will benefit from repeating LFTs if pt becomes symptomatic in the future. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO DAILY 2. Simvastatin 10 mg PO QPM 3. Levothyroxine Sodium 125 mcg PO DAILY 4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 2. Rivaroxaban 15 mg PO BID Duration: 21 Days Dose #1 of 2: Please take 15mg twice daily for 3 weeks, then switch to Dose #2 of 2 RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily Disp #*42 Tablet Refills:*0 3. Rivaroxaban 20 mg PO DAILY Dose #2 of 2: Please start 20mg daily after ___ complete 3 weeks of 15mg twice daily RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia 5. Famotidine 20 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Pulmonary Embolism (segmental and subsegmental PE) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ presented to the ___ ED with right flank and right upper abdominal pain, accompanied with right-sided posterior chest wall pain that worsened with inspiration. ___ were assessed with labs and imaging, and a CT scan of your chest showed several pulmonary emboli as well as an associated pulmonary infarction (a damaged area of the lung due to lack of blood flow). Due to the above finding of a pulmonary embolism and pulmonary infarction, ___ were admitted to the inpatient service, where ___ were assessed with labs and monitored on telemetry. ___ had no difficulty maintaining your oxygen saturation, and your pain was well controlled while admitted to the inpatient service. ___ were transitioned from Lovenox to Rivaroxaban, a medication to prevent further development of blood clots in your lungs or elsewhere in your body. ___ will readdress how long ___ need to be on your Rivaroxaban with your outpatient primary care physician and outpatient hematologist, however ___ will likely continue Rivaroxaban for a minimum of 6 months. Please ensure that ___ take your prescribed medications as instructed below, and ensure that ___ take this medication every day to prevent future clots. Please also followup at the appointments noted below that have been arranged on your behalf. It was a pleasure being involved in your care. Your ___ care team Followup Instructions: ___

10043039-DS-9

DS

2133-04-01 00:00:00

2133-04-01 11:14:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Imitrex / Penicillins Attending: ___. Chief Complaint: Right tibial plateau fracture Major Surgical or Invasive Procedure: Right tibial plateau ORIF ___, ___ History of Present Illness: ___ male history hypertension, anxiety, depression, ADD, alcohol abuse who presents with right knee pain status post fall while ice skating yesterday. Denies head strike or loss of consciousness. Unable to ambulate today which prompted his visit to urgent care. unable to take an x-ray at urgent care due to severe pain, so transferred here for further workup. Noted to have a cold foot with weak ___ pulse, so vascular surgery consulted and CTA of the right leg performed. Denies numbness or tingling. Past Medical History: HYPERTENSION ANXIETY DEPRESSION ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY ALCOHOL ABUSE PSYCHIATRIST Social History: ___ Family History: nc Physical Exam: Discharge PE: 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: * dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm 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 tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right tibial plateau ORIF which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with home ___ was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touchdown weightbearing in the right lower extremity, and will be discharged on Lovenox 40 mg 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: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs inhaled every 4 hours as needed for cough, wheeze, sob CODEINE-GUAIFENESIN - codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid. 10 ml by mouth twice daily as needed for cough DEXTROAMPHETAMINE-AMPHETAMINE - dextroamphetamine-amphetamine 15 mg tablet. 1 tablet(s) by mouth two times per day as needed for concentration HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1 tablet(s) by mouth once a day LISINOPRIL - lisinopril 10 mg tablet. TAKE 1 TABLET BY MOUTH DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. Amphetamine-Dextroamphetamine 15 mg PO BID 7. Hydrochlorothiazide 25 mg PO DAILY 8. Lisinopril 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right tibial plateau fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent 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: -Touchdown weightbearing right lower extremity in an unlocked ___ MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox 40 mg 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. -You may take down your Ace wrap once home. You may change your dressing if saturated in place a new clean gauze if draining - 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 > 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 FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. 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. Physical Therapy: Touchdown weightbearing right lower extremity in an unlocked ___, range of motion as tolerated Treatments Frequency: Remove ace wrap once home Change dressings if saturated, apply dry sterile dressing daily if needed after primary dressing removed if not draining leave open to air wound checks staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___

10043321-DS-17

DS

2154-01-07 00:00:00

2154-01-07 22:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with longstanding untreated OSA, DM, and HTN p/w progressively worsening exertional dyspnea. She reports that she has had DOE for nine months. She noted it primarily with walking up stairs and it has been slowly progressive. No rest symptoms, no chest pain/pressure during the past few months. She has gained about 12 pounds over the past 6 months and attributed her symptoms to that. Also has dry cough - feels like she needs to clear sputum but is unable to. She went to PMD last week, who heard crackles and felt she might have a bronchitis and told her to use albuterol/flovent and return in a week. Seen again a few days ago and still had crackles on exam. She obtained a CXR that was consistent with pulmonary edema. A CXR in ___ showed no active process. She was subsequently started on lasix 2 days ago, which she has had 3 doses of. Given no clear etiology for CHF, went to have stress echo performed today, at which she had a profound desaturation to 78% after 4 min of exercise. Concern for possible PE and sent to ED for evaluation. Denies any chest pain during stress test, denies leg swelling, denies HA. In the ED, initial VS were: 98.1 93 140/74 18 93%. Labs significant for trop <0.01, WBC 16.9 (N:60 Band:0 ___ M:7 E:5 Bas:0 Atyps: 2), D-D-dimer 1550, proBNP: 73, CXR showed increased pulm vascularity and prominence of interstitium, no consolidation or effusion, mild cardiomegaly. Started on heparin drip. CTA not done because of previous reaction so plan to admit and V/Q scan in the am. VS on transfer: 97.6 92 114/72 18 95%. Currently, she feels well with no complaints. She notes occasional posterior right sided chest pain with movement, not pleuritic in nature. No leg swelling, PND, orthopnea. ___ years ago was in ___, ___ year ago in ___, no recent travel to ___, ___. Notes that her ankles swell after eating salty food. No unusual exposures she can think of although has worked as a histologist for ___ years and so has been exposed to chemicals in that line of work. Past Medical History: HTN Tubal ligation Pancreatic cyst excision ___ with distal splenectomy, pancreatectomy, and cholecystectomy OSA DM2 HLD Migraine HA h/o post-operative SBO Submucosal fibroid Leiomyoma Rotator cuff tear Social History: ___ Family History: Father with CAD and CABG in late ___, mother with melanoma and ___, sister with breast cancer. Denies pulmonary parencymal disease, blood clots, autoimmune disorders. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS:98.1 132/74 94 16 94%RA Desaturated to 83% with gentle ambulation from her room to to the end of the hallway. GENERAL: well appearing, NAD HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD: flat LUNGS: late bibasilar crackles, inspiratory squeaks and pops througout lung fields, especially RUL that did not clear with coughing HEART: RRR, no MRG, nl S1-S2 ABDOMEN: obese, normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, normal gait PHYSICAL EXAM ON DISCHARGE: VS 97.6 106/63 69 16 94%RA GEN NAD, comfortable HEENT NCAT, OP mildly erythematous, clear nasal discharge NECK Supple, no LAD PULM Diffuse crackles and expiratory wheezes, bibasilar crackles, unchanged CV RRR normal S1/S2 ABD obese, soft NT ND normoactive bowel sounds EXT WWP 2+ pulses bilaterally Pertinent Results: ___ 05:46PM D-DIMER-1524* ___ 05:40PM proBNP-73 ___ 05:40PM cTropnT-<0.01 ___ 05:40PM WBC-16.9* RBC-4.91 HGB-15.7 HCT-46.9 MCV-96 MCH-32.0 MCHC-33.5 RDW-12.8 ___ 05:40PM NEUTS-60 BANDS-0 ___ MONOS-7 EOS-5* BASOS-0 ATYPS-2* ___ MYELOS-0 ___ 05:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL ___ 05:40PM PLT SMR-NORMAL PLT COUNT-355 ___ 05:40PM ___ PTT-30.1 ___ ___ 05:40PM GLUCOSE-137* UREA N-21* CREAT-0.7 SODIUM-139 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15 ___ 05:40PM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-75 TOT BILI-0.7 ___ 05:40PM ALBUMIN-4.5 CT Chest IMPRESSION: 1. Diffuse moderate to severe small airway obstruction, but no particular bronchial wall thickening, mucoid impaction, bronchiectasis, or atelectasis. The explanation for small airway obstruction is not obvious radiographically. 2. Minimal regional fibrosis, both upper lobes, there is not a generalized process. 3. Probable pulmonary arterial hypertension conceivably but not necessarily that due to small airways obstruction. 4. Left anterior descending coronary atherosclerosis. 5. Fatty infiltration of the liver. Brief Hospital Course: ___ with longstanding untreated OSA, NIDDM, and HTN p/w progressively worsening exertional dyspnea, found to have interstitial lung disease and mild-to-moderate pulmonary hypertension. #Hypoxemia: Etiology of acute hypoxemia unclear, as ambulatory and nocturnal desaturations out of proportion to findings on CT and TTE. Patient presents with six months of gradually worsening exertional dyspnea, found to have mosaic CT attenuation and mild-to-moderate pulmonary hypertension on echo. She was given supplemental O2 2L/NC to keep O2>90% and albuterol nebs, with some mild symptomatic improvement. A stress echocardiogram did not reveal any evidence of an acute ischemic process, but was terminated prematurely due to fatigue and exertional dyspnea along with hypoxemia. Pulmonary saw her, and PFTs showed moderate restriction and impaired diffusion, consistent with interstitial pulmonary process. Patient's history of chronic occupational exposures, fen-phen exposure, and smoking would further support ILD. She underwent a rheumatologic workup as well, for collagen vascular disease, sarcoidosis, and vasculitis, with results pending on discharge. An early interstitial process, coupled with pulmonary hypertension, is likely contributing to her degree of hypoxemia. It is highly possible that her pulmonary hypertension is likely attributable to her h/o longstanding OSA with recurrent nocturnal hypoxemia vs. diastolic dysfunction (LAE with high LVEF 70% would further support this). D-dimer was elevated though CTA PE protocol ruled-out pulmonary embolism. She had negative troponins, reassuring EKG, and BNP 73, and recent stress echo without evidence of ischemia. TEE with bubble study was negative. She was clinically improved and was evaluated by physical therapy, satting at 94% on room air, but still had persistent nocturnal and exertional hypoxemia with desaturations to the mid-80s, thus we initiated home supplemental oxygen on discharge along with pulmonary rehab. She is scheduled to see pulmonology for further work-up of her interstitial pulmonary process and pulmonary hypertension. Plan for repeat sleep study, right heart cath for further evaluation of pulmonary hypertension, will be performed as an outpatient. # Leukocytosis: Patient has had a chronic history of intermittently elevated WBC in Atrius records dating back to ___. Etiology is unknown. Patient had elevated WBC during her hospitalization: 16.9->16.8->12.4->11.2->13.8. This has been a chronic, stable issue. No urinary symptoms concerning for UTI. Differential with 5% eos and 2% atypicals. Further workup to be performed as an outpatient. # Diabetes mellitus: We held her metformin and covered with ISS while she was admitted. # Hypertension: Patient's BP was well controlled with ACEi and thus we continue enalapril while she was inpatient. # HLD: stable, patient was continued on home dose simvastatin for dyslipidemia. Transitional issues: -------------------- - Will need outpatient RHC, sleep study, consideration for V/Q scan - Outpatient pulmonary follow up - Will require coronary cath for LAD Atherosclerosis seen on CT, probably can schedule with RHC if happening in the near future - Discharged on oxygen 2 L NC to be used when ambulatory and nocturnal Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Enalapril Maleate 40 mg PO DAILY hold for SBP < 90 3. MetFORMIN (Glucophage) 1000 mg PO DAILY 4. Simvastatin 30 mg PO DAILY 5. Potassium Chloride 10 mEq PO DAILY Hold for K > 6. Furosemide 20 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Simvastatin 30 mg PO DAILY 4. Enalapril Maleate 40 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO DAILY 7. Acetaminophen 500 mg PO Q6H:PRN Headache 8. Oxygen Please provide oxygen at 2L/min through NC continuous pulse dose for portability. Pulmonary hypertension. 9. Outpatient Physical Therapy Evaluate and treat for pulmonary rehab. Pulmonary Hypetension 10. Potassium Chloride 10 mEq PO DAILY Hold for K > 4.0 Discharge Disposition: Home Discharge Diagnosis: Interstitial lung disease, pulmonary hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure participating in your care at ___ ___. You came in with shortness of breath. While you were here, we put you on supplemental oxygen, we evaluated your cardiac, vascular, and pulmonary function with cardiac echo, chest X-ray, chest CT, and pulmonary function tests. The cardiac echocardiogram was reassuring from a cardiac standpoint and detected some mild-to-moderate pulmonary hypertension. Chest imaging revealed evidence of an interstitial pulmonary process. We would like you to follow-up with your pulmonologist and PCP following your discharge for further evaluation of your pulmonary hypertension. No changes were made to your home medications except for using oxygen when ambulatory and at night. Sincerely, Your ___ Care Team Followup Instructions: ___

10043622-DS-17

DS

2130-10-18 00:00:00

2130-10-18 16:27:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP Pertinent Results: ___ 05:44PM WBC-9.3 RBC-4.38 HGB-12.9 HCT-37.9 MCV-87 MCH-29.5 MCHC-34.0 RDW-13.4 RDWSD-41.7 ___ 05:44PM NEUTS-59.2 ___ MONOS-10.3 EOS-0.9* BASOS-0.2 IM ___ AbsNeut-5.53# AbsLymp-2.67 AbsMono-0.96* AbsEos-0.08 AbsBaso-0.02 ___ 05:44PM PLT COUNT-253 ___ 10:00PM ___ PO2-28* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA ___ 10:00PM LACTATE-1.6 ___ 09:21PM GLUCOSE-254* UREA N-17 CREAT-0.6 SODIUM-136 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-19 ___ 09:21PM estGFR-Using this ___ 09:21PM WBC-15.9* RBC-4.26 HGB-13.0 HCT-37.1 MCV-87 MCH-30.5 MCHC-35.0 RDW-13.3 RDWSD-41.5 ___ 09:21PM PLT COUNT-269 ___ 08:20PM URINE HOURS-RANDOM ___ 08:20PM URINE UCG-NEGATIVE ___ 08:20PM URINE UHOLD-HOLD ___ 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:20PM URINE RBC-6* WBC-<1 BACTERIA-NONE YEAST-MOD EPI-3 ___ 08:20PM URINE MUCOUS-RARE Brief Hospital Course: On ___ MS. ___ was admitted to the Gynecology service from the Emergency Department. She received IV morphine in the ED for pain control. A UA was negative for infection however showed red blood cells. An initial pelvic ultrasound showed "Impression: Asymmetric enlargement of the left ovary compared to the right without detection of vascular flow, concerning for ovarian torsion. Small amount of simple left adnexal free fluid." A chest Xray showed was negative. A CT scan showed "Impression: 1. No nephrolithiasis or ureterolithiasis. 2. Asymmetric enlargement and hypodensity of the left ovary is also seen on pelvic ultrasound from the same day, and may reflect non vascularity seen on that exam." A repeat pelvic ultrasound on ___ showed "Impression: Essentially unchanged exam compared to the pelvic ultrasound from 6 hours prior, with asymmetry of the ovaries. No detectable left ovarian vascularity. Given no interval change, suspicion for torsion is low. Additionally, the ovary does not look particularly edematous, and decreased or undetectable ovarian blood flow can be seen in postmenopausal woman. I think that torsion is unlikely though not entirely excluded." Her WBC count was initial 15.9, however downtrended to 9.3. For her diabetes, she was placed on an insulin sliding scale and her blood glucose was monitored. Her pain was controlled with Tylenol and toradol. She was initially kept NPO for possible procedure, however her vital signs remained stable and her pain remained well controlled. On hospital day 1 her diet was advanced and she tolerated this well. She was discharged to home in stable condition with outpatient follow-up as scheduled. Medications on Admission: Lantus 20 QHS, pioglitazone, glimpiride Discharge Medications: 1. Acetaminophen ___ mg PO Q6H Do not exceed 4,000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food or milk. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to the gynecology service. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

10043646-DS-10

DS

2184-02-10 00:00:00

2184-02-13 18:43:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Leg swelling and shortness of breath Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: ___ with recent admission to ___ for asthma exacerbation, was found to have new diagnosis of CHF and Afib. After a 10 day stay at ___ she was discharge home yesterday with ___ and now presenting with worsen ___ edema and SOB. She notes that since she left the hospital yesterday, her legs were getting "much bigger" and she had difficulty bringing them up to bed. She had the ___ visiting her today who noticed that her legs had ___ edema and she had a 5lb wt gain. She eat a sandwich last night with lunch meat, but denies eating any other salty foods. She had been started on Lasix 20mg which she notes that she took it this AM and it did not do anything for her. She also noted to have increase in SOB today, but overall states that this was much better than on the prior week when she was hospitalized. She denies having any chest pain, denies fevers. She continues to have a cough- mainly non-productive and occ wheezing. Recently started on coumadin and has a large area of ecchymosis on her R flank which she thinks it has been stable. She denies having any trauma to the area. In the ED, initial vitals were: 97.2 79 174/65 24 100%. Her physical exam was notable for diffuse wheezes bilaterally, RRR+S1S2, obese abdomen with bruising on R flank, 3+ bilateral pitting edema. speaking full sentneces. Her cxray showed no pleural effusion or acute pulmonary process. She was given 40 mg of IV lasix and she had 900cc urine out. Most recent vitals were 97.9 100 20 sat 98 ra 162/61 prior to admission. On the floor, pt states that she is feeling much more comfortable than earlier. She denies feeling SOB and is resting comfortable in bed. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HTN Pulmonary TB Varicose veins with chronic leg edema Colon polyps Cataract surgery in both eyes Osteoarthritis Asthma Presnycope Social History: ___ Family History: Maternal grandmother had DM2. Her mother died at ___ of throat cancer. Her father died young in an accident. Her brother is ___ with DM2. She has a ___ sister but does not know much about her medical condition. Physical Exam: On Admission: VS: 98.7 160/57 (154-160) 72 18 98%RA GENERAL: Well-appearing in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MM-dry, OP clear. NECK: Supple, no thyromegaly, JVD at 12 cm, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, except for exp wheezes heard throughout. No crackles. Good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, large hematoma on the R abd/flank area which pt states that does not think that this has changed in size EXTREMITIES: WWP, no c/c with +2 pitting edema. 2+ peripheral pulses. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout On Discharge: Vitals - 98.0 145/27 69 20 99%RA Weight - 116.4-->114.3-->113.3-->110.3-->110.4-->107.7-->108.0 IO - ___ Peak flow - 250 GENERAL: Well-appearing in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MM-dry, OP clear. NECK: Supple, no thyromegaly, JVD at 10 cm, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat. No crackles. Good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, large hematoma on the R abd/flank area which is unchanged. EXTREMITIES: WWP, no c/c with +1 pitting edema. 2+ peripheral pulses. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout Pertinent Results: On Admission: ___ 06:35PM BLOOD WBC-10.9# RBC-3.09* Hgb-10.0* Hct-31.1* MCV-101* MCH-32.3* MCHC-32.1 RDW-13.7 Plt ___ ___ 06:35PM BLOOD ___ PTT-31.9 ___ ___ 06:35PM BLOOD Glucose-167* UreaN-26* Creat-1.2* Na-139 K-4.8 Cl-101 HCO3-28 AnGap-15 ___ 05:51AM BLOOD LD(LDH)-301* TotBili-0.4 ___ 06:35PM BLOOD cTropnT-<0.01 ___ 06:35PM BLOOD Calcium-8.7 Phos-2.4* Mg-2.4 ___ 05:51AM BLOOD calTIBC-224* VitB12-1326* Folate-9.7 ___ Ferritn-102 TRF-172* ___ 06:05AM BLOOD TSH-0.39 ___ 05:51AM BLOOD tTG-IgA-2 On Discharge: ___ 06:33AM BLOOD WBC-5.9 RBC-3.20* Hgb-10.3* Hct-33.0* MCV-103* MCH-32.3* MCHC-31.4 RDW-14.7 Plt ___ ___ 06:33AM BLOOD ___ PTT-34.2 ___ ___ 06:33AM BLOOD Glucose-108* UreaN-28* Creat-1.4* Na-139 K-4.3 Cl-100 HCO3-34* AnGap-9 ___ 05:51AM BLOOD LD(LDH)-301* TotBili-0.4 ___ 06:33AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2 ___ 05:51AM BLOOD calTIBC-224* VitB12-1326* Folate-9.7 ___ Ferritn-102 TRF-172* Studies: ECG - The rhythm is sinus arrhythmia with premature atrial complexes and a possible short run of supraventricular tachycardia. Non-specific ST segment and T wave abnormalities. Otherwise, no specific change compared to previous tracings. CXR - IMPRESSION: No evidence of acute disease. EGD - Impression: Small nonobstructing Schatzki's ring was noted Normal mucosa in the duodenum Food was noted in the stomach likely related to the pyloric stenosis Two nonbleeding ulcers were noted in the pyloric channel with associated mild pyloric narrowing (biopsy) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Ms. ___ is an ___ year-old female with history of diastolic CHF, asthma and atrial fibrillation (on coumadin) who presented with shortness of breath and was treated for an exacerbation of her congestive heart failure. HOSPITAL COURSE --------------- The patient presented with complaint of shortness of breath. In the emgergency department she was given 40 mg of IV lasix and she had 900cc urine out. Admitted to the cardiology floor. . On the cardiology floor the patient was continued on intra-venous lasix with good urine output. Also started on spironolactone. Her weight decreased and ___ edema improved. The patient completed her steroid taper and was maintained on PRN inhalers. Diltiazem/Digoxin were stopped and metoprolol started. The patient's fluid balance continued to improve and she was transitioned to PO lasix on ___. Discharged with plans to continue 80mg PO lasix daily and close follow-up with her PCP and cardiology. Weight at discharge was 107kg. CHRONIC CONDITIONS ------------------- # Atrial Fibrillation: The patient was in sinus rhythym for the majority of her hospitalization but was noted to have intermittent runs of afib on telemetry. She was continued on coumadin with goal INR ___. # Anemia/Gastric Ulcers: The patient had a macrocytic anemia on presentation. She has a known B12 deficiency for which she received B12 injections. Given a slowly declining hematocrit and treatment with coumadin, the patient was seen by GI who performed an endoscopy. The endoscopy revealed a narrow pyloris and ulcers at the pylorus. She was placed on BID PPI. Her H. pylori Ab returned (+) and she was started on triple therapy. The patient will require repeat EGD 8 weeks after discharge. # HTN: The patient's BP ran ~150 systolic throughout her stay. Her lasix was increased and she was started on spironolactone. Also uptitrated metoprolol. TRANSITIONAL ISSUES ------------------- - Cardiology f.u and titration of lasix dose to maintain dry weight - Repeat EGD in 8 weeks - Uptitrate metoprolol as tolerated Medications on Admission: - colchicine [Colcrys] 0.6 mg Tablet 1 Tablet(s) by mouth once a day - cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution 1,000 mcg IM x 1 a month ___ - fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose Disk with Device 1 puff(s) ih twice a day - ipratropium-albuterol [Combivent] 18 mcg-103 mcg (90 mcg)/Actuation Aerosol 2 puffs in q 6 h prn ___ - lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day ___ - pramipexole 0.125 mg Tablet 1 Tablet(s) by mouth at bedtime - aspirin, buffered [Aspridrox] - calcium carbonate-vitamin D3 [Calcium 500 + D] - multivitamin-minerals-lutein [Centrum Silver] - Lasix 20mg daily - Digoxin 0.125 daily (which she had not picked up from her pharmacy) - Diltiazem Extended-Release 240 mg PO DAILY - Coumadin 5mg once daily (uncertain about dose) - Prednisone taper 30mg for 3days and 20mg for 3 days, then 10mg per day -Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: 1000 (1000) mcg Injection once a month. 3. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1) Puff Inhalation twice a day. 4. Combivent ___ mcg/actuation Aerosol Sig: Two (2) Inhalation every ___ hours as needed for Wheezing. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 9. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Caps* Refills:*0* 11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 14. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*32 Tablet(s)* Refills:*0* 15. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 ___: Please have your INR checked at your doctor's appointment on ___. Disp:*90 Tablet(s)* Refills:*0* 16. furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 17. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0* 18. Outpatient Lab Work Please have a chemistry panel and coagulation studies checked at your primary care visit on ___. 19. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia for 2 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Congestive Heart Failure Asthma Gastric Ulcers 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: It was a pleasure taking care of you at ___! You were admitted due to an excess of fluid on your body. In the hospital you underwent diuresis and your breathing and leg swelling greatly improved. Your fluid build up is due to a stiffening of the heart muscle. You also had an endoscopy performed due to anemia and trace blood in your stool. The endoscopy revealed a narrowing of the connection between your stomach and intestine. There were also ulcers around this opening that were likely due to the pain medications you have been taking over the past year. See below for changes made to your home medication regimen: 1) Please START Furosemide 80mg daily 2) Please START Metoprolol Succinate 75mg daily 3) Please STOP Diltiiazem 4) Please STOP Digoxin 5) Please STOP Prednisone 6) Please START Spironolactone 25mg daily 7) Please START Omeprazole 40mg twice daily 8) Please START Metronidazole 500mg twice daily and continue for 8 additional days to complete a 10-day course 9) START Clarithromycin 500mg every 12 hours and continue for 8 additional days to complete a 10-day course 10) Please REDUCE your Warfarin dose to 3mg daily and have your INR levels followed 11) Please STOP all non-steroidal pain medications including Advil, Alleve, Ibuprofen, and Motrin. You can use Tylenol (Acetaminophen) for minor aches and pain. 12) START Ambien 5mg. Please discuss further use of this medication with your primary care doctor. See below for instructions regarding follow-up care: Followup Instructions: ___

10044189-DS-4

DS

2172-11-11 00:00:00

2172-11-15 15:08:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Decreased responsiveness; nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: Small Bowel Enteroscopy History of Present Illness: ___ F with Hx of ___ disease and seizure disorder presenting with AMS, weakness, and emesis x 1. ACS consulted for question SMA syndrome seen on CT scan. Per husband, patient has ___ disease and attends a day program at ___ but lives with him at home. She ate breakfast this morning, and her mental status was at baseline (alert, conversing but forgetful.) In the afternoon, she was walking to the bathroom with a staff member, when she became weak, confused, and diaphoretic. She had one episode of emesis. Prior to today, she has had no emesis and has not had any difficulty eating or early satiety. She was briefly constipated last week and has occasionally complained of back pain and abdominal pain over the last month. No BRBPR, diarrhea or fevers/chills, per husband. She has lost about 20 lbs over the last ___ years, but her weight has been stable over the last year. After discovery of massive gastric distension on CT, NGT was placed in ED and so far has drained about 2 liters of light-colored fluid. Of note, the patient has a history of a seizure disorder (two seizures in the last year, most recently one month ago) for which she is on keppra. Past Medical History: ___ disease x ___ years, Hx of breast CA s/p surgery and radiation, cervical radiculopathy, HTN (no meds), seizures Social History: ___ Family History: non-contributory Physical Exam: Physical Exam on Admission- VS: 98.6, 57, 134/76, 16, 100% RA Gen - NAD, unresponsive to voice, nonverbal, NGT in place Heart - RRR Lungs - CTAB Abdomen - soft, mildly distended, voluntary guarding throughout but mostly on left Extrem - warm, no edema Physical Exam on Discharge: VS: 98.0, 78, 141/77, 18, 97%RA GEN: Pt is alert, oriented to self and date of birth. Unable to state location, date/year, DOWB and reason for hospitalization. Pt is agitated at moments but easily redirected. CV: HRR, no m/r/g RESP: LS diminished at bases, respirations even/unlabored ABD: Soft, NT. +BS EXT: No edema. +pulses Pertinent Results: ___ 05:55AM BLOOD WBC-5.7 RBC-3.65* Hgb-11.0* Hct-34.1* MCV-93 MCH-30.2 MCHC-32.4 RDW-13.4 Plt ___ ___ 05:45AM BLOOD WBC-5.9 RBC-3.69* Hgb-11.3* Hct-33.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-13.0 Plt ___ ___ 04:45AM BLOOD WBC-6.7 RBC-3.62* Hgb-10.7* Hct-33.6* MCV-93 MCH-29.6 MCHC-31.8 RDW-13.5 Plt ___ ___ 05:30AM BLOOD WBC-7.9 RBC-3.62* Hgb-10.9* Hct-33.4* MCV-92 MCH-30.2 MCHC-32.7 RDW-13.5 Plt ___ ___ 02:15PM BLOOD WBC-8.5 RBC-4.37 Hgb-13.4 Hct-40.4 MCV-92 MCH-30.7 MCHC-33.2 RDW-13.2 Plt ___ ___ 05:35AM BLOOD Glucose-93 UreaN-5* Creat-0.9 Na-141 K-4.3 Cl-104 HCO3-28 AnGap-13 ___ 05:55AM BLOOD Glucose-101* UreaN-6 Creat-0.9 Na-140 K-4.5 Cl-104 HCO3-29 AnGap-12 ___ 05:45AM BLOOD Glucose-102* UreaN-6 Creat-0.9 Na-139 K-4.2 Cl-103 HCO3-28 AnGap-12 ___ 04:00AM BLOOD Glucose-104* UreaN-6 Creat-0.9 Na-136 K-4.0 Cl-102 HCO3-28 AnGap-10 ___ 03:45AM BLOOD Glucose-105* UreaN-7 Creat-0.8 Na-142 K-4.4 Cl-105 HCO3-29 AnGap-12 ___ 05:35AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2 ___ 05:55AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 ___ 05:45AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.7 Mg-2.1 Iron-55 ___ 04:00AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1 ___ 03:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4 ___ 02:15PM BLOOD ALT-19 AST-31 AlkPhos-82 Amylase-162* TotBili-0.3 ___: HEAD CT: No evidence of acute intracranial process. ___: CT ABD & PELVIS WITH CONTRAST: 1. Massively distended, fluid-filled stomach and proximal duodenum with caliber change at the level of the third portion of the duodenum as it crosses between the aorta and SMA, possibly due to SMA syndrome, although the appearance is somewhat atypical given intervening fat plane between the SMA and collapsed duodenum. No wall thickening or discrete mass seen. Focal narrowing of the left renal vein is also noted at this level. 2. No intra-abdominal free air or free fluid. 3. Scattered subcentimeter hepatic hypodensities are too small to characterize, but are statistically most likely to represent cysts. 4. Nonspecific apparent jejunal wall thickening is incompletely evaluated due to underdistension and may in part relate to underdistention. ___: UGI: Evidence of holdup of contrast within the stomach with slow movement throughout the duodenum into the small bowel, similar to that seen on CT and findings, which may represent SMA syndrome. ___: ABDOMEN XRAY: Passage of contrast out of the small bowel, now present in the descending and sigmoid colon. ___: Small Bowel Enteroscopy Report: Erythema in the stomach body compatible with NGT trauma. Otherwise normal small bowel enteroscopy to jejunum. No evidence of obstructive mass or lesion Brief Hospital Course: Ms. ___ is a ___ year old woman with a PMH significant for advanced Alzheimers disease and epilepsy who was admitted to ___ ___ for nausea, vomiting and management of a possible SMA syndrome vs gastroenteritis vs small bowel obstruction. A nasogastric tube was placed when she presented with immediate output of 1.7 liters of bilious fluid. CT scan of the abdomen showed increased rectal thickening, pneumatosis in ascending colon and an UGI showed holdup of contrast in the stomach which may represent SMA syndrome. Neurology was also consulted given her change in mental status. They thought there was no evidence of superimposed encephalopathy and recommended seizure precautions and continuing home medications once she was able to take medications by mouth. Overnight on HD1 she had very low urine output, for which she received 2L of IV fluids with resumption of normal urine output. Her urinalysis on HD2 was positive, and her urine culture grew E. Coli sensitive to ciprofloxacin. She was treated with ciprofloxacin. GI was consulted and they performed a small bowel enteroscopy on HD6. This showed Erythema in the stomach body compatible with NGT trauma and an otherwise normal small bowel enteroscopy to jejunum. There was no evidence of obstructive mass or lesion. GI recommended a trial of high calorie liquid diet. Nutrition was consulted and the patient was started on a liquid diet with high protein Scandishakes TID. On HD7, the patients foley was discontinued and she was voiding without difficulty. She was tolerating the liquid diet without difficulty. She had completed her course of ciprofloxacin for the UTI and she was hemodynamically stable. Physical therapy was consulted to evaluate the patient, as she was well below her baseline functioning from her acute illness. Physical therapy recommended she be discharged to a rehabilitative center to regain her strength. On day of discharge, the patient was hemodynamically stable and tolerating a full liquid high protien diet. She was voiding without difficulty. Her abdominal exam was benign. Discharge planning and instructions were discussed with the patient and her family with voiced agreement. The patient will follow up in the ___ clinic as well as with GI and neurology. Medications on Admission: DONEPEZIL [ARICEPT] - Aricept 10 mg tablet. one Tablet(s) by mouth qam with food LEVETIRACETAM - levetiracetam 250 mg tablet. one-half tablet(s) by mouth bid for one week, then one bid MEMANTINE [NAME___] - Name___ 10 mg tablet. one Tablet(s) by mouth twice a day after starter pack QUETIAPINE [SEROQUEL] - Seroquel 100 mg tablet. ___ to 1 Tablet(s) by mouth twice a day as needed for agitation ASPIRIN - aspirin 81 mg chewable tablet. one Tablet(s) by mouth once a day. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain do not exceed 3000mg/day 2. Donepezil 10 mg PO HS 3. Heparin 5000 UNIT SC TID 4. LeVETiracetam 250 mg PO BID 5. Memantine 10 mg PO BID 6. QUEtiapine Fumarate 50 mg PO BID 7. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Gastroenteritis vs SMA syndrome 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: You were admitted to the hospital with vomiting and abdominal pain and were found to have an obstruction that was causing a very distended stomach, requiring nasogastric decompression. You were maintained on bowel rest with IV fluids for several days. There was initially a concern for Superior mesenteric artery (SMA) syndrome, but the GI doctors did ___ and found that there was no blockage and you likely had a severe viral gastroenteritis. You are now doing well with your full liquid diet and you are ready to be discharged to a short term ___ facility to get back to your baseline of functioning. You are to remain on a full liquid diet with high protein supplements for the time being. Please note the following discharge instructions: Please call your doctor or come to the emergency room if you develop any of the following: -fever greater than 101 -nausea, vomiting, abdominal distention -diarrhea or constipation -inability to take in liquids -any new or concerning symptoms You will be following up with the GI doctors as ___ outpatient as well as in the Acute Care Surgery (ACS) clinic. Please also follow up with your neurologists and your primary care provider. Followup Instructions: ___

10044997-DS-13

DS

2153-11-05 00:00:00

2153-11-05 16:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: shellfish derived / iodine Attending: ___. Chief Complaint: Left hand table saw injury Major Surgical or Invasive Procedure: ___: left hand washout of multiple open fractures thumb index middle ring fingers, nerve repair x 1, PIP fusion ring finger, first dorsal metacarpal artery flap for thumb pulp recontruction History of Present Illness: ___ is a ___ year old male with PMH notable for hypertension presents with table saw injury to his left hand. He accidentally caught multiple digits and in the saw. He was seen at an outside ED where he had a digital block performed. He was given tetanus and Ancef. He is right-hand dominant. He sustained multiple serious injuries to the left hand fingers and was sent here for higher level of care. Denies any other injuries. Otherwise asymptomatic. Past Medical History: Hypertension Social History: ___ Family History: Noncontributory Physical Exam: GEN: AOx3 WN, WD in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: unlabored breathing with symmetric chest rise, no respiratory distress EXT: Flap pink, good cap refill, WWP SILT over thumb and all digits, including flap site Flexing/extending thumb IP joint, flap pink and well perfused No erythema, no drainage Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have multiple injuries to the left hand at all the digits including the thumb except for the small finger and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for procedure as noted above, 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 OT who determined that discharge to home with outpatient occupational therapy was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left upper extremity. 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. amLODIPine 10 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain Partial fill ok. Wean. No driving/heavy machinery. RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*25 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Disposition: Home Discharge Diagnosis: Left hand third finger deep laceration, left hand fourth finger partial amputation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing left upper extremity 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 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. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB FOLLOW UP: Please follow up with your Hand Surgeon, Dr. ___ one week. 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. Followup Instructions: ___

10045326-DS-17

DS

2152-11-23 00:00:00

2152-11-23 19:53:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___ Chief Complaint: Shortness of breath, lethargy, weakness, poor appetite Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o man with pmhx of newly diagnosed lung ca, who presents from home with ___ days of progressive dyspnea. He states that he has been feeling badly for weeks now since diagnosis of lung cancer nearly a month ago. He endorses poor PO intake due to mild nausea but mostly no appetite. He has tried dronabinol (terrible side effects of diarrhea and cramping) as well as marijuana (now no drive to even use that). He endorses nearly 30 pounds of weight loss over past few months. More acutely, he for the past few days has had increasing shortness of breath without significant cough or sputum production. He denies any fevers or chills. Does have some substernal pressure that is worse with coughing. No diagnosed lung disease apart from lung cancer, but does have decades of tobacco use and used to work in ___ so feels like had lots of exposure to potential toxins. He feels that he should have presented to ED multiple days ago, but did not have the drive to. Finally pushed by mother and girlfriend to come in. Of note, patient most recently saw Dr. ___ Atrius oncology on ___, at which point he was planned to start chemotherapy (___) on ___. He did take dexamethasone as instructed ___. He has not had any chemotherapy yet. Detailed oncologic history as below. In the ED, initial vitals were: 95.8 85 122/80 24 100% RA - Exam notable for: diffuse expiratory wheezing bilaterally, increased work of breathing with subcostal and supraclavicular respiratory muscle involvement - Labs notable for: WBC 39.8, flu A/B negative - Imaging: CXR without acute process, known lung mass - Duonebs and diazepam was given. Upon arrival to the floor, patient endorses the above history. He feels weak, +anorexia, hasn't slept in many days. He would like a diazepam to help him sleep. Feels breathing is still not at baseline. Has some mild chest tightness, but no other symptoms. REVIEW OF SYSTEMS: As per HPI. Past Medical History: Newly diagnosed lung cancer as below History of alcohol abuse History of substance abuse Atrial septal defect Stroke, small vessel in ___ without residual deficits, on aggrenox Tobacco dependence Hypercholesteremia Insomnia, unspecified ONCOLOGIC HISTORY PER ATRIUS: PATHOLOGY RESULTS: ___- cervical node biopsy (FNA)- non-diagnostic ___- left axillary node biopsy (FNA)- negative ___- EUS/Adrenal gland core biopsy: - Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. Clinical/imaging correlation is recommended. Social History: ___ Family History: No family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM VITAL SIGNS: 98.2 116/76 87 18 96 RA GENERAL: Chronically ill appearing, tired, but in NAD HEENT: NC/AT, wearing glasses, dry mucous membranes, tongue midline on protrusion NECK: supple, symmetric CARDIAC: RRR, no m/r/g LUNGS: air movement with poor effort is present but poor in all fields; no crackles, rhonchi, or wheezes can be appreciated in this context; no increased work of breathing and speaking in full senteces ABDOMEN: Soft, mildly tender on palpation diffusely, non-rigid, no r/g, BS+ EXTREMITIES: thin, WWP, no pitting edema, distal pulses intact NEUROLOGIC: alert and oriented; moving all extremities; symmetric smile, sensation to light touch symmetric and intact in all divisions of CN5, UE, torso, ___ strength ___ in b/l UE, able to lift both legs up against gravity and downward pressure b/l SKIN: no bruises or petechiae DISCHARGE PHYSICAL EXAM Vital Signs: T 97.6 PO BP 100 / 60 HR 86 RR 18 O2 93 RA General: Sitting up on a chair, eating breakfast, no acute distress Head: Normocephalic/ atraumatic, teeth and gums normal Lungs: Poor air movement throughout all lung fields, decreased breath sounds, no increased work of breathing, speaks in full sentences Heart: regular rate and rhythm, S1, S2 normal Abdomen: soft, non tender, normal bowel sounds Extremities: warm, well perfused, no edema Neuro: Alert and oriented, UE strength grossly normal, ___ strength normal. Sensation grossly intact throughout all extremities Pertinent Results: ADMISSION LABS --------------- ___ 10:03PM BLOOD WBC-39.8* RBC-4.54* Hgb-12.7* Hct-38.9* MCV-86 MCH-28.0 MCHC-32.6 RDW-14.2 RDWSD-43.8 Plt ___ ___ 10:03PM BLOOD Neuts-86.0* Lymphs-5.8* Monos-4.7* Eos-1.0 Baso-0.7 Im ___ AbsNeut-34.23* AbsLymp-2.30 AbsMono-1.89* AbsEos-0.38 AbsBaso-0.27* ___ 07:50AM BLOOD ___ PTT-29.7 ___ ___ 10:03PM BLOOD Glucose-84 UreaN-15 Creat-0.9 Na-137 K-4.8 Cl-96 HCO3-23 AnGap-23* ___ 10:03PM BLOOD CK(CPK)-25* ___ 07:50AM BLOOD ALT-12 AST-13 LD(LDH)-320* AlkPhos-168* TotBili-0.3 ___ 10:03PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:50AM BLOOD Albumin-3.1* Calcium-9.4 Phos-4.0 Mg-1.8 ___ 07:50AM BLOOD Cortsol-15.4 ___ 10:12PM BLOOD ___ pO2-25* pCO2-46* pH-7.42 calTCO2-31* Base XS-3 ___ 10:12PM BLOOD Lactate-1.4 ___ 10:35AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 10:35AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 10:35AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 MICROBIOLOGY ------------ Time Taken Not Noted Log-In Date/Time: ___ 7:26 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING --------- CXR (___): No acute cardiopulmonary process. Re- demonstration of left apical mass, better assessed on previous CT. Upper lobe predominant emphysema. CT CHEST (___): Growing left upper lobe lung mass. At least 3 rib metastases responsible for pathologic fractures, one healed and 2 not healed, were present in ___. No new metastases. Coronary atherosclerosis. Findings below the diaphragm including large bilateral adrenal masses will be reported separately. CT ABDOMEN/PELVIS (___): 1. 10 x 8 mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature is new from the recent prior exam of ___, worrisome for soft tissue metastasis. 2. Bilateral heterogeneously hypoenhancing adrenal metastases are significantly larger since ___, now measuring up to 6.5 cm on the right and 5.5 cm on the left (previously up to 2.4 and 2.5 cm, respectively). 3. Please see separate report for intrathoracic findings from same-day CT chest. DISCHARGE LABS --------------- ___ 08:10AM BLOOD WBC-37.9* RBC-4.36* Hgb-12.1* Hct-37.4* MCV-86 MCH-27.8 MCHC-32.4 RDW-14.1 RDWSD-43.7 Plt ___ ___ 08:10AM BLOOD Glucose-50* UreaN-12 Creat-0.9 Na-139 K-4.4 Cl-97 HCO3-25 AnGap-21* ___ 08:10AM BLOOD Calcium-10.0 Phos-4.7* Mg-2.7* Brief Hospital Course: Mr. ___ is a ___ male with a ___ smoking history and recent diagnosis of lung cancer in ___ with metastasis to adrenal glands, who presents for failure to thrive, leukemoid reaction, and progression of his metastatic disease. # Failure to thrive. In the setting of progression of his metastatic lung cancer, Mr. ___ has been experiencing a decline in his ability to care for himself. Notable weight loss of ~20lbs in the past few months, decreased appetite, exhaustion and decreased physical activity. He has taken Dronabinol in the past but experienced significant diarrhea and cramping. Initial concern for adrenal insufficiency due to adrenal metastases was reassured by AM cortisol of 15. Patient was seen by physical therapy, social work, palliative care, and nutrition. Palliative care recommended symptomatic treatment of his constipation with Milk of Magnesia and appetite stimulants were discussed (consideration for dronabinol versus medical marijuana). He should have a bowel movement at least once every three days. If he does not, we advised him to take milk of magnesia till he has a bowel movement. Patient declined any additional appetite stimulants at this time; he did not want to be "stoned" during the day. Nutrition advised nutritional supplementation with Ensure supplements at meals. Patient remained hemodynamically and clinically stable throughout his hospital stay. Ambulatory O2sat on discharge was 98%. # Leukemoid reaction. Patient presented with leukocytosis to 39.8 which was a significant rise from his last CBC (normal in ___, though prior to diagnosis of his lung cancer). Clinically the patient did not appear infected (no fever, cough, diarrhea). Infectious workup is negative to date (blood cultures, urine culture, C. diff, CXR). Blood smear did not reveal any concern for a primary hematologic disorder and was consistent with a significant leukemoid reaction, likely in the setting of his progressive, metastatic, lung cancer. # Lung cancer, metastatic. Presenting with fatigue, general malaise, poor appetite and worsening dyspnea in the setting of recent diagnosis of lung cancer (___). CT abdomen and pelvis on this admission is concerning for progression of his adrenal metastasis and a new 10 x 8 mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature (concerning for soft tissue metastasis). CT chest revealed growing left upper lobe lung mass. After discussions with Atrius oncology, patient will be discharged to begin chemotherapy on ___, as an outpatient. He will start Dexamethasone 4 mg daily today for three days. # Hyperlipidemia. Consider stopping statin given his shortened life expectancy versus time required for benefit of statin. # Insomnia. Patient has longstanding insomnia and is prescribed diazepam 15mg qhs. He noted that he frequently takes anywhere between ___ per night. He has not tried good sleep hygiene practices. Additionally, his primary problem is maintenance of sleep (not initiation) so it would be helpful for him to try medicaitons for maintenance of sleep as he is slowly weaned off diazepam (given his longstanding use of benzodiazepines for sleep). TRANSITIONAL ISSUES ------------------- FAILURE TO THRIVE [ ]Nutrition: Tried Dronabinol in the past but experienced diarrhea and cramping. Medical marijuana was discussed as an appetite stimulant, which he refuses at this time. PO supplementation with Ensure shakes has been advised [ ]Constipation: Patient has been advised to take Milk of Magnesia as needed if he is not experiencing bowel movements at least once every three days LEUKEMOID REACTION -WBC on discharge was 37.9 [ ]F/up on pending blood and urine cultures LUNG CANCER, METASTATIC TO ADRENALS/RIBS/LEFT BUTTOCK [ ]Patient to begin chemotherapy on ___ [ ]Advised to take Dexamethasone 4 mg daily on the day prior, day of, day after chemotherapy. Start date ___. End date ___ INSOMNIA [ ]Advised slowly titrating off Diazepam. Promotion of maintenance of sleep medications (Ambien), not initiation of sleep -Continue to encourage good sleep hygiene #Discharge weight: 57.4kg #CODE: FULL CODE for now #CONTACT: ___ Mother ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dexamethasone 4 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. Multivitamins W/minerals 1 TAB PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 8. Simvastatin 20 mg PO QPM 9. Dipyridamole-Aspirin 1 CAP PO BID 10. Sildenafil ___ mg PO PRN intercourse Discharge Medications: 1. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by mouth every six (6) hours Refills:*2 2. Dexamethasone 4 mg PO DAILY Duration: 3 Days 3. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 4. Dipyridamole-Aspirin 1 CAP PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Sildenafil ___ mg PO PRN intercourse 11. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Failure to thrive, Leukemoid reaction secondary to progressive metastatic lung cancer, Constipation Secondary diagnoses: Metastatic Stave IV lung cancer, hyperlipidemia, insomnia 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 ___ for weakness, poor appetite, decreased activity, and exhaustion. These symptoms are most consistent with your underlying lung cancer and the progression of the disease. We have advised nutritional supplementation with Ensure, Milk of Magnesium for your constipation (to be taken if you are not having a bowel movement every three days), and physical therapy as tolerated. Imaging and labs are negative for an infection at this time. You have an elevated white blood cell count (a marker of inflammation or infection) and in this case, we think it is a reflection of the progression of your lung cancer (as confirmed on imaging). We have spoken with the Oncology team at ___. They would like you to start chemotherapy on ___. You will take three days of Dexamethasone to begin today and to end on ___. Please make sure to take your bowel regimen medication. You should have a bowel movement atleast once every three days. If you do not have a bowel movement by the third day please take Milk of Magnesia till you have a bowel movement. It is important that you attend the follow-up appointments listed below. It was a pleasure taking care of you! We wish you the best! Your ___ Team Followup Instructions: ___

10045326-DS-18

DS

2152-11-28 00:00:00

2152-11-28 21:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: flank pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ yo man wit newly diagnosed poorly differentiated metastatic lung cancer based upon a biopsy of an adrenal lesion followed by Dr ___ admitted with right flank and RUQ abdominal pain and transient left leg discomfort and tingling. Past Medical History: Newly diagnosed lung cancer as below History of alcohol abuse History of substance abuse Atrial septal defect Stroke, small vessel in ___ without residual deficits, on aggrenox Tobacco dependence Hypercholesteremia Insomnia, unspecified ONCOLOGIC HISTORY PER ATRIUS: PATHOLOGY RESULTS: ___- cervical node biopsy (FNA)- non-diagnostic ___- left axillary node biopsy (FNA)- negative ___- EUS/Adrenal gland core biopsy: - Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. Clinical/imaging correlation is recommended. Social History: ___ Family History: No family history of cancer. Physical Exam: VS: 98.2 PO 92 / 55 102 18 93 RA GEN: cachectic appearing in NAD HEENT/Neck: anicteric sclera, MMM, OP clear, neck supple HEART: RRR no m/r/g LUNGS: CTAB no wheezes, rales, or crackles. Symmetric expansion ABD: soft NT/ND +BS no rebound or guarding EXT: warm well perfused, no pitting edema NEURO: alert and oriented. Fluent speech. CN II-XII intact. No focal deficits on strength testing, ___ strength with gross sensation intact Pertinent Results: ___ 08:52PM LACTATE-1.0 ___ 01:10PM URINE HOURS-RANDOM ___ 01:10PM URINE UHOLD-HOLD ___ 01:10PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:10PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 10:07AM TYPE-ART COMMENTS-GREEN TOP ___ 10:07AM LACTATE-1.5 ___ 10:01AM GLUCOSE-79 UREA N-26* CREAT-0.8 SODIUM-135 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18 ___ 10:01AM ALT(SGPT)-72* AST(SGOT)-43* ALK PHOS-178* TOT BILI-0.5 ___ 10:01AM LIPASE-35 ___ 10:01AM ALBUMIN-3.6 ___ 10:01AM WBC-34.0* RBC-3.78* HGB-10.7* HCT-32.6* MCV-86 MCH-28.3 MCHC-32.8 RDW-14.2 RDWSD-44.5 ___ 10:01AM NEUTS-90.9* LYMPHS-5.3* MONOS-0.6* EOS-1.4 BASOS-0.3 IM ___ AbsNeut-30.93* AbsLymp-1.80 AbsMono-0.20 AbsEos-0.47 AbsBaso-0.11* ___ 10:01AM PLT COUNT-370 FINDINGS: The liver appears normal in grayscale appearance and size without focal lesion of concern. No biliary ductal dilation. Gallstones noted within the gallbladder though there is no evidence for acute cholecystitis. Sonographic ___ sign is negative. Common bile duct measures up to 3 mm. The known right adrenal metastasis is visualized though better characterized on same-day CT exam. A simple appearing cyst is seen in the right kidney interpolar region measuring 2 cm in diameter. Lymphadenopathy adjacent to the pancreas better assessed on same-day CT. No ascites. IMPRESSION: 1. Cholelithiasis without evidence of cholecystitis. 2. Right adrenal mass and enlarged peripancreatic nodes better assessed on same-day CT exam. IMPRESSION: 1. No evidence of acute pulmonary embolism or aortic abnormality. 2. Interval worsening and enlargement of retroperitoneal lymph nodes, specifically with development of at least 3 centrally necrotic lymph nodes along the posterior aspect of the pancreas. 3. Slight interval increase in size of left gluteal soft tissue nodule since ___. 4. Bilateral adrenal metastatic lesions are unchanged in size from ___ but significantly larger than ___. 5. Unchanged left upper lobe pulmonary mass. Brief Hospital Course: ___ yo M with poorly differentiated metastatic lung cancer with adrenal mets, lymphadenopathy, s/p recent pemetrexed/carboplatin ___, who presented with R flank pain and episode of L leg numbness now resolved. Acute R flank pain: Work up as above and essentially negative except for cholelithiasis. Resolved after 24 hrs. Cause unclear. ___ be side effect from chemotherapy. ___ be biliary colic as well. RUQ US without cholecystitis or evidence of obstruction. Imaging re-assuring and not consistent with renal colic, pancreatitis, or referred pain. Follow up with oncology scheduled for day after discharge. Metastatic poorly differentiated lung cancer: s/p chemo on ___. Reviewed case with Dr. ___ ___ oncology. Cont Folate LLE numbness: Resolved. Possibly due to sciatica though no back pain. Metastatic dz to spine is also to be considered, though PET imaging was negative and symptoms resolved on their own spontaneously. One would expect persistent symptoms if there were a mass lesion. - Outpatient follow up Hypotension: IVF given Anxiety: stable h/o CVA: Continued aggrenox Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 7. Prochlorperazine 10 mg PO Q6H:PRN nausea 8. Simvastatin 20 mg PO QPM 9. Sildenafil ___ mg PO PRN intercourse 10. Dexamethasone 4 mg PO DAILY 11. Milk of Magnesia 30 mL PO Q6H:PRN constipation Discharge Medications: 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Milk of Magnesia 30 mL PO Q6H:PRN constipation 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea 7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Sildenafil ___ mg PO PRN intercourse 10. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Metastatic lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of right sided pain and left leg numbness. Evaluation was negative. Your symptoms improved. Please stay well hydrated, take your medications as prescribed, and follow up with your oncologist as scheduled tomorrow Followup Instructions: ___

10045574-DS-6

DS

2194-06-12 00:00:00

2194-06-13 15:44:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever, headache Major Surgical or Invasive Procedure: None History of Present Illness: ___ without any significant past medical history presents to ED with one day of bitemporal headache, fever to 102 and nausea and one episode of nonbloody nonbilious emesis. She reports that she does not have any photophobia or meningismus. No cough abdominal pain, diarrhea or dysuria or increased urinary frequency. No fall or trauma. Denies history of headaches. Also denies weakness, difficulty walking, mylagias, sinus tenderness, nasal congestion. She has not been around anyone else that is sick and has not recently traveled. In the ED intial vitals were: 10 102.1 93 131/78 18 98% ra - Labs were significant for wbc 17k, 78%N. Na was 132 and bicarb 21. U/A unremarkable and lactate normal. LP was done showing normal protein, glucose and 2wbc + 8RBC. gram stain was neg. CT head showed aerosolized secretions within paranasal sinuses c/w ?acute sinusitis. - Patient was given: 2000ml NS, tylenol ___ Vitals prior to transfer were: 3 99.2 86 128/78 18 99% RA On the floor, pt's niece, ___ translated for me. She reports that she feels much better and no longer has the headache. She has not had a fever since this AM and has not had emesis since this AM. Pt reports mild sore throat. Past Medical History: None Social History: ___ Family History: No family history of cancer. Physical Exam: ON ADMISSION: Vitals- 99.1, 104/60, 83, 20, 100% RA General- pleasant, no acute distress HEENT- conjunctiva are injected bilaterally. no icterus, PERRLA, EOMI, no photophobia with light. OP slightly erythematous without exudates Neck- ___ small shotty nontender cervical nodes. Lungs- clear to auscultation bilaterally CV- rrr no murmurs rubs or gallops Abdomen- soft nontender nondistended, no rebound or guarding. No organomegaly. GU- deferred Ext- pulses 2+ b/l in all extremities. No c/c/e. Neuro- grossly intact, no meningismus Skin - normal LABS: see below ON DISCHARGE: Vitals: Tm 100.2 (1520), Tc 98.6 BP106/68 P73 RR20 100RA General: ___ speaking, pleasant, no acute distress. HEENT: Sclera anicteric, dry mucous membranes, enlarged tonsils with exudate over left tonsil. Neck: Supple, no JVD, no cervical or supraclavicular lymphadenopathy. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm. Normal S1, loud P2. ___ systolic murmur loudest at apex. No S3, S4. Abdomen: +BS, soft, nondistended, nontender to palpation. Ext: Warm, well perfused, 2+ pulses, no peripheral edema. Skin: No rash. Lymph nodes: No cervical, supraclavicular, axillary, and inguinal lymph nodes palpated. Neuro: CN II-XII grossly intact. Moves all extremities. Pertinent Results: ON ADMISSION: ======================================= ___ 01:40PM BLOOD WBC-17.8*# RBC-4.46 Hgb-12.8 Hct-38.1 MCV-85 MCH-28.8 MCHC-33.7 RDW-11.9 Plt ___ ___ 01:40PM BLOOD Neuts-87.7* Lymphs-7.4* Monos-4.3 Eos-0.2 Baso-0.3 ___ 08:39PM BLOOD ___ PTT-26.4 ___ ___ 01:40PM BLOOD Glucose-115* UreaN-12 Creat-0.6 Na-132* K-3.6 Cl-98 HCO3-21* AnGap-17 ___ 01:40PM BLOOD ALT-15 AST-23 AlkPhos-107* TotBili-0.5 ___ 07:30AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.8 INFLAMMATORY MARKERS: ======================================= ___ 06:55AM BLOOD ESR-60* ___ 06:55AM BLOOD CRP-224.6* ON DISCHARGE: ======================================== ___ 06:44AM BLOOD WBC-15.2* RBC-4.17* Hgb-12.0 Hct-36.0 MCV-86 MCH-28.6 MCHC-33.2 RDW-12.2 Plt ___ ___ 06:44AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-138 K-3.8 Cl-101 HCO3-24 AnGap-17 ___ 06:55AM BLOOD LD(LDH)-317* MICROBIOLOGY: ======================================== ___ 11:25 am THROAT FOR STREP **FINAL REPORT ___ R/O Beta Strep Group A (Final ___: Reported to and read back by ___ ___ @1341, ___. BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH. ___ 8:45 pm Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. ___ 6:26 pm CSF;SPINAL FLUID TUBE #3. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ___ 1:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. STUDIES: =================================== EKG (___) Sinus rhythm. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. CXR (___) Heart size is normal. Mediastinal and hilar contours are unremarkable. Lungs are clear and the pulmonary vasculature is normal. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. CT HEAD w/o CONTRAST (___) There is no acute hemorrhage, edema or shift of the midline structures. The ventricles and sulci are of normal size and configuration. The gray white matter differentiation is preserved and there is no evidence for an acute territorial vascular infarction. The basal cisterns are patent. There are aerosolized secretions within the posterior ethmoidal air cells and minimal mucosal thickening involving the sphenoid and right maxillary sinuses. The mastoid air cells are well aerated. There is no fracture. Adenoids appear enlarged for age. IMPRESSION: 1. No acute intracranial process. MRI is more sensitive for detecting intracranial lesions. 2. Aerosolized secretions within the paranasal sinuses may indicate acute sinusitis in the appropriate clinical setting. 3. Posterior nasopharyngeal mucosal thickening should be further evaluated with direct visualization. CT TORSO (___) CT THORAX: The thyroid gland is unremarkable. The airways are patent to the subsegmental level. There is no central or axillary lymphadenopathy. The heart and great vessels are within normal limits. There is no pericardial effusion. The esophagus is within normal limits without evidence of wall thickening or hiatal hernia. Lung windows do not show any focal opacity concerning for pneumonia. There are small bilateral pleural effusions with minimal associated bibasilar atelectasis. There is no pneumothorax. CT ABDOMEN: The liver enhances homogeneously, without focal lesions or intrahepatic biliary duct dilatation. The gallbladder is unremarkable and the portal vein is patent. The pancreas, spleen, adrenal glands are within normal limits. The kidneys show symmetric nephrograms and excretion of contrast. There is no hydronephrosis. A 6 mm hypodensity in the lower pole of the left kidney is too small to characterize but statistically likely a simple cyst. The small and large bowel are within normal limits, without evidence of wall thickening or dilatation to suggest obstruction. The appendix is visualized and is not inflamed. The aorta and its main branches are patent and nonaneurysmal. There is no mesenteric or retroperitoneal lymph node enlargement by CT size criteria. There is no ascites, abdominal free air or abdominal wall hernia. CT PELVIS: The urinary bladder and ureters are unremarkable. The uterus is bulky compatible with multiple fibroids with one exophytic fibroid measuring 2.2 cm originating from the left anterolateral aspect of the uterus (2: 95). There is no pelvic wall or inguinal lymphadenopathy. No pelvic free fluid is observed. OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for malignancy. IMPRESSION: Fibroid uterus. Otherwise unremarkable torso CT examination. No lymphadenopathy identified. Brief Hospital Course: ___ with no significant PMH presents with 1 day of fever and headaches. # Fever: Given fevers and severe headache, a lumbar puncture was performed. CSF was unremarkable with with only 2 WBC, and protein/glucose. Gram stain and cultures returned negative. Nasopharyngeal swab returned negative for influenza. CXR and urinalysis were also negative. CT head suggestive of acute sinusitis, however we felt this did not correlate with her significant leukocytosis with neutrophil predominance. Upon arrival to the medical floor, patient only complained of sore throat, occasional coughing of blood-tinged sputum, and night sweats. Patient was unclear of her PPD status, however CXR was negative. She denied other infectious symptoms such as cough, sinus tenderness, shortness of breath, abdominal pain, diarrhea, dysuria, rash, or joint pain. She denied any recent weight loss, history of cancer in her family, or recent tuberculosis exposure. Patient had a ___ systolic murmur that was undocumented in outpatient records, however no other stigmata of endocarditis. Blood cultures have also been negative to date. Because lack of localizing infectious symptoms, antibiotics were held. The patient continued to spike fevers, up to ___. Because of elevated inflammatory markers and slightly elevated LDH, the patient underwent a CT torso to evaluate for lymphadenopathy, which was negative. One day prior to discharge, patient developed an exudate on her left tonsil. The exudate was swabbed, and cultures returned positive for Group A beta-hemolytic strep. Patient was started on Augmentin, which she will complete a 10 day course. Patient's WBC remained elevated, however trended down by the time of discharge. # Hyponatremia: Likely secondary to hypovolemia as patient reports poor PO intake. She was given 2L of IVF in the ED with resolution. TRANSITIONAL ISSUES: - Patient to complete a 10 day course of Augmentin for Group A beta-hemolytic streptococcal pharyngitis. - Consider ___ for resolution of leukocytosis. - Consider influenza vaccine as patient has not received it this season. - CT head with thickening of nasopharyngeal mucosa. Per radiology, can not differentiate between normal, infectious, vs malignancy. Consider further evaluation should patient have symptoms. Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain, fever 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Group A beta hemolytic strep pharyngitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to the hospital with fevers and headache. A variety of tests including a spinal tap, CT scan, and flu testing were negative. We swabbed your throat, and the cultures revealed a bacterial infection, which is why you are having throat pain. We started you on antibiotics, Augmentin for which you will complete a 10 day course (end date ___. Please finish the course of antibiotics, as instructed. You can continue to you acetaminophen (Tylenol) as needed for fever, though do not use more than 3,000mg (3g) daily. Please follow-up with your primary doctor (___) this week. An appointment was made on your behalf. It was a pleasure participating in your care, thank you for choosing ___! Followup Instructions: ___

10045854-DS-9

DS

2121-03-20 00:00:00

2121-03-24 18:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cipro Attending: ___ Chief Complaint: Consideration of cath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with ___ CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM, who presented to BI-P with chest pain, found to have NSTEMI (tropI 10) and ST depressions in anterolateral leads, ST elevation in aVR, transferred to ___ for consideration of cath. Initially presented to BI-P on ___ with syncope (negative trauma evaluation) but with diffuse ST depressions on ECG and troponin I rise from 0.06 to 20 to peak of 70. He was asymptomatic at that time. TTE at that time showed EF50% but akinetic infero-lateral wall and basal to mid ___ wall. He received medical management with ASA, IV heparin, plavix, beta blocker and was discharged on discharged ___ from BI-P. However this AM he developed crushing R chest pain (his anginal equivalent) and thought he was "going to die." BIBEMS to BI-P, there trop-I 10 and ECG again showed diffuse ST depressions and ST elevation in aVR. CXR with pulmory edema edema. Received ASA324mg, NTG paste, started on heparin gtt. Labs there also noted mild stable anemia (Hb mid-high 9s) with negative FOBT, chem panel with Cr 1.6 (baseline appears 1.6-1.8). Cardiology evaluation there felt to have L main lesion requiring emergent transfer for stenting. Pre-transfer, VSS and 95%RA. At ___, pt reports currently is chest pain free. No abd pain, nausea, vomiting, diaphoresis, fever, chills, diarrhea, urinary c/o. In the ED: Initial VS: 98.0 84 154/79 16 96% RA EKG: NSR with RBBB, LAFB, ST depressions in anterolateral leads, and ST elevation in aVR Labs notable for: tropT 3.8, CKMB 50, Cr 1.5, BNP 18435, Mg 1.4 Studies notable for: CXR Overall improvement in central pulmonary edema, now mild-moderate. No focal consolidation. Consults: cardiology Patient was given: Iv heparin, IV Mg, clopidogrel 300 mg, Vitals on transfer: 98 81 143/70 18 95% RA On the cardiology service, he endorses the history above. He reports the chest pain has resolved and he is not experiencing any pain or pressure currently. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies fevers or chills. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD/remote CABG (?in ___) at ___, reportedly with DES x2, unclear anatomy 3. OTHER PAST MEDICAL HISTORY - GERD Social History: ___ Family History: NC Physical Exam: Admission exam ============== VS: 98.0 143 / 70 ___ GENERAL: Well developed, well nourished 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: No JVD CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric Discharge exam ============== 24 HR Data (last updated ___ @ 1706) Temp: 97.3 (Tm 99.2), BP: 103/57 (100-125/48-70), HR: 62 (61-82), RR: 16 (___), O2 sat: 96% (93-97), O2 delivery: RA 24 HR Data (last updated ___ @ 1706) GENERAL: Well developed, well nourished 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: No JVD CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admision labs ============= ___ 01:00PM BLOOD WBC-9.5 RBC-3.01* Hgb-9.2* Hct-30.1* MCV-100* MCH-30.6 MCHC-30.6* RDW-13.6 RDWSD-49.7* Plt ___ ___ 01:00PM BLOOD Neuts-74.6* Lymphs-13.1* Monos-9.3 Eos-2.2 Baso-0.3 Im ___ AbsNeut-7.11* AbsLymp-1.25 AbsMono-0.89* AbsEos-0.21 AbsBaso-0.03 ___ 01:08PM BLOOD ___ PTT-102.5* ___ ___ 01:00PM BLOOD Glucose-114* UreaN-15 Creat-1.6* Na-135 K-4.4 Cl-100 HCO3-20* AnGap-15 ___ 08:39PM BLOOD ALT-13 AST-66* AlkPhos-92 TotBili-0.6 ___ 01:08PM BLOOD CK-MB-50* MB Indx-10.2* ___ ___ 01:00PM BLOOD Calcium-8.9 Phos-2.3* Mg-1.4* ___ 08:39PM BLOOD HDL-40* CHOL/HD-3.2 Discharge labs ============== ___ 06:40AM BLOOD WBC-11.3* RBC-2.53* Hgb-7.8* Hct-24.1* MCV-95 MCH-30.8 MCHC-32.4 RDW-13.7 RDWSD-47.6* Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-168* UreaN-21* Creat-1.7* Na-131* K-4.8 Cl-95* HCO3-24 AnGap-12 ___ 06:40AM BLOOD ALT-10 AST-18 AlkPhos-82 ___ 06:40AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6 Imaging ======= TTE ___ CONCLUSION: The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. Overall left ventricular systolic function is moderately-to-severely depressed secondary to hypokinesis of the inferior free wall and akinesis (with focal dyskinesis) of the posterior and lateral walls. The visually estimated left ventricular ejection fraction is 30%. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with depressed free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is depressed. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate [2+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: inferoposterolateral myocardial infarct CXR ___ FINDINGS: In comparison to the prior radiograph, diffuse bilateral reticular opacities and septal thickening are improved compared to the prior study. There is mild-moderate persistent central pulmonary edema slightly worse on the left. There is bronchovascular cuffing. Likely trace left pleural effusion. No pneumothorax. No large focal consolidation. The heart is mildly enlarged. The mediastinum is stable in size. Postsurgical changes after median sternotomy and CABG are demonstrated. IMPRESSION: Overall improvement in central pulmonary edema, now mild-moderate. No focal consolidation. Brief Hospital Course: TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 66 kg(145.5 lb) DISCHARGE Cr: 1.7 DISCHARGE DIURETIC: None MEDICATION CHANGES: - NEW: Nitroglycerin SL 0.3 mg, Atorvastatin 80 mg daily - STOPPED: nifedipine 30mg daily, Simvastatin 80mg daily - CHANGED: Increased Metoprolol succinate XL from 12.5mg daily to 50 mg daily TRANSITIONAL ISSUES: [] Did not start ___ due to elevated Cr. and soft blood pressures, can be considered as outpatient. FOR PCP: [] A1c 7.2%, will require continued monitoring as outpatient [] please recheck sodium and creatinine within 1 week to ensure not hyponatremic and no ___ --likely due to decreased PO Intake from hospital food [] continue to assess goals of care and ___ and need for rehab # CODE STATUS: DNR/DNI # CONTACT: Name of health care proxy: ___ ___ number: ___ ========= SUMMARY ========= ___ with ___ CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM, who presented to BI-P with chest pain, found to have NSTEMI (tropI 10) and ST depressions in anterolateral leads, ST elevation in aVR, transferred to ___ for consideration of cath, now with plan for medical management. CORONARIES: prior CABG, 2xDES, unknown coronary anatomy PUMP: EF 50% ___ RHYTHM: NSR =============== ACTIVE ISSUES: =============== # Type I NSTEMI: History of CAD and remote CABG and 2xDES (he doesn't remember the details). Initial presentation on ___ to ___ for syncope with rising troponin diffuse ST depressions with ST elevation in aVR, concerning for diffuse ischemia such as L main disease. He was medically managed with ASA, heparin gtt, BB, plavix and discharged on ___. His peak troponin I was 70. He then represented on ___ for chest pain and had troponin I of 10 ___epressions as before. He was started on heparin gtt, ASA 325 mg and transferred to ___ for consideration of cath. At ___, he reported being chest pain free. TropT 3.8 with MB down-trending 50 to 47. TTE ___ showed EF 30% with inferoposterolateral myocardial infarct. Event was thought to be >72 hours out and given his age and prior CABG, risks/benefits were discussed with interventional attending and cardiology fellow who recommended medical management and reassessment if he were to develop chest pain. Discussed with patient and he would rather avoid cath if possible. We discussed that if he were to have worsening chest pain we may pursue this option and could reverse his DNR/DNI ___. He and his family agree with this noninvasive plan. Plan to optimize medical management. He was treated with ASA 81mg, Plavix 75mg, Atorvastatin 80mg, Metoprolol. Restarted his home isosorbide mononitrate 30mg daily. Initally treated with IV heparin gtt. ACEI was not started due to his Cr. Can be considered in outpatient if Cr. improves. Stopped nifedipine 30mg daily as he his metoprolol was increased. #DM A1c at BI-P 7.2% - Restarted on home glipizide on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 12.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 4. NIFEdipine (Extended Release) 30 mg PO DAILY 5. Simvastatin 80 mg PO QPM 6. Pantoprazole 40 mg PO Q12H 7. GlipiZIDE XL 2.5 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. PARoxetine 10 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Take 1 tab every 5 mins as needed for chest pain, if pain doesn't resolve after 3 tablets, call ___ RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Every 5 mins Disp #*30 Tablet Refills:*0 3. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. GlipiZIDE XL 2.5 mg PO DAILY RX *glipizide [Glucotrol XL] 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 9. PARoxetine 10 mg PO DAILY RX *paroxetine HCl 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis ================= Type I NSTEMI Secondary diagnosis =================== Type 2 Diabetes Mellitus Hypertension 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: ================================================ DISCHARGE INSTRUCTIONS ================================================ Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a heart attack. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were found to have some damage to your heart. Together with you, we decided to avoid looking inside the arteries of your heart (Cardiac catherization). We gave you medications to treat your heart instead. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Followup Instructions: ___

10045960-DS-10

DS

2193-07-31 00:00:00

2193-07-31 18:03:00

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 Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a history of HFpEF (EF 60%), COPD, AFib, CAD, OSA who presented with shortness of breath. He describes developing sudden shortness of breath at home yesterday evening which woke him from sleep. He describes orthopnea at that point although he generally sleeps with two pillows. He's had a dry cough for weeks, as well as insidious weight gain. He has been going to pulmonary rehab as recommended by his Pulmonologist, and underwent a session that morning. He thinks his diet has been the same, has not had sick contact. His only medication change was starting labetalol one week ago by his PCP. He denies fever/chills, chest pain, lightheadedness, palpitations. This morning he called EMS, who found him hypertensive to the 200s. He received oral nitro and was placed on CPAP on transfer. Of note, he had PEA arrest in ___ in the setting of hypoxia from a COPD exacerbation. He was diagnosed with AFib in that occasion and given an event monitor. He was also recently admitted on ___ with a CHF exacerbation which improved after diuresing. In the ED, Initial vital signs: T 97.7, HR 60, BP 230/130, RR 18, O2 sat 100% CPap Exam notable for: No exam documented. EKG: Sinus bradycardia w/ 1st degree AV block (PR 219), old anterioseptal MI (T wave inversions I, aVL, V4-6) Labs were notable for: CBC - WBC 7, Hgb 14.4, Plt 126; coags -INR 1.5; BMP - Cr 1; proBNP 1030; vBG 7.34/56/41 -> 7.42/45/55 ; lactate 1.6, trop negative. Studies performed include: CXR - Moderate pulmonary vascular congestion and edema. Bibasilar opacifications likely reflect a combination of atelectasis and edema, however a superimposed pneumonia would be difficult to exclude. New elevation of the left hemidiaphragm compared to ___. Probable small left pleural effusion. Patient was given: 4 SL nitro en route (1 additional in ED), Duonebs x 2, 40 mg IV Lasix, ceftriaxone, azithromycin, apixaban, aspirin, labetalol. His ED course was notable for starting BiPap on arrival and plan for ICU admission. However, his O2 requirement decreased to 5L NC so he was admitted to the floor. Vitals on transfer: HR 50, BP 163/85, RR 24, O2 sat 96% 5L NC Upon arrival to the floor, he is feeling well although still a little short of breath. Past Medical History: PEA arrest in the setting of hypoxia in ___ COPD HFpEF (EF 60% in ___ CAD (s/p DES to LCX ___ AFib Moderate AS L diaphragmatic paralysis OSA (ordered for outpatient BiPAP but declined this) Social History: ___ Family History: Father died from bone cancer at the age of ___. Mother died of dementia in her ___. Physical Exam: ADMISSION ========= VITALS: T 97.4, BP 185/84, HR 52, RR 18, O2 sat 97% 5L GEN: In NAD. HEENT: PERRL, moist mucous membranes, oropharynx clear without exudates. NECK: JVP to mandible, no cervical lymphadenopathy. CV: RRR, soft systolic ejection murmur at base. PULM: CTAB, no wheezing/crackles/rhonchi. ABD: Soft, non tender, non distended. EXTREM: Trace ___ edema. Pulses +2 ___P, ___ bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. DISCHARGE ========= VITALS: Reviewed in OMR GENERAL: Alert and oriented, no acute distress ENT: NT/AC, MMM, EOMI CV: Bradycardic, regular. No murmurs, rubs, or gallops RESP: CTAB, normal work of breathing GI: NT/ND, BS+ EXT: Warm and well perfused, non-edematous NEURO: CNII-XII grossly intact, no focal neurologic deficits Pertinent Results: ADMISSION ========= ___ 04:47AM WBC-7.0 RBC-4.77 HGB-14.4 HCT-43.6 MCV-91 MCH-30.2 MCHC-33.0 RDW-14.5 RDWSD-48.9* ___ 04:47AM NEUTS-69.3 LYMPHS-18.0* MONOS-8.3 EOS-3.3 BASOS-0.7 IM ___ AbsNeut-4.82 AbsLymp-1.25 AbsMono-0.58 AbsEos-0.23 AbsBaso-0.05 ___ 04:47AM PLT COUNT-126* ___ 04:47AM ___ PTT-33.5 ___ ___ 04:47AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.9 ___ 04:47AM proBNP-1030* ___ 04:47AM cTropnT-<0.01 ___ 04:47AM GLUCOSE-156* UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11 ___ 05:02AM LACTATE-1.6 ___ 05:02AM ___ PO2-41* PCO2-56* PH-7.34* TOTAL CO2-32* BASE XS-2 ___ 06:04AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 06:04AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:04AM URINE UHOLD-HOLD ___ 06:04AM URINE HOURS-RANDOM ___ 06:16AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 03:21PM ___ PO2-55* PCO2-45 PH-7.42 TOTAL CO2-30 BASE XS-3 ___ 05:59PM GLUCOSE-85 UREA N-10 CREAT-0.7 SODIUM-147 POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-21* ANION GAP-12 DISCHARGE ========= ___ 06:15AM BLOOD WBC-6.0 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91 MCH-30.1 MCHC-33.3 RDW-14.5 RDWSD-47.8* Plt ___ ___ 06:15AM BLOOD Glucose-117* UreaN-20 Creat-1.2 Na-145 K-4.3 Cl-101 HCO3-27 AnGap-17 IMAGING ======= ___ CXR: 1. Moderate pulmonary vascular congestion and edema. 2. Bibasilar opacifications likely reflect a combination of atelectasis and edema, however a superimposed pneumonia would be difficult to exclude. 3. New elevation of the left hemidiaphragm compared to ___. 4. Probable small left pleural effusion. Brief Hospital Course: Mr. ___ is a ___ w/ PMH HFpEF (EF 60%), COPD, AFib, CAD, OSA presenting acute on chronic dyspnea presenting with acute on chronic hypoxemic respiratory failure initially requiring BiPAP but quickly transitioned to O2 via NC and then room air with diuresis. ACUTE ISSUES ============ #Dyspnea #HFpEF exacerbation Reported dry weight from last hospitalization 155 lb. Trigger for exacerbation is unclear, possibly flash pulmonary edema in the setting of labile BPs versus dietary indiscretion with recent weight gain. He was direused with IV furosemide and transitioned to oral torsemide. #HTN - Continued home ___ (losartan instead of non-formulary olmesartan) - Held home carvedilol, labetalol due to bradycardia, started on amlodipine 5MG daily for BP control in ___ of these agents. CHRONIC ISSUES ============== #COPD No wheezing, fevers, chills, productive cough, or other signs/symptoms of COPD exacerbation this admission. #CAD #AS Mild AS on TTE from ___. - Continued aspirin, atorvastatin #AFib #S/p cardiac arrest Patient with PEA cardiac arrest on ___, felt to be ___ acute hypoxic respiratory failure, with negative cath and required temporary pacer. Now with LINQ monitor. AFib developed during that hospitalization. - Held rate control with home carvedilol as above - Continued rhythm control with amiodarone - Continued AC with apixaban TRANSITIONAL ISSUES =================== Discharge Wt: 160 lb Discharge Cr: 1.2 [] Patient was discharged on Torsemide 10MG daily, please continue to monitor volume status closely and recheck CHEM7 at PCP follow up. [] Both carvedilol and labetalol were on the patient's preadmission medication list. Both of these were held on discharge due to bradycardia to the low ___ throughout this admission. [] Started on amlodipine 5MG for BP control in the setting of stopping carvedilol/labetalol as above, consider increasing if BP is still elevated or decreasing if beta blockers are restarted. [] Isolated thrombocytopenia this admission to 110-130s, no signs/symptoms of bleeding, consider further workup as outpatient if persistent. [] Patient should be on BiPAP at night as outpatient, but has been non-compliant. Would continue to reinforce using this as his OSA is probably contributing to HTN issues and heart failure exacerbations. #CONTACT: ___ (Son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. olmesartan 40 mg oral DAILY 2. CARVedilol 6.25 mg PO BID 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Atorvastatin 80 mg PO QPM 6. Furosemide 20 mg PO DAILY 7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 8. Aspirin 81 mg PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. dutasteride 0.5 mg oral QHS 11. Ranitidine 150 mg PO DAILY 12. Labetalol 300 mg PO BID Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Torsemide 10 mg PO DAILY RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 8. dutasteride 0.5 mg oral QHS 9. olmesartan 40 mg oral DAILY 10. Ranitidine 150 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. HELD- CARVedilol 6.25 mg PO BID This medication was held. Do not restart CARVedilol until Follow up with your PCP/Cardiologist 13. HELD- Labetalol 300 mg PO BID This medication was held. Do not restart Labetalol until follow up with your PCP/Cardiologist Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on Chronic Diastolic Heart Failure Secondary: Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Atrial Fibrillation 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 having trouble breathing WHAT HAPPENED TO ME IN THE HOSPITAL? - Your trouble breathing what thought to be due to increased fluid in your body that backed up into your lungs. - You were treated with IV medications to help remove the fluid and were transitioned to a stronger medication called torsemide that you will continue to take on discharge. - Your home blood pressure medications were held due to your low heart rate and you were started on a new blood pressure medication. You should follow up with your PCP and your cardiologist about this. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Your weight at discharge is 160 lbs. Please weigh yourself today at home and use this as your new baseline. - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs in one week. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10046166-DS-16

DS

2132-12-10 00:00:00

2132-12-10 18:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) / Fosphenytoin Attending: ___ Chief Complaint: right hand weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ RH man with a PMHx significant for CAD s/p CABG and stent placement, DM2, HTN, HL who presents today with acute onset right hand weakness and numbness. He had been in his USOH until today, when he was walking on a treadmill at the gym prior to going to work. Approximately 45 minutes into his exercise, he noted that his right hand began to feel weak, stating that his grasp was progressively loosening on the handrail of the treadmill. He estimates that this continued for a 15 minute period during his workout. He also describes numbness, stating that his hand didn't feel "right". No headache, no visual changes, no nausea, no vomiting. He showered and was contemplating going to work, but was concerned about his hand, which was still not moving well. He then called his wife and drove home. There, his wife notified his PCP and the covering physician advised him to activate EMS and go to his local ED for urgent evaluation. EMS was activated but he declined transport, stating that he didn't want to go to his local OSH (he was coming from ___. His daughter therefore agreed to drive them to the ___ ED for urgent evaluation. Concerned about a stroke, a code STROKE was activated and the neurology team was invited to emergently consult. Past Medical History: 1. CAD s/p CABG in ___ and stent placement 2. HTN 3. HL 4. DM2 Social History: ___ Family History: Mother with dementia, brother with RA. Physical Exam: ADMISSION EXAM: Physical Examination: VS: T: 96.5 HR: 69 BP: 188/69 RR: 16 O2: 99% Genl: Awake, alert, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Abd: soft, NTND, NABS Ext: No lower extremity edema bilaterally Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect, though became appropriately tearful towards the end of exam. Oriented to person, place, and date. Attentive, says presidents backwards through ___ I. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. Reading intact. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Facial movement symmetric. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. Unable to perform finger tapping on right hand Del Tri Bi WE WF FE FF IP H Q DF PF R ___ ___ ___ ___ L ___ ___ ___ ___ Sensation: Intact to light touch, pinprick, vibration, position sense, and cold sensation throughout. No extinction to DSS. Reflexes: 1+ and symmetric throughout except UTO on b/l achilles. Toes downgoing bilaterally. Coordination: finger-nose-finger slow on right hand but without dysmetria. Gait: deferred. DISCHARGE EXAM Notable for weakness of the right hand, with inability to fully extend the fingers, and ___ FF, WE and WF. Pertinent Results: ADMISSION LABS: ___ 10:55AM BLOOD WBC-5.2 RBC-4.85 Hgb-14.2 Hct-41.8 MCV-86 MCH-29.4 MCHC-34.1 RDW-12.8 Plt ___ ___ 10:55AM BLOOD Neuts-64.5 ___ Monos-3.8 Eos-2.5 Baso-1.1 ___ 10:55AM BLOOD ___ PTT-28.0 ___ ___ 10:55AM BLOOD UreaN-22* ___ 10:55AM BLOOD Creat-1.1 ___ 10:55AM BLOOD ALT-15 AST-18 AlkPhos-85 TotBili-0.4 ___ 10:55AM BLOOD TotProt-7.0 Albumin-4.3 Globuln-2.7 Calcium-9.6 Phos-3.0 Mg-1.7 ___ 11:04AM BLOOD Glucose-177* Na-139 K-4.7 Cl-104 calHCO3-22 DISCHARGE LABS: ___ 05:45AM BLOOD WBC-5.5 RBC-4.46* Hgb-13.0* Hct-39.9* MCV-90 MCH-29.1 MCHC-32.5 RDW-12.5 Plt ___ ___ 05:45AM BLOOD Glucose-131* UreaN-12 Creat-0.8 Na-142 K-3.6 Cl-107 HCO3-27 AnGap-12 ___ 05:45AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.8 ___ 05:25AM BLOOD %HbA1c-7.6* eAG-171* ___ 05:25AM BLOOD Triglyc-122 HDL-40 CHOL/HD-3.9 LDLcalc-90 IMAGING: CTA Head and neck: IMPRESSION: 1. Left frontal lobe parenchymal hemorrhage, with no evidence of underlying AVM or other vascular abnormality. 2. No CTA "spot sign" indicating active contrast extravasation to suggest risk of rapid expansion. 3. Persistent central relative low-attenuation with concerning for cystic necrosis within an underlying mass (though none is definitely seen), given the findings, below. 4. Large superior mediastinal conglomerate lymph node mass, as well as right hilar lymphadenopathy. Findings are concerning for underlying malignancy, perhaps bronchogenic, with hemorrhagic brain metastasis MRI brain w/ and w/o contrast: IMPRESSION: 1.Left frontal intraparenchymal hemorrhage with pronounced ___ edema and central enhancing lesion that most likely represents a metastatic focus. 2. No evidence of additional enhancing masses. 3. Several subcortical foci of microhemorrhage for which differential considerations include long standing anti-coagulation or amyloid disease among others. CT Chest/Ab/Pelvis: IMPRESSION: 1. Large necrotic mediastinal and hilar lymph nodes. 2. Solitary non-calcified right lower lobe 6 mm pulmonary nodule. 3. Calcifications within the spleen, hilum and a pulmonary nodule are consistent with old granulomatous disease, likely histoplasmosis. 4. Essentially normal exam of the abdomen and pelvis. Brief Hospital Course: Mr. ___ is a ___ RH man with a PMHx significant for CAD s/p CABG and stent placement, DM2, HTN, HL who presented on ___ with acute onset right hand weakness and possible numbness who was found to have left frontal intraparenchymal hemorrhage. Etiology of hemorrhage was thought to be from a malignancy. He was admitted for observation and management of his bleed and BP. . # Neuro: On his CTA in the ED he was incidentally found to have 2 large lymph nodes concerning for malignancy. His aspirin was held. His MRI brain showed no evidence of microhemorrhage making amyloid a less likely cause of his hemorrhage, and given the lymph nodes noted on CTA, he underwent a CT torso to evaluate for possible primary malignancy. . # CARDS: While here we treated pt with PRN hydralazine for SBP >160. We continued his lisinopril. His SBP was occasionally in the 160's so we increased his metoprolol to 50mg BID (from metoprolol succinate 75mg QD). We stopped pt's simvasatin given possible increased risk of bleeding. On ___ he experienced an episode of chest pain that felt "just like" his usual stable angina pain when he exercises. His cardiac enzymes were negative x2, and no changes on EKG. As we had just recently explained we were looking for a malignancy, and he was very anxious about this, it was presumed that the anxiety elevated his HR to the level it normally is to activate his stable angina. . # PULM: patient's CTA incidentally showed 2 large lymph nodes that were concerning for malignancy. He then underwent a CT torso, which confirmed the CTA findings as well as showed mulitple calcifications likely from a old histoplasmosis infection. He underwent a broncoscopy guided biopsy of his paratracheal node on ___. This necessitated general anethesia. The results of this biopsy are still pending . # ENDO: patient's HGA1C was 7.6, indicating that he may need tighter glucose control at home. While here because he was got multiple CT's with contrast, we held his home glycemic oral medications and treated him with an ISS. His home metformin was restarted on discharge . # Prophylaxis: -PPX: famotidine and pneumoboots (HELD subq heparin) . # CODE/CONTACT: FULL as confirmed with patient. HCP: wife ___: cell: ___. home: ___. Daughter ___: ___ PENDING LABS: Final biopsy results TRANSITIONAL CARE ISSUES: Patient will need to arrange for hematology/oncology follow-up. He was given the number to arrange this and told it was very important to follow-up for the results of his biopsy. Medications on Admission: Aspirin 325 mg Tab 1 Tablet(s) by mouth once a day lisinopril 40 mg Tab one Tablet(s) by mouth once a day simvastatin 40 mg Tab 1 Tablet(s) by mouth once a day Glipizide SR 10mg 24 hr Tab (dose uncertain) Metformin 500mg BID metoprolol succinate ER 50 mg 24 hr Tab ___ Tablet(s) qday Discharge Medications: 1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. glipizide 10 mg Tablet Extended Rel 24 hr Oral 6. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety for 1 weeks: DO NOT DRIVE UNTIL YOU KNOW HOW THIS MEDICATION EFFECTS YOU. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Intracerebral hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. NEURO EXAM: RUE distal extensor weakness Discharge Instructions: Dear Mr. ___, You were seen in the hospital because of hand weakness and were shown to have had a small bleed in your head. While here, we did an MRI which showed the same small bleed. We are not sure what caused this bleed. We made the following changes to your medications: 1) We CHANGED your METOPROLOL SUCCINATE to METOPROLOL TARTRATE at 50mg twice a day. 2) We STARTED you on ATIVAN 1mg every 4 hours as needed for anxiety for a 1 week supply. Do not drive while taking this medication as it can make you dangerously sleepy. Do not drink alcohol or take any other sedating medications as this can also make you dangerously sleepy. 3) We DECREASED your ASPIRIN to 81mg once a day. We want you to ONLY RESTART THIS ON ___. DO NOT RESTART THIS PREVIOUSLY. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: ___

10046166-DS-19

DS

2133-03-24 00:00:00

2133-03-24 17:15:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) / Fosphenytoin Attending: ___. Chief Complaint: hypoglycemia Major Surgical or Invasive Procedure: none History of Present Illness: HPI: ___ yo M with HTN, DM2 on oral agents, melanoma with mets to brain s/p L sided craniotomy with resection of met, cyberknife treatment, and recent completion of whole brain radiation on steroids, h/o seizures with recent admission (___) who was routinely checking blood sugar this morning and had a fingerstick of 29. Repeat testing by patient and EMTs confirmed hypoglycemia even after breakfast and he was referred to the ED. He was asymptomatic throughout with no sweating, palpitations. He did have some seizure activity this morning (shaking right hand) Of note, his metoprolol dose was doubled on his last admission. His fingersticks were running in the 150-180s the day before. He has been following a low carb diet in an effort to improve glucose control. No other new symptoms. He continues to have loose stools up to 5 per day without associated abd pain, fevers. In ER: (Triage Vitals: 97.7 84 140/67 16 97%RA) Meds Given: D50, levetiracetam, dexamethasone, Fluids given: 2L NS, Radiology Studies: R nodule, no acute process. . Past Medical History: PAST ONCOLOGIC HISTORY: - ___: noted weakness in his right arm progressively going into loss of sensation --> ___ ED - CT revealed a 2.9 x 1.6 parenchymal hemorrhage in the superior left frontal lobe with surrounding vasogenic edema and sulcal effacement.A focal hypodensity within the central portion of this hemorrhage could represent clotted active hemorrhage; however, this is not confirmed by post-contrast CTA images. - MRI showed left frontal intraparenchymal hemorrhage with pronounced perilesional edema and central enhancing lesion that most likely represent metastatic focus. - ___ - CT torso eval showed a large mediastinal mass measuring 40 x 33 mm, heterogeneously enhancing lymph node or conglomerate of lymph nodes. There is a right hilar lymph node, which measured 17 x 15 mm. In the right lower lobe, is a 6-mm round pulmonary nodule adjacent to pleural surface that could represent underlying lung cancer. - ___ - bronchoscopy to eavluate LN in mediastinus revealed metastatic melanoma. - see in neuro-onc group and in biologic therapy clinic - Left sided craniotomy for resection of met by Dr ___ on ___ - ___ - single fraction CyberKnife treatment to his right parietal resection cavity (at 1800 cGY and 79% isodose) - ___ - focal seizures of right hand started - ___ - Brain MRI shows two brain lesions with vasogenic edema and hemorrhage. - hospitalized with seizures (___) - whole brain radiation completed ___ - divalproex added for ongoing seizures . PAST MEDICAL HISTORY: CAD status post CABG in ___ and stent placement squamous cell carcinoma of the skin hypertension hyperlipidemia diabetes type 2 cholecystectomy Social History: ___ Family History: Mother with dementia. Brother with rheumatoid arthritis. Maternal grandfather with pancreatic cancer. Physical Exam: admission exam T 97.0 P 79 BP 176/60 RR 16 O2Sat 96 RA ___- 403 GENERAL: alert, pleasant, sitting in chair, mentating clearly Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted Ears/Nose/Mouth/Throat: +++ oral thrush, upper dentures Neck: supple, no JVD appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: Reg S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or organomegaly noted. Genitourinary: no flank tenderness Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: R upper extremity with ___ strength, normal bulk. No abnormal movements noted. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: pleasant and interactive . discharge exam VS: 95.4 112/68-160/70 ___ 20 95% RA GENERAL: alert, pleasant, sitting in chair, mentating clearly HEENT: no scleral icterus, MMM Respiratory: Lungs CTA bilaterally Cardiovascular: Reg S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or organomegaly noted. Skin: no rashes or lesions noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses b/l. Neurologic: Alert, oriented x 3. Pleasant and interactive Pertinent Results: admission labs ___ 11:00AM BLOOD WBC-11.6* RBC-4.40* Hgb-13.1* Hct-37.9* MCV-86 MCH-29.8 MCHC-34.6 RDW-15.0 Plt ___ ___ 11:00AM BLOOD Neuts-94.2* Lymphs-3.6* Monos-1.9* Eos-0.2 Baso-0 ___ 11:00AM BLOOD Glucose-47* UreaN-52* Creat-1.1 Na-130* K-5.7* Cl-95* HCO3-11* AnGap-30* ___ 11:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9 ___ 01:59PM BLOOD K-5.1 ___ 10:19PM BLOOD Lactate-5.3* . other pertinent labs ___ 01:30PM BLOOD VitB12-___ ___ 06:30AM BLOOD TSH-0.23* . discharge labs ___ 06:30AM BLOOD WBC-7.3 RBC-4.49* Hgb-13.1* Hct-39.1* MCV-87 MCH-29.1 MCHC-33.5 RDW-15.3 Plt ___ ___ 06:30AM BLOOD Neuts-91.8* Lymphs-4.6* Monos-3.0 Eos-0.6 Baso-0.1 ___ 06:30AM BLOOD ___ PTT-20.8* ___ ___ 06:30AM BLOOD Glucose-274* UreaN-32* Creat-0.9 Na-134 K-4.6 Cl-99 HCO3-27 AnGap-13 ___ 06:30AM BLOOD ALT-17 AST-10 AlkPhos-50 TotBili-0.5 ___ 06:30AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9 . micro 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. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . blood cx x 2 pending at time of discharge . studies ECG: Sinus rhythm. Possible prior inferior infarction with slurring of the intial forces in leads III and aVF. Probable anterior myocardial infarction as well. The rate has slowed as compared with previous tracing of ___ and the lateral ST-T wave abnormalities persist without diagnostic interim change. . CXR FINDINGS: Frontal and lateral views of the chest were obtained. Rounded calcified nodule in the region of the posterior right lung base is seen and represents calcified granuloma on CTs dating back to ___, likely secondary to prior granulomatous disease. Previously seen pretracheal lymph node conglomerate and right hilar lymph nodes are better seen/evaluated on CT. No focal consolidation is seen. There is no pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are stable with possible slight decrease in right paratracheal prominence. IMPRESSION: No radiographic findings to suggest pneumonia. Brief Hospital Course: ___ yo M with DM2 on oral agents with labile blood sugars, melanoma with mets to brain on steroids, recently completed whole brain irradiation, HTN presents with hypoglycemia. . # DM2: poorly controlled (last A1c 9.2) and likely exacerbated by steroids. Patient hypoglycemic on presentation with lactic acidosis. Patient given D50 in the ED and finger sticks improved to the 200s-400s. Electrolytes improved with IVF. Oral hypoglycemics were discontinued. ___ was consulted. Patient was started on insulin regimen which was titrated during admission. He was discharged on levemir 12 units BID and 7 units of humalog with meals with an additional sliding scale as needed. He will need to be seen in ___ within 1 week of discharge. . # Anion Gap Metabolic acidosis - Patient presented with anion gap metabolic acidosis. This was likely secondary to lactic acidosis (lactate 5.3 initially) which may be due to high metformin dosing. Patient given IVF and lactate trended down and gap closed. . # Hyperkalemia: K was 6.4 on presentation. ECG showed more pronounced T waves in v1-v4. Patient was given kayexalate on admission and acidosis was corrected. ACE inhibitor was initially held, but was restarted at a lower dose of 10mg daily. Potassium normalized prior to discharge. . # Hyponatremia: Patient appeared hypo/euvolemic on exam. Sodium low in the setting of high sugars, however, remained low despite correction of glucose. Hyponatremia likely related to hypovolemia as it improved with IVF to within normal range. . # HTN: Continued metoprolol. Initially held lisinopril and blood pressures remained stable mostly in 110s-140 systolic. When K normalized, lisinopril was restarted at a lower dose of 10 mg daily. This can be uptitrated as blood pressure and potassium levels allow. . # Metastatic melanoma with brain mets: Recently completed whole brain irradiation. Patient continued on dexamethasone 4 mg every 6 hours. . # Seizures: characterized by right hand/arm shaking and right eye drooping lasting ___ minutes. Last seizure on morning of presenation. He was continued on levetiracetam and divalproex. . # CAD - continued beta blocker, statin. ACE inhibitor restarted prior to discharge. Aspirin had been discontinued as an outpatient and did not restart during this admission. . # Diarrhea: Stool studies negative for infection. Patient treated with immodium prn with relief. . # Oral thrush: likely related to steroids. Patient denied odynophagia. He was started on fluconazole 200 mg daily. He was discharged with plans to complete a 2 week course. . # Leukocytosis: Patient had no fevers or localizing symptoms of infection. Leukocytosis likely related to high dose steroids. Urine culture negative. Blood cultures with no growth at time of discharge. . Transitional Issues - patient will need close follow up at ___. His insulin regimen will likely need further adjustment - lisinopril dose lowered from 40 to 10 mg daily as he was normotensive when the lisinopril was held due to hypokalemia. This can be uptitrated as blood pressure and potassium allows. - patient reported diarrhea for 3 months. Infectious etiologies were ruled out. He was started on immodium with symptomatic relief. This may need further outpatient investigation - TSH was low, this will need to be rechecked at follow up - patient was started on a 2 week course of fluconazole for thrush - patient was full code on this admission Medications on Admission: pioglitazone 15mg glipizide 20mg BID metformin 1500mg BID atovaquone solution 1500mg daily divalproex delayed release 500mg BID levetiracetam 1000mg TID sertraline 50mg daily metoprolol 50mg bid nitro SL prn simvastatin 40 mg daily lisinopril 40mg daily dexamethasone 4mg q 6 hours (taper to 2mg on ___ alprazolam 0.5mg qAM, 0.25mg qPM cialis 20mg q 3 days omeprazole 20mg daily aspirin 81mg (recently discontinued) Discharge Medications: 1. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous use as directed. Disp:*1 kit* Refills:*0* 2. FreeStyle Lite Strips Strip Sig: One (1) box Miscellaneous use as directed. Disp:*qs units* Refills:*2* 3. Levemir Flexpen 100 unit/mL (3 mL) Insulin Pen Sig: One (1) injection Subcutaneous twice a day: please refer to your insulin sliding scale. Disp:*qs units* Refills:*0* 4. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1) injection Subcutaneous use as directed: please refer to your insulin sliding scale. Disp:*qs units* Refills:*0* 5. BD Insulin Pen Needle UF Short 31 X ___ Needle Sig: One (1) needle Miscellaneous use as directed: please refer to the insulin sliding scale. Disp:*qs needles* Refills:*0* 6. Ketostix Strip Sig: One (1) strip Miscellaneous once a day as needed for for glucose > 250. Disp:*1 box* Refills:*0* 7. equipments one hemiwalker 8. equipments one wheelchair 9. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY (Daily). 10. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*100 Tablet(s)* Refills:*0* 15. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 16. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 17. Cialis 20 mg Tablet Sig: One (1) Tablet PO every ___ (72) hours. 18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 19. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:*14 Tablet(s)* Refills:*0* 20. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Capsule(s) 21. diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 22. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 23. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary diagnosis: hypoglycemia secondary diagnosis: metastatic melanoma, type 2 diabetes, hypertension, coronary artery disease 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 while you were admitted to ___. You were admitted because you were found to have very low blood sugars. You were given sugar in the emergency room and treated with intravenous fluids. Your electrolyte abnormalities were corrected. You were evaluated by the diabetes specialist team from ___ and ___ were started on insulin to help better control your blood sugars. . The following changes have been made to your medication regimen. Please START taking - levemir 12 units twice daily - humalog 7 units before meals and as directed by sliding scale - fluconazole 200 mg daily for 2 weeks for thrush . Please STOP taking - metformin - pioglitazone - glipizide . Please CHANGE - lisinopril from 40 to 10 mg daily (your doctor may increase this dose in the future as your blood pressure and potassium tolerates) . Please have your electrolytes checked on ___ when you follow up with Dr. ___ in clinic Followup Instructions: ___

10046166-DS-21

DS

2133-09-20 00:00:00

2133-09-21 09:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) / Fosphenytoin Attending: ___. Chief Complaint: status post fall Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ M with melanoma c/b brain mets s/p whole brain radiation and cyberknife, who presents with worsening instability and generalized shaking with 2 episodes of near syncope. His neurological problem began on ___ when he was exercising on a treadmill. He noticed a subacute loss of function in the right hand over ___ minutes that eventually rendered the right hand non-functional. This happened at about 07:30 a.m. He had slight nausea but no vomiting. He came to the emergency department at ___ and a head CT showed hemorrhage in the left frontal brain. A subsequent head MRI showed an enhancing mass with hemorrhage. He was admitted to NeuroMedicine Service, placed on dexamethasone, and a torso CT on ___ revealed a necrotic mediastinal mass with hilar lymphadenopathy. He underwent a mediastinoscopy with biopsy on ___ that eventually showed metastatic melanoma. He was discharged from the hospital on ___. He saw Dr. ___ from medical oncology during his hospital stay. He later underwent an FDG-PET that showed the FDG-avid disease at mediastinum and left frontal brain; in addition, he also had another FDG-avid lesion in the left lateral pelvis adjacent to bowel thought to represent and inflammed diverticula. He then underwent a surgical resection of a left frontal melanoma brain metastasis on ___ by ___, followed by CyberKnife radiosurgery to 1,800 cGy at 79% isodose line on ___. He started whole brain cranial irradiation on ___. He was admitted to the OMED Service at ___ for focal motor seizures in the right upper extremity from ___ to ___. He was hospitalized again in ___ from ___ to ___ for hypoglycemia and metformin-induced lactic acidosis. Over the course of ___, a new metastatic lesion was identified in the left occipital lobe following which he received stereotactic radiosurgery to that region. Since that time he was doing well but intermittent had instability and generalized weakness. His wife reports that he has been shaky and somewhat confused for several weeks. Last week he completed a course of cyberknife for his frontal lesion. Today, he felt that his problems on weakness and instability worsened. He was going to breakfast with his wife and when attempted to get out of the car. He had a moment of freezing and looked unwell and states that he felt as if he was going to pass out but didnt. He then proceeded to go to the restaurant but afte rsitting down continued to have this presyncopal sensation. He endorsed nausea and some lightheadedness. He went back to the car and his wife brought him home. At that point he was so generally weak that his son needed to bring him up to bed. He slept several hours and his wife decided to bring him in. At 3 pm, when she woke him up, he felt much better and walked to the car himself. He was reportedly back to baseline. He did not have LOC with these episodes or anywhere in between. There was no rythmic shaking, tongue biting or incontinence. He remembers every episode quite well. He does not feel any different now than his did yesterday. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal 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: Past Medical History: He has ___ year history of type II diabetes. He has hypercholesterolemia and hypertension but no COPD. Past Surgical History: He had CABG x 4 vessels, cholecystectomy, and 2 mohs procedures (one at right forehead and the other at left upper lip), and removal of 3 cysts from the scalp. Social History: ___ Family History: Mother with dementia. Brother with rheumatoid arthritis. Maternal grandfather with pancreatic cancer. Physical Exam: Physical Exam on Admission: Vitals: T:97.6 P:60 R: 16 BP: 138/64 SaO2: 95%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 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. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history but somewhat confused as to the timeline. Attentive but not able to name ___ backward. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia ? neglect of the right side. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to finger counting III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Pronator drift on the right. High amplitude coarse tremor b/l worse on the right. No asterixis noted. ___ throughout except for the following: RUE ___ movement in finger flexors, 4+/5 strength in biceps, ___ strength in triceps, ___ strength in deltoid. RLE: IP 4+/5 TA ___ -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was mute bilaterally. -Coordination: High amplitude intention tremor, unable to perform on the right, no clear dysmetria on FNF on the left. -Gait: defered Physical Exam on Discharge: afebrile, vital signs stable Relevant for right hemiparesis with 4+ hamstring, TA, ___ ___ in delts, triceps, finger extensors/flexors. Coarse intention tremor in the right UE, intention and postural Grasp reflex b/l, R>L gait: steady, narrow based Pertinent Results: Labs on Admission: ___ 06:45PM WBC-7.2 RBC-3.52* HGB-10.6* HCT-31.4* MCV-89 MCH-30.2 MCHC-33.9 RDW-15.3 ___ 06:45PM NEUTS-89.4* LYMPHS-6.6* MONOS-3.6 EOS-0.2 BASOS-0.2 ___ 06:45PM VALPROATE-61 ___ 06:45PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-1.9 ___ 06:45PM GLUCOSE-216* UREA N-30* CREAT-1.0 SODIUM-134 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18 ___ 06:49PM GLUCOSE-204* LACTATE-2.7* ___ 08:19PM ___ PTT-26.5 ___ ___ 08:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 08:45PM URINE RBC-38* WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 08:45PM URINE HYALINE-4* ___ 08:45PM URINE MUCOUS-RARE Imaging: Chest x-ray Upright AP and lateral chest radiographs were obtained. The lungs are low in volume, which obscure the right lower lung calcified granuloma. No focal consolidation is seen. There is no pleural effusion or pneumothorax. The heart is normal in size with post-surgical changes including intact mediastinal wires. IMPRESSION: No acute intrathoracic process. Non contrast head CT FINDINGS: New hemorrhage with a hematocrit level is seen in a 17 x 20 mm focus of metastasis in the left frontal lobe (2:18) along with hemorrhage in a left parietal metastasis, measuring 14 x 9 mm. Additional metastatic lesions with and surrounding vasogenic edema are unchanged in the right frontal and left frontoparietal and occipital lobes. Dense left periventricular metastasis is also unchanged. No definite other metastatic deposits are seen, though MR is more sensitive. The ventricles and sulci remain minimally prominent, compatible with age-related involutional changes. Gray-white matter differentiation is otherwise preserved. There is no shift of normally midline structures. Imaged osseous structures are unremarkable with post-craniotomy changes in the left frontoparietal region. Soft tissues are unremarkable. Imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Hemorrhage in left frontal and left parietal metastatic lesions as described above. Brief Hospital Course: Mr. ___ is a ___ yo man with known melanoma and brain mets s/p cyber-knife and several doses of Whole brain radiation who presents with acute on chronic unsteadiness and fall. # Neuro: Patient was with his wife day prior to admission on his way to a restaurant. In the car, he had some abdominal pian. When he was stepping out of hte car he felt weak and fell down. He went ot the restaurant, and there, felt lightheaded and nauseaous, like he was going to pass out. His exam relevant for right sided hemiparesis, RUE tremor, neuropathy in his feet b/l (chronic per patient and wife) as well as bilateral grasp reflex. Most relevant is that he was profoundly orthostatic. Most likely, his fall was in the setting of orthostatic hypotension which fits with presyncopal symptoms. On imaging, CT head ___ and ___ show a new hemorrhagic left anterior rontal lobe lesion not seen on prior ___ MRI head. Mr. ___ was treated with 1 L NS bolus and asked to discontinue lisinopril. He was back to baseline on discharge. He will follow up with ___ clinic with Dr. ___. # Cardio: Orthostatic hypotension as above. Discontinued lisinopril. Patient was offerred ___ services for BP monitoring, but declined. Will monitor himself. TRANSITIONS OF CARE: - will f/u in ___ clinic Medications on Admission: 1. ALPRAZolam 0.25 mg PO TID 2. Atovaquone Suspension 750 mg PO DAILY 3. Dexamethasone 2 mg PO DAILY 4. Divalproex (DELayed Release) 500 mg PO BID 5. LeVETiracetam 1000 mg PO TID 6. Omeprazole 20 mg PO DAILY 7. Simvastatin 40 mg PO DAILY 8. Sertraline 50 mg PO DAILY 9. insulin detemir *NF* 100 unit/mL Subcutaneous BID per your sliding scale 10. HumaLOG KwikPen *NF* (insulin lispro) 100 unit/mL Subcutaneous per sliding scale per sliding scale 11. Nitroglycerin SL 0.4 mg SL PRN chest pain take once per day as needed for chest pain; if persists, call your doctor or 911 12. DiphenhydrAMINE 50 mg PO HS 13. Lisinopril 5mg PO qd Discharge Medications: 1. ALPRAZolam 0.25 mg PO TID 2. Atovaquone Suspension 750 mg PO DAILY 3. Dexamethasone 2 mg PO DAILY 4. Divalproex (DELayed Release) 500 mg PO BID 5. LeVETiracetam 1000 mg PO TID 6. Omeprazole 20 mg PO DAILY 7. Simvastatin 40 mg PO DAILY 8. Sertraline 50 mg PO DAILY 9. insulin detemir *NF* 100 unit/mL Subcutaneous BID per your sliding scale 10. HumaLOG KwikPen *NF* (insulin lispro) 100 unit/mL Subcutaneous per sliding scale per sliding scale 11. Nitroglycerin SL 0.4 mg SL PRN chest pain take once per day as needed for chest pain; if persists, call your doctor or 911 12. DiphenhydrAMINE 50 mg PO HS Discharge Disposition: Home Discharge Diagnosis: Orthostatic hypotension Melanoma metastatic to the brain, new lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after you felt light headed and fell. This fall was most likely due to dehydration and lowering of your blood pressure with standing. At home, please be careful to be hydrated. We offered to have a visiting nurse ___ come periodically to check your blood pressure. You preferred to do this yourself, which fine. If you blood pressures are less than 100/60, please drink more fluids and recheck later in the day. If it continues to be low, please call your doctor. We checked you for an infection as well, and you did not have one. As we discussed, you have a new metastatic lesion in your brain. Please follow up with Dr. ___ neuro-oncologist, as scheduled below, to discuss this further. We have made the following changes to your medications: STOP taking Lisinopril (since your blood pressure is low) Please attend your follow up appointments as listed below. It was a pleasure taking care of you, we wish you all the best! Followup Instructions: ___

10046241-DS-18

DS

2142-05-25 00:00:00

2142-05-30 20:13:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, malaise, vomiting, diarrhea Major Surgical or Invasive Procedure: EGD ___ ERCP ___ History of Present Illness: ___ year old male with history of alcoholism, HTN, new diagnosis of diabetes here with 2 weeks of generalized weakness, malaise, and 1 week of vomiting and diarrhea. Reports at recent PCP appointment was told he might be diabetic but has not started any meds. Went to urgent care on ___ where he was given zofran and cyclobenzabrine for abdominal cramping and told that he had the flu. He denies ever having a flu swab. The patient has not had any tamiflu. The patient says that on 1 day prior to admission he was unable to walk to the bathroom without becoming extremely exhausted. The patient called his PCP on ___ morning and was told to come to the emergency room. Of note the patient's creatinine on ___ was 0.8. Patient increased his Lisinopril from 10mg to 20mg on the ___. On arrival to the ED the patient was found to have vitals of 0 97.5 88 77/44 16 92% RA. Patient bolused fluids and his blood pressure improved. The patient's labs were significant for a transaminitis, Cr of 6.2, Na of 129 and hyperbilirubinemia of 2.1. The patient was seen by the GI team. US showed mild dilation in bile duct, but no active signs of cholecystitis. On arrival to the floor patient's vitals were 97.8 110/60 85 18 94 RA. Patient was anxious but not in acute distress. 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: Chronic HYPERCHOLESTEROLEMIA BPH HYPERTENSION - ESSENTIAL, BENIGN FATTY LIVER ESOPHAGEAL REFLUX Sleep apnea Alcoholism Type 2 diabetes mellitus, uncontrolled Social History: ___ Family History: Father passed away of bladder cancer Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.8 110/60 85 18 94 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly; no stigmata of liver disease Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes, scars or legions Neuro: WNL DISCHARGE PHYSICAL EXAM: ======================== Vitals: 97.9 Tmax 98.2 131/80 (___) 88 20 97 RA lying 140/93 86 sitting 142/90 95 standing 146/99 102 General: Alert, oriented, no acute distress HEENT: icteric sclera, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, ___, mildly distended, bowel sounds present but soft, no rebound tenderness or guarding, no organomegaly; no stigmata of liver disease Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: jaundiced; no rashes, scars or legions Neuro: WNL Pertinent Results: ADMISSION LABS: =============== ___ 09:20AM ___ ___ ___ 09:20AM PLT ___ LOW PLT ___ ___ 09:20AM ___ ___ ___ 09:20AM ___ ___ ___ 09:20AM ___ ___ ___ 09:20AM ___ ___ 09:20AM ___ ___ 09:20AM ALT(SGPT)-99* AST(SGOT)-87* ALK ___ TOT ___ DIR ___ INDIR ___ ___ 09:20AM ___ this ___ 09:20AM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 09:35AM ___ ___ 09:35AM ___ NA+-133 K+-3.5 CL--84* ___ ___ 09:20PM PLT ___ ___ 09:20PM ___ ___ ___ 09:20PM ___ ___ 09:20PM ___ ___ ___ 09:20PM ALT(SGPT)-83* AST(SGOT)-90* LD(LDH)-696* CK(CPK)-464* ALK ___ TOT ___ DIR ___ INDIR ___ ___ 09:20PM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 09:43PM ___ ___ 09:43PM ___ TOTAL ___ BASE ___ ___ 10:10PM URINE ___ ___ 10:10PM URINE ___ UREA ___ ___ DISCHARGE LABS: =============== ___ 06:25AM BLOOD ___ ___ Plt ___ ___ 06:35AM BLOOD ___ ___ ___ 06:25AM BLOOD Plt ___ ___ 06:50AM BLOOD ___ ___ ___ 06:25AM BLOOD ___ ___ ___ 06:25AM BLOOD ___ LD(LDH)-519* ___ ___ ___ 06:35AM BLOOD ___ ___ 06:25AM BLOOD ___ ___ ___ 06:25AM BLOOD ___ TH ___ ___ 06:25AM BLOOD ___ ___ 02:45PM BLOOD ___ MICROBIOLOGY: ============= ___ 9:20 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ======== Cardiovascular ReportECGStudy Date of ___ 9:27:14 AM Baseline artifact. Sinus rhythm. Intraventricular conduction delay. Mild ST segment elevation in leads V2, V5 and V6 of uncertain significance. No previous tracing available for comparison. Clinical correlation is suggested. Read ___. ___ ___ CXR IMPRESSION: No acute cardiopulmonary process. ___ Renal US IMPRESSION: No hydronephrosis or focal renal lesion. ___ RUQUS IMPRESSION: 1. Mild intrahepatic biliary ductal dilation partially imaged without evidence of acute cholecystitis. Gallbladder sludge without definite stones seen. GI consultation advised with possible MRCP or ERCP to further assess potential cause for biliary obstruction. 2. Markedly echogenic liver likely due to fatty deposition. Please note, more advanced forms of liver disease cannot be excluded on the basis of this appearance. Radiology ReportMRI ABDOMEN W/O CONTRASTStudy Date of ___ 8:24 AM IMPRESSION: 1. Findings suggestive of hemorrhage within the pancreatic head tracking along the mesentery and duodenum may be secondary to pancreatitis, however underlying pancreatic mass cannot be excluded. 2. Increased T1 signal within the right and left bile ducts suggestive of hemobilia. 3. Diffuse hepatic steatosis. Radiology ReportCT ABD W&W/O CStudy Date of ___ 4:30 ___ IMPRESSION: 1. Necrotizing pancreatitis, predominately involving the pancreatic head. Underlying neoplasm cannot be excluded and repeat imaging is suggested after acute issues resolve. Extensive surrounding inflammation with duodenitis. No discrete fluid collection. 2. Nonocclusive thrombus within the main portal vein, intrahepatic portal venous branches, splenic vein and possibly the SMV with occlusion of the portal confluence. Perigastric and paraesophageal varices. 3. No evidence of arterial pseudoaneurysm. ___ ERCP with stent placed in CBD Impression: Edema, erythema and congestion in the duodenum compatible with duodenitis likely ___ pancreatitis The major papilla appeared normal. The surrounding duodenal mucosa was edematous and obscured the papilla. The scout film was normal. The bile duct was deeply cannulated with the sphincterotome. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. There was a 3cm stricture in the ___ with ___ dilation. This is likely secondary to external compression from severe acute pancreatitis in the head of the pancreas. The CBD was 9mm in diameter proximally. No other filling defects identified. Opacification of the gallbladder was incomplete. Given the significant surrounding duodenitis and the history of upper GI bleed, a biliary sphincterotomy was not performed. A ___ x 7cm plastic CBD stent was placed across the stricture successfully. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum Brief Hospital Course: ___ year old male with history of alcoholism, HTN, new diagnosis of diabetes here with 2 weeks of generalized weakness, malaise, and 1 week of vomiting and diarrhea. Found to have acute renal failure, pancreatitis, transaminitis and hyperbilirubinemia with concern for a gall stone in bile duct/pancreatic duct. Patient started on IVF with goal UOP >1cc/kg/hr and made NPO. Patient had melena on day 1 on admission and started on PPI IV gtt. H/H decreasing initially with fluid boluses but stabilized on day ___ of admission. MRCP on day 1 without contrast showed concern for pancreatitis of the head of the pancreas and cannot rule out underlying mass. Patient evaluated by both ERCP and Gastroenterology and determined for ___ ERCP w/EUS and EGD. Both procedures occurred on ___ showing no active bleeding in the stomach. ECRP showed no gallstones in either tracts but evidence of pancreatitis constricting the common bile duct. A single stent was placed without complication. Please see procedure note for full details. Patient had no complications after procedure. On ___ patient had rising WBC count and had CT w/wo contrast showing hemorrhagic pancreatic necrosis, however no active bleeding, and also evidence of portal thrombosis and splenic vein thrombosis. Patient's crits were stable and WBC trending down at time of discharge. Patient ___ follow up with Atrius Gastroenterology and see Dr. ___ as an outpatient. The patient ___ also follow up with Dr. ___ surgery. Patient's ___ fully recovered with IVF hydration with creatinine and BUN returning to baseline (cr<1). Patient's ___ held initially, however was hypertensive in the post procedure setting. Patient starting on Labetalol and Lisinopril for mngt of his blood pressure. Patient tolerated full diet on ___ with improvement of lab values and clinical improvement. Patient ___ follow up with his PCP and with ___ new Gastroenterologist after discharge. ACUTE ISSUES # Pancreatitis with associated Transaminitis/Hyperbilirubinemia The patient's transaminitis and hyperbilirubinemia are acutely elevated. The differential for his LFT abnormalities include cholelithiasis, hypotension, alcohol, autoimmune, wilsons, hypothyroidism, malignancy or infection. It is likely multifactorial in etiology. On ___ MRCP showed possible mass at the head of the pancreas with atrophy of the body and tail. The patient had evidence of gall bladder dilation without evidence of gallstones. The patient ERCP/EUS showed evidence of acute pancreatitis at the head of the pancreas and cannot rule out an underlying mass. The patient had a single stent placed in the CBD to allow for drainage. The patient transaminitis and hyperbilirubinemia decreased after placement of the stent. On ___ the patient had resolving labs, except for increasing white count. CT with contrast was completed showing hemmoragic pancreatic necrosis of the head of the pancreas with drainage into the bile duct/intestinal tract. The patient's H/H trended down slowly. This finding on CT is very suggestive of acute pancreatitis and cannot rule out underlying mass. F/u MRI in ___ weeks after inflammation decreases to evaluate for underlying mass. CA 125 elevated to 210 and Ca ___ elevated to 116. Viral serologies negative. Patient evaluated by the pancreatic surgery team due to necrosis noted on CT scan. He ___ follow up with At___, Dr. ___ and Dr. ___ after discharge. It was emphasized to the patient that in order to prevent recurrence the patient must abstain from alcohol. # Hypertension Patient has hypertensive prior to discharge, likely in the setting of holding home ___ combined with alcohol withdrawal and andrenergic tone from pancreatitis. Patient has adequate control of blood pressures with labetalol and lisinopril. ___ need to be readdressed as outpatient. Patient started on labetalol 200mg PO BID and Lisinopril 20mg PO Daily. # Melena/GI Bleed Patient began having melanotic stools on ___ with symptoms of orthostasis and mild lightheadedness. Resting heart rate was around 100 BPM on exam/interview on ___. Patient claimed that he had taken ___ doses of NSAIDS in the week prior to admission. The patient also had been having mild to moderate epigastric pain over the last week. Cr is resolving faster than BUN with fluids with BUN/Cr >20 supporting evidence of acute GI bleed. Patient'd EGD on ___ showed no evidence of bleeding in the stomach or duodenum. CT scan on ___ with contrast showed hemorrhagic pancreatic necrosis with drainage into the intestinal tract. The patient's melana is likely from slow drainage from the pancreatic hemorrhage. Patient continued on protonix 40mg PO BID, PO thiamine/folate and ___ follow up with the GI team per above. # Acute Renal Failure Patient presented with nausea, vomiting, anorexia and poor PO intake. She was found to have acute elevation in his creatinine of 6.2 which is elevated since last checked on ___ (baseline cr of ___. The cause of the ARF is likely multifactorial including ___ azotemia combined with recent elevation in Lisinopril. It is also possible that the patient has a post renal obstruction secondary to BPH or renal stones, however given no hydronephrosis on US, obstructive nephropathy is unlikely. Intrinsic renal disease is a posibility and the patient has elevated protein in the urine without significant blood in the urine. Urine lytes/albumin on admission indicated a ___ picture. Patient creatinine returned to normal on ___ with high volume resuscitation. # Hyponatremia Patient hyponatremic on admission. Likely hypovolemic hyponatremia vs SIADH. The patient appeared dry on physical exam, with dry mucous membranes. He also endorsed low urine output and decreased PO intake. Resolved on ___ with IV fluids. CHRONIC ISSUES # Alcoholism The patient admitted to binging on hard alcohol in the week leading up to his symptoms. This is likely the etiology of the patient's acute and chronic pancreatitis. The patient was given multiple levels of counseling while inpatient by both his primary, GI and social work team. The patient ___ have close follow up as an outpatient. # Uncontrolled Type II Diabetes Melitus- Possibly ___ to patient's pancreatitis. Patient was controlled with ISS while in the hospital. The patient was transitioned to metformin 500mg PO daily on discharge. # Hypertension: Held atenolol/lisinopril due to renal failure. Transitioned to labetalol and lisinopril on discharge. # HLD: Held atorvastatin on admission but restarted on discharge. # Insomnia: Continued trazedone. TRANSITIONAL ISSUES =========================== - in ___ weeks following discharge patient ___ need repeat MRCP w/contrast to evaluate for possible mass at the head of the pancreas - ERCP recommended ___ days of Ciprofloxacin 500mg PO BID for prophylaxis post stent (Day 1 was ___ given elevated WBC we opted for 7 day course with final dose given with dinner on ___ - patient ___ need repeat CBC for HCT/WBC monitoring, Chem 7 (metformin and kidney f/u), LFTs (AST, ALT, TBili) at first PCP appointment - patient ___ need social work/support for continuing use of alcohol; patient is at High risk of relapse; ___ need close follow up as outpatient - patient missed outpatient ___ of elevated PSA >6.0. Was instructed to reschedule outpatient eval ___ be transitional issue) - ___ need f/u ERCP for stent removal: ERCP team ___ contact - ___ need f/u MRCP and f/u with ___. ___ - ___ need f/u with PCP early next week with repeat CBC/Chem 7 (patient/wife prefers next ___ b/c son getting wisdom teeth out ___ - Patient ___ abstain from all NSAIDS, and Alcohol NEW MEDS - Ciprofloxacin 500mg BID PO (last day on ___ - Vitamin B12, Folate, Multivitamin, Thiamine - Labetalol 200mg PO BID for high blood pressure - Metformin 500mg PO Daily for Diabetes - Protonix 40mg PO BID for Upper GI Bleed ___ continue until follow up with PCP ___ GI) MEDS DISCONTINUED - atenolol (changed to Labetalol) - aspirin (hemorrhagic pancreatitis) PCP and surgical/GI teams were all updated prior to and on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Atenolol 25 mg PO DAILY 4. TraZODone 25 mg PO QHS:PRN insomnia 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth Daily Disp #*28 Tablet Refills:*0 2. TraZODone 25 mg PO QHS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*14 Tablet Refills:*0 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0 4. Cyanocobalamin 50 mcg PO DAILY RX *cyanocobalamin (vitamin ___ [Vitamin ___ 50 mcg 1 tablet(s) by mouth Daily Disp #*28 Tablet Refills:*0 5. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 6. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 7. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily ___ 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 8. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 9. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 11. MetFORMIN (Glucophage) 500 mg PO DAILY RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. Acute on Chronic Pancreatitis with Common Bile Duct stricture 2. Acute Kidney Injury 3. Hypertension 4. Alcohol Withdrawal 5. Hyponatremia 6. Hypokalemia 7. Hypophosphatemia 8. Leukocytosis unspecified 9. Elevated PSA 10. Hepatitis 11. Hepatic steatosis 12. Thrombosed Mesenteric veins 13. Hemorragic Pancreatitis / Hematobilia SECONDARY: 1. Uncontrolled Type II DM 2. HLD 3. Insomnia 4. Alcoholism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to take part in your care during your stay here at ___. You came into the hospital for nausea, mild abdominal pain, and vomitting. In the Emergency Room you were found to have labs concerning for damage to both your kidneys, liver, and pancreas. You were admitted to the ___ Service. On the floor you were evaluated by the Gastroenterology service who were concerned for inflammation of your pancreas that was causing constriction of your common bile duct (the duct that connects your liver/gall bladder to your intestines). They performed an ERCP and Endoscopy and found no evidence of stones, but inflammation constricting the duct. You had a stent placed with improvement of your blood tests. You also had a imaging scan called a CT scan to evaluate your pancreas. You ___ continue on the medications started in the hospital and ___ follow up with your primary care provider and ___ new gastroenterologist. Thank you for allowing us to participate in your care during your stay in the hospital. Sincerely, Your ___ Team Followup Instructions: ___

10046241-DS-20

DS

2142-06-14 00:00:00

2142-06-14 15:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cc: thrombosis Major ___ or Invasive Procedure: None History of Present Illness: ___ yo M with EtOH abuse admitted with pancreatitis early in ___ complicated by hemorrhage and necrosis now walled off, discharged recently following an admission for symptomatic hypotension who returns for initiation of anticoagulation for SMV/portal vein thrombosis. Pt admitted from ___ due to pancreatitis compliated by distal CBD stricture and hemorrhage/necrosis at the head of the pancreas. Pt underwent stenting of the CBD. Pt showed improvement and was discharged home. He returned again on ___ after bing sent in by his primary care physician for systolic blood pressure in the 80's despite stopping one of two of his home antihypertensives. Pt was taken off antihypertensives and given IVF during the admission. Pt with stable anemia with no clinical GIB. CT abdomen was done during that admission which showed progressive thrombosis of the SMV and portal vein. Pt discharged home again and followed up in surgery clinic today. Pt admitted by surgeon for initiation of anticoagulation of his thrombosis in a monitored setting. Pt denies abdominal pain or nausea. He has been able to tolerate a regular diet. No diarrhea, steatosis, hematochezia, or melena. No EtOH intake since discharge. He does report that he feels pre-syncopal when standing for too long or ambulating long distances. He says this has persisted even with the discontinuation of his BP meds. In fact, he states that it has had these symptoms for about 4 months now. ROS: negative except as above Past Medical History: PANCREATITIS - EtOH related, complicated by hemorrhage/walled off necrosis and SMV/Portal Vein thrombus BPH HYPERTENSION - ESSENTIAL, BENIGN FATTY LIVER ESOPHAGEAL REFLUX Sleep apnea Alcoholism Type 2 diabetes mellitus - recently diagnosed Social History: ___ Family History: Father with bladder CA. Physical Exam: Admission Vitals: 98.4 130/86 108 17 99%RA Gen: NAD HEENT: moist mm CV: rrr, no rmg Pulm: clear b/l Abd: soft, mild tenderness in epigastrum, no masses Ext: no edema Neuro: alert and oriented x 3, no focal deficits Discharge: Vitals: 98.8 122/80 110 16 98%RA Gen: NAD HEENT: moist mm CV: rrr, no rmg Pulm: clear b/l Abd: soft, NT, ND, no masses Ext: no edema Neuro: alert and oriented x 3, no focal deficits Pertinent Results: ___ 02:34PM WBC-5.8 RBC-3.08* HGB-10.4* HCT-30.6* MCV-99* MCH-33.7* MCHC-33.9 RDW-13.2 ___ 02:34PM PLT COUNT-278 ___ 02:34PM GLUCOSE-140* UREA N-8 CREAT-0.6 SODIUM-142 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14 ___ 02:34PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-99 TOT BILI-1.0 ___ 02:34PM LIPASE-10 ___ 02:34PM ALBUMIN-3.6 ___ 02:52PM LACTATE-1.6 ___ 06:03PM ___ PTT-33.6 ___ ___ 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 02:25PM URINE RBC-13* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 TTE ___: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF = 70%). 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 appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. CTA Chest ___: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Clear lungs. 3. Distended gallbladder, biliary dilation and varices formation better characterized on recent dedicated abdominal study. Brief Hospital Course: ___ yo M with history of alcoholism, with history of recent pancreatitis s/p ERCP and pancreatic duct stenting, also with evidence of hemorrhagic pancreatitis amd SMV / portal vein thrombosis, persistently tachycardic in the outpatient setting and admitted for lightheadedness, tachycardia and close monitoring anticoagulation initiation. # SMV and Portal Vein Thromboses # Hemorrhagic Pancreatitis Likely alcohol related pancreatitis complicated by hypercoagulability prior to admission. Biliary strictures s/p ERCP with stenting during prior hospitalization. Dr. ___ ___ patient in clinic and recommended anticoagulation so patient admitted for close monitoring. He remains extemely high risk for acute blood loss complications given pancreatic hemorrhage. During admission he was placed on a Heparin drip given reversibility and shorter half life than Lovenox and bridged to Coumadin. ERCP and ___ surgery followed in house. With therapeutic INR and PTT levels he had no evidence of acute blood loss. Heparin discontinued. He received 5 mg of coumadin from ___, his INR rapidly increased from 1.4 on ___ to 3.3 on ___. He was told to hold coumadin on ___ and follow-up in Dr. ___ in ___ days for repeat INR. # Type II Diabetes Melitus Newly diagnosed, poorly controlled, non-insulin dependent, not known to be complicated. Possibly related to pancreatitis / necrosis. Held Metformin while in house and placed on HISS. Restarted metformin on discharge. # Hypertension: Chronic, previously on atenolol / Labetalol and lisinopril. Antihypertensives held during admission and his BPs remained in good control with SBPs in 120s # Tachycardia: Persistent tachycardia following last hospitalization. This could be related to poor cardiac filling in setting of SMV and PV thrombosis. Potentially rebound from being off beta-blocker. Appeared volume replete and did not improved after IVFs. No pain or anxiety noted. CTA ruled out PE. TSH and Cortisol were normal. TTE showing normal LVEF and cardiac filling wtihout valvular pathology. His tachycardia was likely in part due to beta-blocker cessation as he has chronically been on beta-blockers. He was restarted on Toprol XL 25 mg daily and tolerated this well, this can be titrated up as an outpatient as needed. He was counselled to stop the Toprol if he developed worsening dizziness or fainting. # Dizziness # Lightheadedness Orthostatic based increase in HR with standing without change in BP. Appropriate tachycardia when standing so dont expect autonomic dysfunction, POTS a possibility but wrong demographic and acuity more indicative of relation to recent acute medical illnesses. Differential similar to tachycardia as above. He was steady on his feet ambulating the hallways without assistance and had no evidence of pre-syncope or syncope during admission. # HLD: Continued Atorvastatin # Insomnia: Continued Trazodone # Alcoholism Social work consult Transitional Issues: - Outpatient INR monitoring Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cyanocobalamin 50 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. TraZODone 25 mg PO QHS Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Cyanocobalamin 50 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q12H 6. TraZODone 25 mg PO QHS 7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY Duration: 1 Dose RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Portal vein thrombosis Sinus tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted for tachycardia. We performed a CT scan which showed no clots near your lungs. We also performed an echo which showed no significant abnormalities. Your tachycardia is likely due to stopping your beta-blocker (the atenolol and metoprolol). We restarted you on a low dose of metoprolol to control your heart rates. Because of your blood clots near your pancreas, we started you on a medicine called warfarin, which you will need to continue as directed by your primary care physician and Dr. ___. You should follow up in Dr. ___ to have your INR checked on either ___ or ___. As your INR level was too high on discharge you should not take coumadin tonight. Related to your pancreatitis, we also needed to start you on medicine for diabetes. Followup Instructions: ___

10046362-DS-21

DS

2189-02-05 00:00:00

2189-02-05 10:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left leg pain, difficulty walking Major Surgical or Invasive Procedure: None during this hospitalization History of Present Illness: ___ y/o female s/p laminectomy and foraminotomy back in ___. The patient presents today with 1 week of back pain. She saw Dr. ___ at clinic at that time and was placed on a Medrol dose pack with no effect. Over the last couple of days she has developed a band like pain across her abdomen along with worsening radiculopathy on the left leg. She presented to an OSH and a CT of the lumbar spine was obtained which showed a fluid collection. She was transferred here to ___ for further evaluation. The patient denies n/v/c/d, bowel or bladder incontinence. Past Medical History: arthritis, gout, diabetes, obesity Social History: ___ Family History: Non-contributory Physical Exam: On admission: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: IP Q H AT ___ G L 4+ 5 4 0 0 4+ Sensation: Intact to light touch, decreased sensation along the outside of the left leg. Reflexes: no clonus On discharge: Awake, alert, oriented. BUE full motor, RLE full, LLE ___ except ___ ___ at baseline. Baseline sensory. Pertinent Results: ___: MRI L spine with and without contrast: IMPRESSION: 1. Status post left L4-L5 hemilaminectomy with an irregular but well -defined fluid collection within the postoperative bed, most likely representing a seroma. Infection is felt to be less likely, but should be correlated clinically. 2. Stable multilevel degenerative changes in the remainder of the lumbar spine. ___ LEFT LOWER EXTREMITY ULTRASOUND IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: On ___ this patient presented to the ___ ED from an outside hospital with complaints of worsening radiculopathy symptoms in the left leg. She is s/p a laminotomy and foraminotomy in ___ and has tried a Medrol dosepak as outpatient without improvement. A CT l-spine at the outside hospital showed a fluid collection at the surgical site. An MRI was done which also showed a fluid collection, likely a seroma per radiology report. She was examined again on morning rounds and is now reporting pain and decreased sensation on her RLE. Physical therapy ordered for further evaluation of functional mobility. On ___, the patient's neurological exam remained stable. A dose of 10mg IV dexamethasone was given once per Dr. ___ inflammation control. The patient was evaluated by Physical Therapy, who deemed that she would benefit from acute rehabilitation. The insurance screening process for acute rehab placement was initiated. On ___, patient remains neurologically and hemodynamically stable. Patient continues to complain of left leg pain, on exam leg/foot is swollen, LLE ultrasound ordered to rule out DVT. For pain medication, switched to percoset to ensure taking Tylenol. Blood sugars continue to be high, changed diet to carb controlled and will monitor closely however most likely related to steroid use. Patient is denying going to acute care rehab due to family concerns of distance away. It was discussed with the patient that it is in her best interest to go to acute rehab however continues to deny. On ___ she remained stable and was discharged to an extended care facility. Medications on Admission: Medications prior to admission: Acetaminophen 325-650 mg PO Q6H:PRN fever/pain Baclofen 20 mg PO TID Bisacodyl 10 mg PO DAILY:PRN constipation Diazepam 5 mg PO Q6H:PRN muscle spasm Docusate Sodium 100 mg PO BID Gabapentin 800 mg PO TID lantus 40 Units Bedtime OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain Pregabalin 100 mg PO QHS TraZODone 100 mg PO QHS:PRN insomnia Discharge Medications: 1. Baclofen 20 mg PO TID 2. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 800 mg PO TID 5. Pregabalin 100 mg PO DAILY 6. Tizanidine 4 mg PO TID 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 8. TraZODone 100 mg PO QHS 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 10. Methocarbamol 750 mg PO TID:PRN Muscle spasm 11. Heparin 5000 UNIT SC BID 12. Diclofenac Sodium ___ 75 mg PO TID 13. Bisacodyl 10 mg PO DAILY 14. Senna 8.6 mg PO QHS Discharge Disposition: Extended Care Facility: ___. Discharge Diagnosis: Post-operative Pain Seroma of the lumbar spine 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 You were admitted for concern of infection, imaging showed no signs of infection but of a fluid collection that should resolve in time. Your pain was evaluated and a pain regimen selected. •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 improved pain control. Otherwise •You make take leisurely walks and slowly increase your activity at your own pace. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •You may take Ibuprofen/ Motrin for pain. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. 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: ___

10046436-DS-17

DS

2154-01-01 00:00:00

2154-01-02 08:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: foreign body ingestion Major Surgical or Invasive Procedure: ___ History of Present Illness: ___ with history of Prader-Willi syndrome initially presented to ___ after being witnessed swallowing glass. He was initially evaluated by GI at the outside hospital and they were unsuccessful in their endoscopic attempts to remove the glass. The duodenum was normal. Given lack of overtube it was felt that the sharp objects could not be safely removed. The patient was the transferred to ___ for further management. In the ED, initial vitals: 98.1 85 ___ 94%. H/H was ___. He was noted not have any obvious bleeding, pain, or respiratory issues. He was given 40mg IV pantoprazole. He had a KUB which showed multiple layering linear densities in the stomach corresponding to ingested foreign materials, with two linear hyperdensities seen on the supine view cannot be identified on the upright view and are not clearly within the stomach. He underwent endoscopy with GI which found no glass in the stomach before the pylorus. On arrival to the MICU, patient was comfortable with no complaints. Patient is unable to provide meaningful history. Past Medical History: Prader Willi Syndrome Bipolar Disorder Osteopenia GERD DM2 Hyperlipidemia Social History: ___ Family History: Non-contributory Physical Exam: ON ADMISSION: Vitals- 97.6 126/80 16 100%RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops 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 ON DISCHARGE: VS - 98.4 136/89 86 18 100% on RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops 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 Pertinent Results: ___ 04:44AM ___ PTT-27.5 ___ ___ 04:44AM ___ PTT-27.5 ___ ___ 04:44AM PLT COUNT-194 ___ 04:44AM NEUTS-72.2* ___ MONOS-7.1 EOS-1.3 BASOS-0.4 ___ 04:44AM estGFR-Using this ___ 04:44AM GLUCOSE-139* UREA N-14 CREAT-0.9 SODIUM-134 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13 ___ 07:16AM GLUCOSE-123* UREA N-14 CREAT-0.9 SODIUM-134 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13 ___ 07:16AM CALCIUM-9.9 PHOSPHATE-4.8* MAGNESIUM-1.7 EGD ___: No foreign body identified on this examination KUB: ___: IMPRESSION: 1. Multiple layering linear densities in the stomach corresponding to ingested foreign materials. However, 2 linear hyperdensities seen on the supine view cannot be identified on the upright view and are not clearly within the stomach. 2. No evidence of free air. EGD ___: Upon entrance into the stomach multiple pieces of glass were noted. The patient was then intubated and a gastric overtube was placed and then over 20 pieces of varying sizes of glass was removed from the stomach using rat tooth forceps and ___ nets through the overtube. One piece was identified in the duodenal bulb and was also removed. Numerous superficial ulcerations were noted throughout the stomach. The overtube was then removed and a repeat EGD was performed wtih full gastric insufflation and deep duodenal intubation and no further pieces of glass were identified. Otherwise normal EGD to third part of the duodenum KUB: ___: IMPRESSION: Shards of glass are seen in the mid right abdomen, perhaps within the ascending colon. No free intraperitoneal air. KUB: ___: IMPRESSION: No glass shards are visible, no free intraperitoneal air. Brief Hospital Course: Patient was admitted to the MICU on ___ in stable condition after EGD performed by GI in the OR. No removable foreign body was identified on EGD. Patient was evaluated by acute care surgery who recommended serial abdominal exam and aggressive bowel regimen. Patient reported acute increase in pain while in the MICU but had a KUB without evidence of perforation. Patient was pain controlled and remained hemodynamically stable. Abdominal exam remained stable while in the MICU. Given the stability of the patient, patient was transferred to the floor on ___ for further monitoring. He denied abdominal pain throughout the hospitalization. He had daily abdominal x-rays which revealed continued presence of glass. On ___, a repeat attempt was made to perform EGD and remove some glass visualized in the stomach on KUB. This was sucessful but some glass was left over beyond the duodenum which could not be removed. The patient was observed closely for changes in abdominal exam or pain but had none. He had a bowel movement with no resulting injuries. Psychiatry was consulted to clear the patient prior to discharge and found him safe to be transferred back to his group home. # Prader ___ - The patient had a 1:1 sitter throughout hospitalization. # Bipolar Disorder-Stable, home medications of lamotrigine and ziprasidone were continued. He was evaluated by the psychiatry team while admitted and there were not felt to be any acute psychiatric issues. He was cleared by psychiatry to return to his group home once medically ready. # Diabetes - On glyburide as an outpatient. The glyburide was held while the patient was hospitalizaed and an insulin sliding scale was initated with resulting good glycemic control. # GERD - stable, continued omeprazole. Transitional Issues: # Foreign Body Ingestion-Minimize ingestable objects and supervise patient carefully to avoid repeat ingestion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID 2. Flunisolide Inhaler 80 mcg/actuation inhalation BID 3. Omeprazole 20 mg PO DAILY 4. Simethicone 120 mg PO TID 5. Calcium Carbonate 500 mg PO BID 6. Vitamin D 400 UNIT PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. TraZODone 50 mg PO QHS 9. flaxseed oil 1,000 mg oral DAILY 10. Docusate Sodium 100 mg PO BID 11. LaMOTrigine 100 mg PO BID 12. naltrexone 50 mg oral QHS 13. Loratadine 10 mg PO DAILY 14. ZIPRASidone Hydrochloride 80 mg PO BID 15. Testosterone Cypionate 100 mg IM MONTHLY 16. GlyBURIDE 1.25 mg PO DAILY 17. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. LaMOTrigine 100 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. ZIPRASidone Hydrochloride 80 mg PO BID 6. Calcium Carbonate 500 mg PO BID 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. flaxseed oil 1,000 mg oral DAILY 9. Flunisolide Inhaler 80 mcg/actuation inhalation BID 10. GlyBURIDE 1.25 mg PO DAILY 11. Loratadine 10 mg PO DAILY 12. naltrexone 50 mg oral QHS 13. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID 14. Simethicone 120 mg PO TID 15. Testosterone Cypionate 100 mg IM MONTHLY 16. TraZODone 50 mg PO QHS 17. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Glass ingestion, Prader-Willi Syndrome Secondary Diagnosis: Bipolar disorder 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 the ___ ___. You were admitted because you swollowed glass. An attempt was made to remove the glass from your stomach, and while a great deal of the glass was able to be removed, some remained so we performed daily x-rays of your abdomen until we did not see any more glass. You passed the glass in your stool, and you are now safe to be discharged. Ingesting glass is extremely dangerous and we strongly recommend that you do not ingest glass in the future. We wish you all the best. Sincerely, Your ___ Team Followup Instructions: ___

10046436-DS-18

DS

2156-06-27 00:00:00

2156-06-27 15:25:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: glass ingestion Major Surgical or Invasive Procedure: EGD ___ Colonoscopy ___ History of Present Illness: ___ yo male with hx Prader-Willi Syndrome, NIDDM, GERD, and multiple prior foreign body ingestions requiring EGD and intubation presenting from ___ s/p glass ingestion after punching a window at his group home. He was reportedly agitated at OSH, was trying to hit police officers, didn't want to go to the hospital. He received 5 mg IM Haldol, 2 mg IM Ativan, D5NS at 110/hr, and tetanus vaccine. Labs were stable: WBC 10.2 Hb 14.9 Hct 44.2 Plt 200, Cr 1.1, Coags WNL. CT showed glass in the stomach and no free air. He was then transferred to ___. Upon arrival to ___ ED: - vitals: T 97.4, 86, 110/80, 16, 99% RA - Abdomen was soft, nontender - Labs showed: 143 102 13 ------------< 110 3.9 25 1.1 WBC 8.4 Hb 13.9 Plt 187 ___: 11.4 PTT: 23.7 INR: 1.1 He was admitted for EGD and went directly to the endoscopy suite. EGD was without abnormalities, but unfortunately the glass had passed on out of view of the scope. ACS was consulted, recommended repeat CT abdomen and serial abdominal exams. Admitted to medicine in stable condition. Past Medical History: Prader Willi Syndrome Bipolar Disorder Osteopenia GERD DM2 Hyperlipidemia Last hospitalization ___ for same presentation, reportedly shattered a picture frame and ingested several pieces of glass, which were not all able to be retrieved, had short course in MICU and no e/o bowel perforation, followed by ACS, and cleared by psychiatry to return to group home. Psychiatry felt his behavior might be in response to family stress and changes in staffing at the group home. OSH records indicate 9 prior EGDs for ingestions. Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 PO ___ 18 96 RA GENERAL: NAD HEENT: AT/NC, anicteric sclerae, pink conjunctiva, MMM NECK: supple, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes, ecchymoses upper L chest mildly tender, R index finger bandaged, R upper forehead 2 cm linear cut DISCHARGE PHYSICAL EXAM: Vitals: 98 PO 118/78 Sitting 96 20 99% RA General: Reserved in conversation . in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: supple CV: RRR, +S1/S2, no murmurs, rubs, gallops Lungs: good inspiratory effort. Clear to auscultation Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ DP pulses Neuro: Alert and oriented, no focal deficits appreciated Pertinent Results: ADMISSION LABS: ___ 05:30PM BLOOD WBC-8.4 RBC-4.72 Hgb-13.9 Hct-41.6 MCV-88 MCH-29.4 MCHC-33.4 RDW-12.1 RDWSD-39.0 Plt ___ ___ 07:30AM BLOOD WBC-7.2 RBC-4.83 Hgb-14.3 Hct-43.0 MCV-89 MCH-29.6 MCHC-33.3 RDW-12.1 RDWSD-39.6 Plt ___ ___ 07:35AM BLOOD WBC-6.4 RBC-4.97 Hgb-15.2 Hct-44.0 MCV-89 MCH-30.6 MCHC-34.5 RDW-12.2 RDWSD-39.5 Plt ___ ___ 05:30PM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-143 K-3.9 Cl-102 HCO3-25 AnGap-16 ___ 07:30AM BLOOD Glucose-126* UreaN-11 Creat-1.0 Na-140 K-4.4 Cl-100 HCO3-25 AnGap-15 IMAGING: CXR: ___ In comparison with study of ___, there again are low lung volumes. Cardiac silhouette is within normal limits without vascular congestion. Mild opacification at the left base most likely reflect combination of atelectasis and pleural fluid. However, in the appropriate clinical setting, it would be difficult to exclude superimposed aspiration/pneumonia. KUB ___: Surgical clips within the right upper quadrant are unchanged in configuration. The ingested foreign bodies originally seen on the ___ CT examination are no longer visualized radiographically. KUB ___: Larger glass fragment in the descending colon, smaller glass fragment at the hepatic flexure. KUB ___: 2.5 and 1.1 cm linear hyperdensities in the right lower quadrant correspond to previously described radiodense glass fragments on prior CT exam and appear located in the cecum and/or proximal ascending colon. CT AP ___: Unchanged position of the 2 radiodense objects with the 25 mm fragment within the cecal base and the 10 mm fragment within the appendiceal base. Given location, especially the fragment within the appendiceal base, these are felt unlikely to progress distally. No bowel rupture or adjacent colonic irritation. CT AP ___: Both of the radiopaque foreign objects are now within the cecum, measuring 2.6 cm and 0.9 cm. No evidence of perforation or bowel obstruction. CT AP ___: Ingested radiopaque foreign body has migrated distally and is seen within a loop of distal small bowel in the right lower quadrant. Another small radiopaque object is noted within the cecum which may represent a detached fragment. No evidence of bowel perforation or obstruction. PROCEDURES: EGD ___: 2 pills were found in the stomach. Both were mobile and not sharp. One was suctioned but the other was not able to be suctioned. No foreign body identified. No evidence of injury to the mucosa. No evidence of injury to the mucosa. No foreign body identified. No evidence of injury to the mucosa. Otherwise normal EGD to third part of the duodenum Colonoscopy ___: The prep was inadequate and several areas, including the cecum were unable to be completely visualized. Small pieces of glass could be missed in areas of poor prep. There was no glass seen near the appendiceal orifice. Otherwise normal colonoscopy to cecum DISCHARGE LABS: Patient declined laboratory draw on ___ day of discharge. ___ 09:25AM BLOOD WBC-9.8 RBC-4.27* Hgb-12.9* Hct-38.4* MCV-90 MCH-30.2 MCHC-33.6 RDW-13.2 RDWSD-43.3 Plt ___ ___ 09:25AM BLOOD Glucose-311* UreaN-24* Creat-0.8 Na-134 K-4.7 Cl-90* HCO3-25 AnGap-19* ___ 03:20PM BLOOD Glucose-267* UreaN-24* Creat-0.7 Na-136 K-4.7 Cl-94* HCO3-26 AnGap-16 ___ 09:25AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8 ___ 07:27AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.1 Hct-42.6 MCV-88 MCH-29.1 MCHC-33.1 RDW-11.9 RDWSD-38.2 Plt ___ ___ 07:49AM BLOOD WBC-7.8 RBC-4.61 Hgb-14.2 Hct-39.6* MCV-86 MCH-30.8 MCHC-35.9 RDW-12.1 RDWSD-37.6 Plt ___ ___ 06:40AM BLOOD WBC-6.7 RBC-4.84 Hgb-14.8 Hct-42.4 MCV-88 MCH-30.6 MCHC-34.9 RDW-12.1 RDWSD-39.0 Plt ___ ___ 07:27AM BLOOD Glucose-168* UreaN-6 Creat-0.8 Na-136 K-4.6 Cl-93* HCO3-28 AnGap-15 ___ 07:49AM BLOOD Glucose-158* UreaN-7 Creat-0.8 Na-137 K-4.6 Cl-95* HCO3-29 AnGap-13 ___ 06:40AM BLOOD Glucose-174* UreaN-3* Creat-0.8 Na-139 K-4.7 Cl-96 HCO3-27 AnGap-16 Brief Hospital Course: Patient Summary for Admission: ============================== ___ yo male with h/o Prader-Willi Syndrome, NIDDM, and GERD, with multiple prior foreign body ingestions requiring EGD and intubation who presented from ___ s/p glass ingestion in the setting of being agitated at his home facility. Patient was transferred to ___ for endoscopic evaluation. Patient was evaluated by GI who attempted an EGD but were unsuccessful in retrieving the glass. He was also evaluated by ACS, but given the lack of evidence of perforation, he did not require surgery. The location of the glass was monitored with serial CT images of the abdomen, and a colonoscopy on ___ was performed but was unsuccessful in retrieving the glass. Given the patient's clinical stability, the patient was transitioned back to a regular diet and bowel regimen and subsequently passed the glass spontaneously. Hospital course was complicated by hyperglycemia following initiation of a regular diet. Patient initially required sliding scale insulin and long acting insulin to control blood sugars. Patient was not adhering with a carbohydrate controlled diet and with improved enforcement of the ordered dietary restrictions, blood sugars trended down. Subsequently glucose control was achieved through increased Glyburide, with plans to restart home Januvia at time of discharge. Patient was discharged once blood sugars were stabilized with plan for close primary care provider follow up. ___ Medical Issues Addressed: ================================ #Glass Ingestion: Patient ingested glass at his home facility and was subsequently transferred to ___ on ___ for endoscopic retrieval. EGD was performed and glass was unable to be retrieved. CT Abdomen and Pelvis completed ___ was notable for a 2.1cm piece of glass in the small bowel. Patient was evaluated by ACS who did not feel acute surgical intervention was needed given there was no evidence of perforation. Mr. ___ had serial abdominal exams, which remained benign. Given low concern for perforation, patient was monitored for passage of the glass. He had not spontaneously passed the glass as of ___P was completed on ___ and ___ which demonstrated the glass migrated to the cecum but remained in the cecum. Patient had a colonoscopy ___, but the glass was not able to be retrieved due to poor prep. Following a discussion with the ___ team and given the patient's hemodynamic stability, the patient was allowed to eat a regular diet and subsequently patient passed the glass spontaneously, which was confirmed with repeat KUB. Patient's abdomen remained without clinical change during admission. # Type 2 diabetes with hyperglycemia: Patient was initially transitioned to sliding scale insulin when admitted and home Glyburide and Januvia were held. Blood sugar was well controlled with HISS while patient was NPO and on a clear diet in anticipation of passing the ingested glass. With transition back to a carb controlled diet patient's blood sugars increased to 300-500. Initial concern was for infection driving the worsening hyperglycemia, however CXR and urine analysis were unrevealing for infection. On ___ patient's anion gap increased to 20 with trace ketones present in urine. With increased fluid and short acting insulin patient's gap subsequently closed. It later became obvious patient was ordering multiple trays at meals which was driving the hyperglycemia. ___ was consulted during admission due to new insulin initiation; however with improvement of sugars the patient was transitioned back to oral agents with an increase Glyburide dose of 10mg daily and plans to restart home Januvia (not on formulary inpatient) at time of discharge. Patient's blood sugars were approximately 120-250 at time of discharge, and he will require close follow up with his primary care provider for ongoing management. # Bipolar Disorder: Patient became agitated at group home resulting in foreign body ingestion. Patient was continued on home Lamotrigine and Ziprasidone and was evaluated by Psychiatry who did not recommend any acute medical changes. Patient had a 1:1 sitter while inpatient. CHRONIC ISSUES: =============== # Prader Willi Syndrome: Patient has a history of Prader Willi as well as impulsivity. Patient had a 1:1 sitter during hospitalization and was continued on home Naltrexone, ziprasidone and lamotrigine. Patient was evaluated by Psychiatry who did not recommend acute medication changes. # GERD: Patient continued home omeprazole, however Simethicone and Rulox were held while patient was waiting to pass the glass. Simethicone and Rulox were started again at time of discharge. # Insomnia: Patient continued home trazodone. Transitional Issues: ====================== Medications Stopped: -Rulox and Simethicone were held during admission but restarted at time of discharge -Januvia 100mg Daily held while inpatient, restarted at time of discharge Medications Added: -Glyburide increased from 1mg to 10mg daily []Patient's Glyburide dose increased significantly while inpatient with addition of Januvia 100mg at time of discharge. This medication change may need to be adjusted as patient returns to usual diet []Patient should check FSBG three times daily with a morning fasting glucose for the next few weeks until blood glucose stabilizes. []Patient will require close follow up by PCP for ongoing management of hyperglycemia []Patient will follow up with PCP ___ ___ at 1 pm Code Status: Full Code HCP: ___ (mother) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gas Relief (simethicone) 125 mg oral TID W/MEALS 2. Calcium Carbonate 600 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. flaxseed oral unknown 5. ZIPRASidone Hydrochloride 80 mg PO BID 6. Loratadine 10 mg PO DAILY 7. Naltrexone 50 mg PO QHS 8. Fluticasone Propionate NASAL 2 SPRY NU BID 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Omeprazole 20 mg PO QAM 11. multivitamin with iron 1 tab oral DAILY 12. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE MEALS 13. TraZODone 50 mg PO QHS 14. Vitamin D 400 UNIT PO BID 15. Januvia (SITagliptin) 100 mg oral QAM 16. Testosterone Cypionate unknown IM QMONTHLY 17. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride) dental unknown 18. GlyBURIDE 1 mg PO DAILY Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 2. GlyBURIDE 10 mg PO DAILY RX *glyburide 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Calcium Carbonate 600 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. flaxseed oral Frequency is Unknown 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. Gas Relief (simethicone) 125 mg oral TID W/MEALS 9. Januvia (SITagliptin) 100 mg oral QAM 10. LamoTRIgine 125 mg PO BID 11. Loratadine 10 mg PO DAILY 12. multivitamin with iron 1 tab oral DAILY 13. Naltrexone 50 mg PO QHS 14. Omeprazole 20 mg PO QAM 15. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride) dental unknown 16. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE MEALS 17. Testosterone Cypionate unknown IM QMONTHLY 18. TraZODone 50 mg PO QHS 19. Vitamin D 400 UNIT PO BID 20. ZIPRASidone Hydrochloride 80 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: =================== Intentional Ingestion (glass) Hyperglycemia Diabetes Mellitus Type 2 Secondary Diagnosis: =================== Prader-___ Syndrome Bipolar Disorder GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for allowing us to be a part of your care at ___ ___! Why was I in the hospital? -You were admitted to the hospital after you swallowed a piece of glass. What was done while I was in the hospital? -While you were in the hospital you were evaluated by the GI team and the Surgical team. -The GI team place a camera in your stomach but were unable to remove the glass. -We continued to watch you and you did not have belly pain or pain in your bottom. -We watched the glass as it made its way through your gut with repeat images of your belly. -You had a colonoscopy on ___, but we were not able to remove the glass. -You were given back a regular diet and you were able to pass the glass on your own. -Your blood sugars were very high and we had to use insulin initially to decrease your blood sugar -We started you on new medications to decrease your blood sugars What should I do when I go home? -You should continue taking your medications as prescribed. -You should check your blood sugar first thing in the morning and two more times during the day. -You should also follow up with your primary care provider early next week to discuss your blood sugar. We wish you the best! Sincerely, Your ___ Medicine Team Followup Instructions: ___

10046543-DS-17

DS

2155-03-20 00:00:00

2155-03-24 08:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: s/p fall, back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ year-old woman with a history of PMR on a prednisone taper, osteoporosis, prior thoracic compression fractures who presented to the ___ ED on ___ with 3 weeks of atraumatic back pain which which acutely worsened yesterday after leaning back to sit in her recliner but fell onto her buttocks. She is typically independent and fully mobile at baseline. She was evaluated by Ortho Spine who recommended TLSO brace for comfort, ED obs for pain control and a ___ evaluation. She was evaluated by ___ who found the patient to be motivated to return home and engage in outpatient physical therapy. Today the patient has been ambulating at baseline, however, in certain positions such as leaning forward or standing her back pain increases. She states she prefers to be admitted for one more night for pain control before going home. On exam the patient still denies fevers, chills, chest pain, palpitations, nausea, vomiting, numbness, tingling, weakness, saddle anesthesia, loss of bowel or bladder function. Past Medical History: Past Medical/Surgical History: PMR Osteoporosis Thoracic compression fractures MGUS Glaucoma Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Exam: Gen: NAD, A&Ox3, pleasant, conversant HEENT: Normocephalic, atraumatic, sclera anicteric Neck: Trachea midline, supple, no c-spine tenderness Resp: Breathing comfortably on room air CV: RRR Back: Tender to palpation in lower thoracic spine, upper lumber spine Abd: Soft, non-tender, non-distended Ext: Warm, well perfused, minimal edema, no abrasions or lacerations noted Discharge Physical Exam: VS: 97.6, 101/66, 79, 18, 95 Ra GEN: A&O x3. sitting up in chair NAD HEENT: WNL CV: HRR PULM: LS ctab ABD: soft NT/ND EXT: WWP no edema. Neuro: low back pain Pertinent Results: Imaging: CT Head ___: There is no evidence of acute intracranial hemorrhage, midline shift, mass effect, or acute large vascular territorial infarct. Mild periventricular and subcortical white matter hypodensities are nonspecific. Extensive calcifications are seen along the cavernous portions of the bilateral carotid arteries. Vertebral artery calcification is also noted. CT Chest ___: Compression deformities of T8, T10, and L1 vertebral bodies compatible fractures of unknown chronicity. L1 fx has acute/subacute appearance. Question of R 3rd rib nondisplaced fx. CT C-Spine ___: Multilevel degenerative changes of C-spine. No evidence of acute fx or traumatic malalignment. Brief Hospital Course: Ms. ___ is a ___ year-old woman with a history of PMR on a prednisone taper, osteoporosis, prior thoracic compression fractures who presented to the ___ ED on ___ with 3 weeks of atraumatic back pain which acutely worsened, found to have T8, T10, L1 compression fracture (acute vs subacute). She was admitted to the acute care surgery service for pain management. Ortho Spine was consulted who recommended no surgical intervention, TLSO for comfort, and no bending or twisting. On the floor, she was advanced to a regular diet, her home medication was restarted, she was started on oral medication for pain control with good affect. The TLSO brace was ordered and came to bedside but the patient stated she was unable to ___ the brace by herself. She was evaluated by physical therapy who felt she would need to go to rehab. At the time of discharge, she was afebrile and hemodynamically stable, pain was well controlled on oral medication alone, tolerating a regular diet, voiding adequately and spontaneously, she was ambulating with assistance in the TLSO, and she was deemed stable for discharge to rehab. She was discharged home with appropriate instructions and follow up and verbalized agreement with the plan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine [Lidocaine Pain Relief] 4 % apply one to lower back daily once a day Disp #*10 Patch Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. TraMADol ___ mg PO Q6H:PRN Pain - Severe RX *tramadol 50 mg 0.5 -1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 6. Vitamin D 1000 UNIT PO DAILY 7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. PredniSONE 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: T8, T10, L1 compression fracture subacute R 3rd rib fx 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 you sustained a fall and were found to have a several spine compression fractures, unclear whether acute or chronic, and a subacute right 3rd rib fracture. You were treated with oral pain medication. You were seen by physical therapy who recommended you be discharged home with home physical therapy You are now ready for discharge home. Please follow these instructions to aid in a speedy recovery: 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. If you have any questions, you may reach the Acute Care Surgery Clinic at the following number: ___ Best Wishes Your ___ Surgery Team Followup Instructions: ___

10046630-DS-18

DS

2171-04-06 00:00:00

2171-04-06 21:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hip pain Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ w/ hx of HTN presented to the ED with pelvis pain and was found to be confused so was admitted to medicine for pain control and confusion workup. He was seen here on ___ with a diagnosis of pelvic ramus fracture. Kept overnight for ___ and CM; sent home with a walker and home services. He returned today with continued pain. He says it is not worse, but it is not better either and it is limiting his ability to function at home. He has been taking Tylenol and ibuprofen. Is still able to ambulate. In the ED, initial vitals were: 97.4 68 180/80 20 98% RA His labs revealed H/H of 12.___, chem7 wnl Imaging revealed - Bilateral LENIS - distal isolated tibial vein thrombosis. No evidence DVT. - Hip/pelvic films - Minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated ___. No new fracture is seen. He received: ___ 16:22 PO TraMADOL (Ultram) 25 mg ___ 20:58 PO TraMADOL (Ultram) 25 mg ___ 20:58 PO Acetaminophen 1000 mg ___ 01:32 PO/NG Acetaminophen 650 mg ___ 01:32 PO OLANZapine 5 mg ___ 10:48 IVF 20 mEq Potassium Chloride / 1000 mL ___ NS He was going to be discharged from the ED, however woke up this morning altered. Head CT was negative. He was admitted to the floor for further work up for altered mental status. On the floor, with the assistance of a ___ interpreter, the patient says that he has pain in his legs. He is confused so did not answer any other ROS questions. Past Medical History: Per wife, HTN only Social History: ___ Family History: not pertinent to current admission Physical Exam: ADMISSION EXAM ============== Vital Signs: 98.4 180/95 64 16 99% RA General: Lying in bed, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no JVD. PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no w/r/c 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: CN II-XII grossly intact. ___ strength in upper extremities, lower extremity exam limited by pain but has ___ strength on plantarflexion of feet DISCHARGE EXAM ============== Vital Signs: 97.8 66-71 ___ 20 96-100% RA General: Lying in bed, appears comfortable HEENT: Head AT/NC, PERRL, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB anteriorly only, no w/r/c Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Legs slightly cool to touch, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, moving all extremities spontaneously, A&Ox3 Pertinent Results: ADMISSION LABS ============== ___ 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 ___ 04:35PM WBC-7.3 RBC-3.63* HGB-11.0* HCT-32.7* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.2 RDWSD-43.0 ___ 04:35PM NEUTS-85.8* LYMPHS-4.6* MONOS-8.6 EOS-0.3* BASOS-0.3 IM ___ AbsNeut-6.28* AbsLymp-0.34* AbsMono-0.63 AbsEos-0.02* AbsBaso-0.02 ___ 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 ___ 04:47PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 04:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04:47PM URINE COLOR-Yellow APPEAR-Clear SP ___ DISCHARGE LABS ============== ___ 07:34AM BLOOD WBC-7.8 RBC-3.65* Hgb-10.9* Hct-33.1* MCV-91 MCH-29.9 MCHC-32.9 RDW-13.2 RDWSD-43.7 Plt ___ ___ 07:34AM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-135 K-3.9 Cl-102 HCO3-26 AnGap-11 ___ 07:34AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 IMAGING ======= ___ CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process. Small vessel disease with age related involutional change. ___ CHEST (SINGLE VIEW) No acute intrathoracic process ___ BILAT LOWER EXT VEINS IMPRESSION: 1. Nonocclusive thrombus in a single posterior tibial vein on the left. 2. No evidence of deep venous thrombosis in the right lower extremity veins. ___ DX PELVIS & HIP UNILATE IMPRESSION: Minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated ___. No new fracture is seen. MICROBIOLOGY ============ UCx ___ - consistent with skin flora BCx ___ x 2, NGTD Brief Hospital Course: BRIEF SUMMARY ============== Mr. ___ is a pleasant ___ M s/p fall and fracture of the left inferior and superior pubic rami on ___, who presented with ongoing pain hip pain and was noted to be confused while in the ED and was found to have a superficial clot of the right lower tibial vein. He was evaluated for causes of delirium with no obvious abnormality. The likely cause of his delirium was pain, medication effect (he was initially treated with oxycodone 2.5 mg for pain), lack of sleep (he did not sleep at all the night prior to his confusion), and being hospitalized in the setting of chronic small vessel disease of the brain. With normalization of his sleep-wake cycle, limiting sedating medications, and administration of fluids he had significant improvement in his mental status and was discharged to rehab. ACUTE ISSUES ============ #Delirium: The patient was noted to be confused upon waking the morning after being seen in the emergency department for continued hip pain in the setting of a pubic ramus fracture two weeks prior to admission. He was admitted to the medicine service, where he underwent a workup for causes of delirium. While on the floor, he exhibited waxing and waning of his mental status, ranging from A&Ox3 to somnolent and barely interactive. A general delirium workup was performed and was negative (see labs for further details). The likely cause of his delirium was a combination of pain, medication effect (he was initially treated with oxycodone 2.5 mg for pain), lack of sleep (he did not sleep at all the night prior to his confusion), and being hospitalized in the setting of chronic small vessel disease of the brain. He underwent a head CT in the ED, which was negative for acute findings. We acquired records from a stay at ___. ___ in ___ at which time he was evaluated for slowing of speech/movement with concern for ___ Disease; an MRI brain from that stay showed enlarged cerebral ventricles, with question of NPH. Given that he was acutely delirious, had fallen recently, and was having incontinence while on the floor, we had our radiologists read the MRI from the outside hospital. They felt that there was no change in the size of his ventricles from this MRI versus his CT scan this admission. The patient was given fluids, Seroquel for sleep, and was put on delirium precautions with improvement in his mental status. He was discharged to rehab and will follow up at ___ with a neurologist later in the month for further evaluation per the patient's wife. #TIBIAL VEIN THROMBOSIS: The patient has a superficial tibial vein thrombosis but with no evidence of DVT. No need to anticoagulate given superficiality of clot. #PELVIC FRACTURE: Sustained fracture of his superior and inferior left pelvic ramus on ___, with no need for operative management per orthopedics. He went home with a walker but had continued pain so returned as above. His pain was initially treated with oxycodone 2.5 mg and standing tylenol, but the oxycodone was discontinued due to concern for worsening of his delirium as above. CHRONIC ISSUES #HYPERTENSION: The patient has a hx of HTN, controlled with PRN metoprolol per wife. On presentation to the floor, patient had SBP to 180 so was give 12.5 mg of PO captopril. He was placed on captopril 6.25 mg TID with improvement in pressures, however he did experience SBPs in the ___ so his captopril was discontinued. He may need addition of an antihypertensive as an outpatient depending on his blood pressure control. #Normocytic anemia: Iron studies were performed and were consistent with anemia of chronic disease; his iron was wnl, TIBC low normal, and ferritin elevated. His H/H remained stable during his course TRANSITIONAL ISSUES =================== - The patient was noted to have labile blood pressures, with his initial SBP at 180. He was placed on captopril 6.25 mg TID with improvement in his pressures, but did experience a couple of SBPs in the ___. This medication was discontinued prior to discharge, and his blood pressures should be further evaluated with possible addition of antihypertensive medication. - The patient was noted to have a normocytic anemia with Hgbs in the ___. Iron studies were consistent with anemia of chronic disease - The patient was evaluated for possible ___ disease at ___ in ___ after experiencing slowing of speech/movement. Per his wife, he has an appointment w/ neurology at ___ on ___ for further evaluation. - The patient was started on Seroquel 25 mg QHS for problems with sleep/wake cycle, however he experienced cognitive slowing so this was discontinued. He may be sensitive to antipsychotics given his possible ___ Disease - Per the patient's PCP, he takes Sinemet ___ 0.5 tab BID for ?___ Disease but the patient was reluctant to take any psychoactive medications due to concern for possible cognitive side-effects # CODE: Full # CONTACT: ___, wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Vitamin D 1000 UNIT PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 6. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #delirium #Superficial tibial vein thrombosis #hypertension 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 Mr. ___, you were admitted to the hospital after you were found to be confused while visiting the emergency department due to leg pain. We performed several tests to identify the cause of your confusion, but no cause was found. It is likely that your confusion was caused by a combination of pain, pain medications (which can be sedating), being in a different environment, lack of sleep, and having some chronic age-related brain changes. You were also found to have a small clot in your right leg, but this did not need treatment. You were seen by our physical therapists who recommended rehab. You were discharged to a rehab facility to help you get stronger. We wish you the best, Your ___ Care Team Followup Instructions: ___

10046724-DS-18

DS

2178-09-10 00:00:00

2178-09-10 16:26:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Found AMS Major Surgical or Invasive Procedure: ___ Left Craniotomy for subdural hematoma evacuation. History of Present Illness: ___ M with Hx of alcohol abuse, was found altered by his friend on the morning of ___ with Right sided weakness. He was brought to ___ where a CT brain was obtained which demonstrated an acute L SDH with max diameter 2cm and 1cm midline shift. EtOH 240, was transferred to ___. Past Medical History: EtOH abuse Social History: ___ Family History: noncontributory Physical Exam: ON ADMISSION: GCS 12 right facial weakness tongue protrudes midline speech slurred, confused follows commands RUE ___, RLE ___ LUE ___, LL%E ___ Babinski + R tremorous ON DISCHARGE: Alert, oriented x3 PERRL. EOMI. ___. TML. Strength ___ throughout Sensation grossly intact no pronator drift left crani incision c/d/I - staples removed. no erythema or discharge Pertinent Results: Please refer to OMR for pertinent imaging and lab results. Brief Hospital Course: ___ is a ___ year old male who was transferred from ___. ___, after being found with altered mental status, and new CT findings of Left subdural hematoma. #Left subdural hematoma Mr. ___ was transferred from ___ on ___ with CT findings of Left SDH max diameter 2mm with 1mm midline shift. Patient's ___ score was 12 at initial presentation. Patient was intubated, and it was determined that the patient needed emergent surgical intervention, and he was immediately taken to the OR that day for a Left Craniotomy and Subdural Hematoma Evacuation with a JP drain placed intra-operatively. Mr. ___ was transferred to the Neuro ICU post-operativly for further management and was started on Keppra for seizure prophylaxis. On ___ Mr. ___ was extubated and JP drain was removed with no complications. Patient remained neuro intact and was transferred out of the ICU to the neurosurgery floor on ___. Mr. ___ remained stable through the rest of his admission. He was evaluated by ___ and OT who recommended him to be discharge home with ___ services. Patient was medically cleared for discharge home on ___. Staples were removed prior to discharge - incision remained c/d/I. #EtOH withdrawal At the time of admission patient blood alcohol content was 240. Once patient was neurosurgically stable, he was started on multivitamins, thiamine and folic acid. Patient was started on phenobarbital before coming out of the ICU for withdrawals. Mr. ___ continued on a phenobarbital taper ___ and remained medically stable. #Anxiety Mr. ___ continues to take his home Valproic Acid for management of anxiety during his admission. Medications on Admission: Divalproex, Gabapentin, Trazodone Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN Headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth pain, headache Disp #*32 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation 6. Gabapentin 300 mg PO TID 7. Valproic Acid ___ mg PO ASDIR 250mg qAM, 250mg at 3pm, 500mg qHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery • You underwent a surgery called a craniotomy to have blood removed from your brain. • Your staples were removed prior to discharge. You may shower. • It is best to keep your incision open to air but it is ok to cover it when outside. • Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. • You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: • Headache is one of the most common symptoms after a brain bleed. • Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. • Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. • There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: • Severe pain, swelling, redness or drainage from the incision site. • Fever greater than 101.5 degrees Fahrenheit • Nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason Followup Instructions: ___

10047172-DS-14

DS

2162-08-03 00:00:00

2162-08-03 18:09:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Attending: ___. Chief Complaint: Asymptomatic fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with past history of metastatic pancreatic cancer (to liver) on chemotherapy who presents ED with fever. Last chemo gem/abraxane ___, neulasta ___, developed chills on ___ after chemo and then temp to 102 on ___ after neulasta. He denies cough, shortness of breath, chest pain, nausea/vomiting, headaches, abd pain, diarrhea, rashes. ED COURSE: v/s 18:28 0 98.5 70 157/56 16 100% RA Labs: lactate 1.6. UA unremarkable other than glycosuria. Chem w glucose of 363, Na 129, K 5.0, BUn/cr ___. LFTS elevated but stable compared to prior w ALT 100 and AP 460 tbili only 0.6. WBC 12.8 with 83% pmns and 5 bands. Hct stable at 26. Plts 120 slightly down from prior. Pt received 10u of SC insulin at 10pm. CXR unread but on my review unchanged from prior on ___ and no obvious infiltrate o0r effusion. On the floor he appears well and has no complaints. He does note that he skipped his insulin last night and had to take extra (total of 20u) this morning (humalog). Denies dysuria. Past Medical History: ___ was diagnosed pancreatic adenocarcinoma metastatic to the liver in ___ when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX ___ which was halted due to rising CA ___ and increased size of liver metastases. In ___, CA ___ elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In ___ he started gemcitabine/Abraxane. Imaging ___ showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Gem/Abraxane given at full dose in every other week regimen due to counts. Course complicated by right thigh muscle infarct presumed ___ in ___. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Other PMHx/PSHx: - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture Social History: ___ Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: GEN: NAD ECOG: 1 VITAL SIGNS: 100.3 136/56 74 18 100% on RA HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2, III/VI low pitched holosystolic murmur at the base - old per patient PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown, excoriation on the right leg, scar on the left second digit NEURO: Nonfocal Pertinent Results: ___ 07:30PM LACTATE-1.6 ___ 07:20PM URINE HOURS-RANDOM ___ 07:20PM URINE HOURS-RANDOM ___ 07:20PM URINE UHOLD-HOLD ___ 07:20PM URINE GR HOLD-HOLD ___ 07:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 07:20PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 07:20PM URINE MUCOUS-RARE ___ 07:15PM GLUCOSE-363* UREA N-27* CREAT-1.2 SODIUM-129* POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-19* ANION GAP-18 ___ 07:15PM ALT(SGPT)-100* AST(SGOT)-101* ALK PHOS-460* TOT BILI-0.6 ___ 07:15PM LIPASE-7 ___ 07:15PM ALBUMIN-3.8 ___ 07:15PM WBC-12.8*# RBC-2.89* HGB-9.0* HCT-26.1* MCV-90 MCH-31.1 MCHC-34.5 RDW-13.7 RDWSD-45.1 ___ 07:15PM NEUTS-83* BANDS-5 LYMPHS-9* MONOS-0 EOS-0 BASOS-0 ___ METAS-2* MYELOS-1* AbsNeut-11.26* AbsLymp-1.15* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 07:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 07:15PM PLT SMR-LOW PLT COUNT-120* CXR negative for PNA US negative for acute process, cholecystitis. Brief Hospital Course: This is a ___ year old male with pancreatic cancer on long term modified gemcitabine and NAB paclitaxel who is newly on Neulasta for blood count support and is now admitted with asymptomatic fever. Neulasta and gemcitabine both can cause fever, and he may actually have had one with his last dose, but did not check it. There are no localizing signs or symptoms. RUQ US this admission showed no evidence of cholecystitis. 1. Fever: Likely related to gemcitabine and Neulasta. Received a dose of ibuprofen 200 mg with good effect. Cultures, CXR, UA, and RUQ US negative. 2. Pancreatic cancer: Treating with palliative intent with gemcitabine plus NAB paclitaxel. 3. Diabetes: Sugars were actually low this admission, consistent with a non-infectious etiology of his presentation. 4. Hypertension: Continue home Carvedilol 12.5 mg PO/NG BID 5. BPH: Continue home Tamsulosin 0.4 mg PO QHS 6. Hyponatremia: Likely dry from chemo fatigue and NPO. Improved with fluids. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 2. Carvedilol 12.5 mg PO BID 3. Amlodipine 10 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 4. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary: Pancreatic cancer, chemotherapy induced fever Secondary: Diabetes, hypertension, mitral stenosis Discharge Condition: VITAL SIGNS: 100.3 136/56 74 18 100% on RA HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2, III/VI low pitched holosystolic murmur at the base - old per patient PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown, excoriation on the right leg, scar on the left second digit NEURO: Nonfocal Discharge Instructions: Dear Mr. ___, You were admitted for a asymptomatic fever. You are being treated for pancreatic cancer with gemcitabine plus NAB paclitaxel with the addition of filgrastim to prevent infections. Gemcitabine and filgrastim can both cause fevers that are not due to infection. Your blood tests, urine tests, chest Xray, and abdominal ultrasound showed no evidence of infection. Given this, the most likely explanation for your fever is gemcitabine or filgrastim. You can take low dose acetominophen or ibuprofen for fever as long as you feel otherwise completely well. Also, please stay well hydrated on chemotherapy and be sure to eat regularly. Followup Instructions: ___

10047172-DS-17

DS

2163-05-30 00:00:00

2163-06-06 15:11:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Attending: ___. Chief Complaint: anasarca Major Surgical or Invasive Procedure: therapeutic paracentesis with ___ History of Present Illness: Professor ___ is a pleasant ___ w/ T2DM, HTN, DL and pancreatic cancer metastatic to the liver (biopsy proven), dx ___, currently on C1D10 Gemcitabine and erlotinib, who p/w leaking paracentesis site on his LLQ, increased abdominal distention, increased b/l ___. His last paracentesis was ___, and 3L removed. He denied any F/CP/SOB but found to have new small b/l pleural effusions Past Medical History: ONCOLOGIC HISTORY: Mr. ___ was diagnosed pancreatic adenocarcinoma metastatic to the liver in ___ when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX ___ which was halted due to rising CA ___ and increased size of liver metastases. In ___, CA ___ elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In ___ he started gemcitabine/Abraxane. Imaging ___ showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed ___ diabetes in ___. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early ___: given discordance with ___, unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on ___ scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -___: Began modified FOLFIRINOX with dose reduction ___ IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at ___ for 3 cycles ___ ago) -___: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -___: Patient started on erlotinib with plan for C1D1 of gemcitabine on ___. -Admitted to ___ on ___ for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI ___ Social History: ___ Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 97.8F 156/72 91 18 97% 158 lbs General: NAD, Resting in bed comfortably, well nourished HEENT: MM dry, + mild thrush along the mandible folds CV: RR, NL S1S2 no ___ apical SEM PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, distended, dressing over LLQ saturated LIMBS: WWP, 2+ pitting ___, no tremors SKIN: No rashes on the extremities, port site looks well, skin overlying left picc intact NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.5 Axillary 140 / 70 92 19 95 RA General: NAD, Resting in bed comfortably, evidence of wasting though with distended abdomen HEENT: MM dry, + mild thrush along the mandible folds CV: RR, NL S1S2 no ___ apical SEM PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, notably distended, LLQ suture in place LIMBS: WWP, 2+ pitting ___, no tremors SKIN: No rashes on the extremities, port site looks well, skin overlying left picc intact NEURO: Grossly normal Pertinent Results: ADMISSION LABS ___ 12:08PM BLOOD WBC-2.4*# RBC-2.47* Hgb-8.0* Hct-23.6* MCV-96 MCH-32.4* MCHC-33.9 RDW-19.1* RDWSD-65.4* Plt ___ ___ 12:08PM BLOOD AbsNeut-1.57*# ___ 12:08PM BLOOD Plt ___ ___ 09:35PM BLOOD Glucose-172* UreaN-35* Creat-1.1 Na-137 K-4.1 Cl-102 HCO3-23 AnGap-16 ___ 09:35PM BLOOD ALT-38 AST-76* LD(LDH)-321* AlkPhos-949* TotBili-1.4 ___ 09:35PM BLOOD TotProt-6.1* Albumin-2.6* Globuln-3.5 ___ 09:45PM BLOOD Lactate-2.7* DISCHARGE LABS ___ 05:44AM BLOOD WBC-4.8 RBC-2.95* Hgb-9.2* Hct-27.7* MCV-94 MCH-31.2 MCHC-33.2 RDW-19.1* RDWSD-62.6* Plt ___ ___ 09:35PM BLOOD Neuts-63 Bands-1 ___ Monos-10 Eos-0 Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-3.42 AbsLymp-1.17* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00* ___ 09:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:44AM BLOOD Plt ___ ___ 05:44AM BLOOD ___ ___ 05:44AM BLOOD Glucose-156* UreaN-32* Creat-1.0 Na-136 K-4.1 Cl-102 HCO3-23 AnGap-15 ___ 05:44AM BLOOD ALT-36 AST-74* LD(LDH)-305* AlkPhos-933* TotBili-1.5 ___ 05:44AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.9 IMAGING: MRI Liver ___ Progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. Additionally, the primary pancreatic cancer in the pancreatic head is very minimally increased in size. CT CHEST w/ CON ___ New irregular nodule in the right upper lobe and interval increase of the right lower lobe nodules concerning for progressive metastatic disease. ERCP ___ EUS was performed using a linear echoendoscope at ___ MHz frequency •The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. •The body and tail [partially] were imaged from the gastric body and fundus. •Mass: A 3.5 cm X 4 cm ill-defined mass was noted in the head of the pancreas. •The mass was hypoechoic and heterogenous in echotexture. •The borders of the mass were irregular and poorly defined. •The mass is involving the confluence, especially the SMV with narrowing of vessel diameter. •FNB was performed. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge needle with a stylet was used to perform biopsy. •Six needle passes were made into the mass. •Biopsies were sent for pathology. •Scan of the left hepatic lobe reveled multiple hypoechoic lesions measured between 0.5-2cm, highly suspected for metastatic disease, FNB was performed from 3 different hepatic lesions •Otherwise normal upper eus to third part of the duodenum CXR ___ 1. Left PICC tip in the low SVC. No pneumothorax. 2. Small bilateral pleural effusions, new in the interval, with bibasilar atelectasis. Brief Hospital Course: ___ w/ T2DM, HTN, DL and pancreatic cancer metastatic to the liver (biopsy proven), dx ___, currently on C1D10 Gemcitabine and erlotinib, recent biliary sepsis s/p stent/completed abx course for klebsiella bacteremia (last dose zosyn ___ who p/w leaking paracentesis site on his LLQ and increased anasarca with ___ edema and new asymptomatic ___ pleural effusions, patient is now s/p therapeutic paracentesis ___. He was seen by his primary oncologist and will follow up with her on ___ and will continue with 1000 mg xeloda bid X 14 days, 7 days off and tarceva continuously once home delivery complete. # Increased Anasarca # Ascites # Leaking Paracentesis site Since ___, pt has gained 24 lbs. Likely multifactorial, but will discuss w/ onc whether this maybe due to capillary leak syndrome from gemcitabine. Other causes include pancreatic ca, pseudocirrohsis from liver mets, protein calorie malnutrition, iatrogenic fluid overload from TPN. INR and LFTs largely stable w/o evidence of hepatic decompensation. He was started on lasix on most recent admission. - home amlodipine, lisinopril held while patient was admitted so that diuretic regimen could be increased. started on 50mg daily and 20mg Lasix daily. TPN was held for contribution to fluid overload. Patient underwent ___ guided therapeutic para ___ # Pancreatic Ca Diagnosed ___ stage 4, progressed on modified FOLFIRINOX, C1 Gemzar ___ received erlotinib. Dr ___ followed through inpatient admission. Did not administer Gemcitabine while inpatient. pt will follow up as outpatient for Gemcitabine, dosing schedule per Dr. ___. ___ consider every other week dosing given significant fatigue, weigh benefits and AEs of chemo. Continued Ritalin and Ativan prn, continued creon 2 caps w/ break, 2 w/ lunch, 1 w/ dinner, 0 w/ snacks # Gastric/Duodenal outlet obstruction # Protein Calorie Malnutrition. Per recent discharge note, he is not a candidate for duodenal stent given high likelihood of migration. He was started on TPN. SHould continue to evaluate contribution of TPN to fluid overload. TPN held during hospitalization for diuresis. # Thrombocytopenia This is most likely due to his hepatic disease and splenomegaly, as well as chemo. However there was c/f HIT on recent admission but ruled out. avoided hsq for now until further clarified w/ Dr ___. continued TEDS # Normocytic Anemia: due to inflammatory block from neoplasm and antineoplastic therapy # Recent Klebsiella bacteremia: completed treatment course with Zosyn on ___. # T2DM: At home takes metformin w/ Glargine 10U w/ breakfast and ISS. Here will hold and keep only on ISS. Of note, he also has insulin in his TPN. # HTN: held amlodipine (which can cause ___ and lisinopril in favor of lasix and aldactone # Heart murmur: chronic x ___ years per his report # BPH: cont tamsulosin bid. TRANSITIONAL ISSUES ================================== -home amlodipine 10 mg and lisinopril 5 mg daily held for BP room as patient started on spironolactone 50 mg for increased diuresis -Please F/U BP, Cr and next apt; d/c weight 158 lbs; presumed dry weight 136 lbs, d/c creatinine 1.0 -Patient advised to call PCP and oncologist regarding extreme weight changes -Left message for ___ TPN center to try to concentrate home TPN to help reduce fluid overload Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY 2. Creon ___ CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. MethylPHENIDATE (Ritalin) 20 mg PO QAM 7. Pyridoxine 50 mg PO DAILY 8. Simethicone 80 mg PO TID:PRN gas 9. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Nystatin Oral Suspension 5 mL PO QID 12. Tamsulosin 0.4 mg PO BID 13. Furosemide 20 mg PO DAILY Discharge Medications: 1. Creon ___ CAP PO TID W/MEALS 2. DULoxetine 30 mg PO DAILY 3. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 5. MethylPHENIDATE (Ritalin) 20 mg PO QAM 6. Nystatin Oral Suspension 5 mL PO QID 7. Pyridoxine 50 mg PO DAILY 8. Simethicone 80 mg PO TID:PRN gas 9. Tamsulosin 0.4 mg PO BID 10. Spironolactone 50 mg PO DAILY RX *spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Furosemide 20 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 13. Erlotinib ___ mg PO DAILY dosing per outpatient oncologist 14. Capecitabine 1000 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pancreatic cancer malignant ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital for continued leakage after undergoing paracentesis. You had stitches placed to good effect to stop the leaking. While in the hospital, you underwent paracentesis with the interventional radiology team and your diuretics were increased to add spironolactone 50mg daily on top of your furosemide 20 mg daily to prevent fluid from accumulating. You are now safe for discharge home with close follow up. We left a message with out TPN team to adjust and concentrate your home TPN. You should also follow up with Dr. ___ in ___. You will continue your chemotherapy at home as planned until you get home delivery of xeldoa (1000 mg twice a day for two weeks on, then one week off) and Tarceva. It was a pleasure caring for you - we wish you well! Sincerely, Your ___ Oncology Team Followup Instructions: ___

10047297-DS-12

DS

2130-02-23 00:00:00

2130-02-23 10:07:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim DS / Purinethol / simvastatin / lovastatin / Pravastatin / Fosamax / Niaspan Extended-Release / Cholest Off / colestipol / citalopram Attending: ___. Chief Complaint: weakness, AMS Major Surgical or Invasive Procedure: None History of Present Illness: CC: weakness, ams HPI(4): ___ female with moderate to severe dementia, on treatment for C. difficile, ulcerative colitis presents with presyncope, altered mental status. Per ED, patient had recurrence of diarrhea yesterday. Today she was increasingly weak and fatigued, not acting as her normal self. The family believes that she was sufficiently weak that they believe that she was close to passing out. They report that her mental status is improved at the time of evaluation. The patient denies any active pain. Denies any fevers. Family denies any history of cough, fevers, report of abdominal pain, vomiting. Per ED she is currently being treated for C Diff. Per ED has PNA and UTI will treat with rocephin and azithro Per nursing, patient presents after experiencing a near syncopal episode earlier today. Patient is actively being treated for cdiff with PO vanco. Per family, patient became drowsy and "talking slow" and denies LOC. Denies hitting head/injury. Denies complaints. Reports decreased PO intake. I reviewed VS, labs, orders, imaging, old records. VSS, HR 90 on arrival, BP was 98/55, improved w/ IVF, RR 23 at max, satting well. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: PROTHOMBIN GENE MUTATION ARTHRITIS SCIATICA TOTAL ABDOMINAL HYSTERECTOMY HEART MURMUR IMPAIRED FASTING GLUCOSE INSOMNIA HYPERCHOLESTEROLEMIA ALLERGIC RHINITIS GASTROESOPHAGEAL REFLUX HEART MURMUR HYPERCHOLESTEROLEMIA IMPAIRED FASTING GLUCOSE OSTEOPENIA PROTHOMBIN GENE MUTATION ULCERATIVE COLITIS OBESITY DEMENTIA Social History: ___ Family History: FAMILY HISTORY: Relative Status Age Problem Onset Comments Mother ___ DEMENTIA Father ___ LUNG CANCER smoker Sister ___ LEUKEMIA Brother Living ___ Brother Living ___ Son Living ___ PROTHROMBIN GENE Son Living ___ DEEP VENOUS THROMBOPHLEBITIS PROTHROMBIN GENE Physical Exam: Admission Exam =================================== EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: soft, diffusely tender abdomen GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge Exam ======================================== Pertinent Results: ADMISSION LABS ========================= ___ 11:35PM BLOOD WBC-15.1* RBC-4.80 Hgb-12.9 Hct-40.2 MCV-84 MCH-26.9 MCHC-32.1 RDW-15.6* RDWSD-46.8* Plt ___ ___ 11:35PM BLOOD Neuts-73.5* Lymphs-14.2* Monos-6.8 Eos-2.7 Baso-0.8 Im ___ AbsNeut-11.06*# AbsLymp-2.14 AbsMono-1.02* AbsEos-0.41 AbsBaso-0.12* ___ 11:35PM BLOOD Plt ___ ___ 11:35PM BLOOD Glucose-84 UreaN-15 Creat-0.7 Na-143 K-3.3 Cl-103 HCO3-21* AnGap-19* ___ 11:35PM BLOOD ALT-16 AST-21 AlkPhos-77 TotBili-0.2 ___ 10:20PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8 ___ 05:55AM BLOOD calTIBC-216* Ferritn-204* TRF-166* ___ 10:43PM BLOOD ___ pO2-108* pCO2-34* pH-7.47* calTCO2-25 Base XS-1 ___ 09:28AM BLOOD Lactate-1.6 DISCHARGE LABS: ========================= MICRO ========================= UCx (___): ___ yeast Stool Cx (___): negative UCx (___): mixed flora BCx (___): pending STUDIES: ========================= EKG (___) NSR at 61 bpm, LAD, PR 116, QRS 88, QTC 458, TWI III (similar to ___ EKG (___): NSR at 72 bpm, borderline LAD, PR 147, QRS 97, QTC 461, TWI III/V3 (QTC increased from 433 in ___ CXR (___): The patient is rotated, limiting evaluation however persisting opacities in the right lower lung are likely not significantly changed. NCHCT (___): Exam is limited by motion despite multiple attempted repeats. Within this limitation, there is no acute intracranial process. CXR (___): Probable right lower lobe pneumonia. Brief Hospital Course: ___ w/ dementia, UC (on prednisone/mesalamine), C. diff (on PO vanco since ___ p/w diarrhea and presyncopal episode. # Pre-syncopal episode: # AMS: # Possible UTI: # Possible CAP: The patient presented with confusion and a near syncopal episode, likely in the setting of increased diarrhea and hypovolemia secondary to undertreated C.diff (patient reportedly non-adherent to PO Vancomycin). WBC initially 15.1, electrolytes and lactate WNL. UA positive, although patient without clear urinary symptoms and UCx with mixed flora (likely contaminated, repeat with yeast). CXR with possible RLL pneumonia, but no clear respiratory symptoms. NCHCT negative for intracerebral hemorrhage. S/S evaluation showed no e/o aspiration. Legionella Ag negative, Strep pneumo pending at discharge. BCx NGTD at discharge. Received IVFs and was started on CTX/azithromycin with resolution of leukocytosis and rapid return to baseline mental status. On the night of ___ the patient was noted to be difficult to arouse after receiving seroquel and ramelteon for insomnia. Labs and VBG were reassuring, and the episode was attributed to medication effect. She was again at baseline mental status the following morning. Although suspicion for infection was relatively low, given her initial leukocytosis and rapid improvement on antibiotics (or perhaps despite antibiotics), she was narrowed to cefpodoxime (PCN allergy and prolonged QTC) and discharged to complete a 10d course (___). She is being discharged to rehab for ___ and additional support in the setting and acute infections. # Diarrhea: # C diff: # Ulcerative colitis: Patient presented with diarrhea in setting of recently diagnosed C.diff and concern for PO Vancomycin non-adherence (husband was reportedly not giving her the medication 4x/d). The GI service was consulted and thought a UC flare less likely. Vancomycin was re-initiated, with improvement in her diarrhea (only ___ loose stools documented daily). Given likely non-adherence, her start date for vancomycin should be considered ___ (not ___ when originally prescribed), with duration of course to be determined by outpatient GI (Dr. ___ but likely 2 weeks after completion of antibiotics (through ___. The patient's home prednisone was changed from 6mg alternating with 6.5mg to 6.5mg daily for ease of administration per GI. Of note, the patient was often unwilling to take mesalamine (didn't appear to have difficulty swallowing capsules but would spit them out). This medication was continued on discharge, but the patient's outpatient gastroenterologist, Dr. ___, was notified that medication adjustment may be necessary in the outpatient setting. # Leukocytosis: WBC 15.1 on admission. Improved with fluids, resumption of PO Vancomycin, and antibiotics for possible PNA vs UTI. On ___ slightly uptrended to 12.4, without clear evidence of new infection. ___ be secondary to known C.diff, for which she is being treated. WBC 10.5 on discharge. # Dementia: # Sundowning: Severe, likely fronto-temporal dementia at baseline (AOx1, pleasant, conversant but largely nonsensical, dependent in most ADLs). Per son, ___., patient is now back to baseline. Home memantine was continued (although limited data in fronto-temporal dementia). She frequently tried to get up without nursing assistance and sundowned in the evenings. Seroquel was trialed initially; in combination with ramelteon it caused hypersomnolence. Given borderline prolonged QTC (450s-460s), trazodone 25mg was trialed without effect. All efforts should be made to minimize pharmacologic treatments if possible. Should pharmacologic options be necessary, QTC should be monitored closely. QTC at discharge was 480. # Microcytic/normocytic anemia: Hct 40.2 on admission, downtrended to 33 and 34.8 on discharge. Ferritin 204, TIBC 216. No e/o active bleeding. Further w/u was deferred to outpatient providers. # Hypernatremia: # Hypophosphatemia: Intermittently mildly hypernatremia and hypophosphatemic, likely due to poor PO intake. Phos was repleted and PO intake encouraged (often required prompting to eat), with resolution of both. # Concern for inadequate home support: The patient's dementia is significant enough that she needs 24 hour help, including with most ADLs. There was concern that her husband (and primary caregiver) may suffer from some dementia himself and is partly unwilling and partly unable to provide necessary around-the-clock care. After a family meeting on ___, the family agree to rehab placement and is considering completion of a ___ application to have long-term care as an option afterwards, which she will likely need. The patient's husband is opposed to this plan but is not the HCP and cannot care for her at home. The patient's HCP confirms that she remains FULL CODE for now as they discuss as a family. ** TRANSITIONAL ** [ ] f/u BCx (pending at discharge) [ ] f/u Strep pneumo Ag (pending at discharge) [ ] check electrolytes, including Na, K, Phos on ______ [ ] monitor QTC if QTC prolonging medications resumed [ ] cefpodoxime course ___ [ ] outpatient gastroenterologist (Dr. ___ to consider alternatives to mesalamine if patient unwilling to take Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ketoconazole 2% 1 Appl TP BID:PRN rash 2. Memantine 10 mg PO BID 3. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT 4. PredniSONE 6.5 alternating with 6 mg PO DAILY 5. QUEtiapine Fumarate 50 mg PO QHS:PRN agitation 6. Sertraline 50 mg PO DAILY 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. PredniSONE 6.5 mg PO DAILY 3. TraZODone 25 mg PO QHS:PRN insomnia 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 5. Ketoconazole 2% 1 Appl TP BID:PRN rash 6. Memantine 10 mg PO BID 7. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT 8. Sertraline 50 mg PO DAILY 9. Vancomycin Oral Liquid ___ mg PO Q6H 10. HELD- QUEtiapine Fumarate 50 mg PO QHS:PRN agitation This medication was held. Do not restart QUEtiapine Fumarate until told to do so by your primary care doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pre-syncope Clostridium difficile Possible UTI Possible CAP Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with confusion and a near fainting episode, likely secondary to dehydration in the setting of diarrhea. Infection was thought unlikely, but given some evidence for a urinary tract infection you were started on antibiotics, continued at discharge (cefpodoxime through ___. Given the status of your heart, Seroquel is likely not the ___ medication for sleep. Please follow up with your primary care doctor to consider alternatives, recognizing that there are no good options available unfortunately. You are being discharged to a rehab facility, where you will have additional assistance with your medications and self care while you recover your strength. With ___ wishes, ___ Medicine Followup Instructions: ___

10047484-DS-2

DS

2160-11-04 00:00:00

2160-11-04 21:58:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Demerol / Iodinated Contrast- Oral and IV Dye Attending: ___. Major Surgical or Invasive Procedure: NGT placement ___ EGD ___ no interventions NGT placement ___ attach Pertinent Results: ADMISSION LABS: =============== ___ 04:15PM BLOOD WBC-11.4* RBC-5.01 Hgb-15.5 Hct-45.6 MCV-91 MCH-30.9 MCHC-34.0 RDW-13.2 RDWSD-43.2 Plt ___ ___ 01:34AM BLOOD ___ PTT-22.8* ___ ___ 04:15PM BLOOD Glucose-136* UreaN-14 Creat-0.9 Na-135 K-5.9* Cl-97 HCO3-19* AnGap-19* ___ 04:15PM BLOOD ALT-46* AST-60* AlkPhos-114 TotBili-0.5 ___ 04:15PM BLOOD Albumin-4.5 ___ 04:45AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9 ___ 04:40PM BLOOD Lactate-3.2* K-4.1 IMAGING: =============== RUQ Ultrasound ___: 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. See recommendations below. ___ Ultrasound ___: "IMPRESSION: Acute deep venous thrombosis of the left common femoral, femoral, popliteal and posterior tibial veins. Minimal flow in the common femoral vein, but there is complete occlusion of the remaining veins. No right lower extremity deep venous thrombosis." CXR ___: "IMPRESSION: No acute cardiopulmonary abnormality." CT Abdomen without contrast ___: "IMPRESSION: 1. Multiple, partially imaged small bowel loops, fluid-filled and dilated to approximately 3.2 cm, with a relatively decompressed terminal ileum. These findings can be seen in the setting of a gastroenteritis, particularly given the presence of fluid within the colon, but an ileus or partial small-bowel obstruction is not definitely excluded. Further assessment with CT imaging of the pelvis may be helpful for further evaluation. 2. Mild pneumobilia within the left hepatic lobe, which could reflect prior sphincterotomy and correlation with any history of endoscopy recommended." CXR ___: "IMPRESSION: The enteric tube extends below the level of diaphragm, with the tip projecting over the stomach." CTA Chest ___: IMPRESSION: 1. Acute, nonocclusive thrombus within the left pulmonary artery that extends distally to involve the left upper and lower lobe arteries and several of their proximal segmental branches. Several nonocclusive thrombi are also seen within the segmental branches of the right pulmonary artery. 2. No evidence of interventricular septal bowing to suggest right heart strain. 3. No evidence of parenchymal opacification to suggest pulmonary infarct. 4. Mildly ectatic ascending thoracic aorta, measuring up to 4.1 cm in diameter. 5. Moderate coronary atherosclerotic disease." KUB for Colonic Transport ___: "IMPRESSION: Persistent small bowel obstruction." KUB Portable ___: "IMPRESSION: 1. Persistent partial small bowel obstruction as evidence by progression of the oral contrast into the colon. 2. Suggest advancing nasogastric tube 5 cm into the stomach." TTE ___: "IMPRESSION: Suboptimal image quality. Mild right ventricular cavity dilation but with preserved free wall motion. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function. Mild aortic root dilation. Unable to quantify pulmonary artery systolic pressure. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and ___ ACC/AHA recommendations, antibiotic prophylaxis is NOT recommended." EGD ___: "Normal mucosa in the whole esophagus. Normal mucosa in the whole stomach. Normal mucosa in the whole examined duodenum. Normal major papilla." KUB ___: IMPRESSION: No evidence of obstruction. CXR - line placement ___: "IMPRESSION: 2 sequential images demonstrate advancement of an enteric tube which ultimately projects over the stomach." CT A/P ___ IMPRESSION: 1. Uncomplicated mild acute diverticulitis involving a diverticula along the markedly redundant sigmoid colon in the right upper quadrant, corresponding to site of tenderness. 2. No evidence of bowel obstruction. 3. Mild left hepatic lobe pneumobilia, slightly increased since previous examination. Status post cholecystectomy. KUB ___ 1. Small stool burden within the colon. 2. No dilated loops of small or large bowel. DISCHARGE LABS: ================= ___ 05:55AM BLOOD WBC-6.7 RBC-4.39* Hgb-13.4* Hct-40.8 MCV-93 MCH-30.5 MCHC-32.8 RDW-13.4 RDWSD-45.2 Plt ___ ___ 05:55AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-142 K-4.0 Cl-107 HCO3-21* AnGap-14 DISCHARGE PHYSICAL EXAM: ==================== 24 HR Data (last updated ___ @ 631) Temp: 97.7 (Tm 98.5), BP: 120/77 (119-148/73-84), HR: 72 (64-87), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: Ra GENERAL: resting comfortably, NAD HEENT: NCAT, PERRLA. R eye with medial conjunctival injection and watery tearing/discharge. No purulence. + rosacea CARDIAC: RRR, normal S1 and S2. No m/r/g LUNGS: CTAB, no w/r/r. No increased work of breathing. ABDOMEN: + BS, distended, tympanic to percussion. No epigastric tenderness to deep palpation EXTREMITIES: 1+ LLE non-pitting edema, L>R. Mild pedal edema bilaterally. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. NEUROLOGIC: awake, alert and interactive. Moving all extremities with purpose Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Medications STARTED: amox-clav 875mg PO Q8H, warfarin [] Medications STOPPED: furosemide 40mg [] GI - Consider capsule study to evaluate potential etiology of pSBO [] PCP: - ___ dose warfarin as needed with a goal INR of ___, repeat INR on ___. Patient discharged with 10 days of lovenox as well as warfarin. Discharge INR 1.5 and warfarin dose on day of discharge 6.5mg. - Please follow-up resolution of abdominal pain from diverticulitis with completion of 10 days amox-clav (last day ___ - Please refer to GI for follow-up with capsule study for UGIB - Noted to have pneumobilia on imaging, EGD consistent with prior sphincterotomy. If he develops RUQ pain, would have low threshold to image to ensure pneumobilia is not source of the pain - Found to have echogenic liver consistent with steatosis, consider fibroscan/MRE in the outpatient setting to r/o cirrhosis/fibrosis - Recommend outpatient therapy for rosacea # CONTACT: Health care proxy: ___ Relationship: Husband Phone number: ___ Cell phone: ___ BRIEF HOSPITAL COURSE: ======================= Mr. ___ is a ___ yo M with hx of bipolar disorder and HTN who presented with bilateral leg swelling, dyspnea on exertion, abdominal pain, nausea and coffee ground emesis found to have acute PE, extensive LLE DVT and pSBO. He was bridged initially with heparin, but transitioned to lovenox while starting warfarin, which will be continued on discharge. In regards to his pSBO, NGT was placed, which put out coffee ground emesis. He was managed conservatively and improved with bowel rest and transitioned to a regular diet. GI was consulted for concern of UGIB and the patient underwent an EGD on ___, which did not find a source of the upper GI bleed. He subsequently developed recurrent abdominal distention with concern for SBO, but CT demonstrated mild diverticulitis, which was treated with amox-clav, which was continued on discharge. He was discharged home and his PCP ___ manage his warfarin moving forward. ACUTE ISSUES: ============== # Acute PE # Extensive LLE DVT Patient presented with dyspnea on exertion and worsening leg swelling over the past ___ weeks, found to have acute nonocclusive thrombus within left PA extending distally to involve the left upper and lower lobe arteries and several of their proximal segmental branches. Several nonocclusive thromi were also seen within segmental branches of right pulmonary artery. Also found to have acute DVT of left common femoral, popliteal, and posterior tibial veins with minimal flow in common femoral vein but complete occlusion of remaining veins. No clear provoking factor but patient does report more sedentary lifestyle since his husband has been ill. He was treated with a heparin gtt initially before starting a lovenox bridge to warfarin. Of note, DOACs were not started due to ineraction with his antipsychotic medications. His primary care physician ___ manage his anticoagulation in the outpatient setting. He is being discharged with Lovenox bridge and warfarin 6.5mg daily with script to have INR checked on ___. # partial Small bowel obstruction: resolved Presented with nausea and emesis found to have multiple, partially imaged dilated, fluid filled small bowel loops to 3.2 cm with decompressed terminal ileum. Seen by ACS in ED who placed an NGT. He was managed conservatively and SBO was persistent on gastrograffin study but then resolved with KUB at later point. He was maintained on mIVF while NPO. The partial SBO resolved with bowel rest and he improved with time. He was able to tolerate a regular diet prior to discharge, was passing flatus, and having bowel movements. The etiology of the pSBO was though to be from local inflammation in the setting of diverticulitis as noted below. # Mild diverticulitis: In setting of recurrent abdominal distension and abdominal discomfort there was initial concern for SBO recurrence. NG tube was placed and ACS was reconsulted. Due to decreased NGT output, CT was obtained and demonstrated acute, mild diverituclitis without evidence of complications. He was started on amox-clav due to ciprofloxacin interactions with his warfarin. His diet was slowly advanced until he was tolerating a regular PO diet. Prior to discharge he had a normal bowel movement. He is discharged with total 10 day course of amoxicillin-clav with last day ___. # Coffee ground emesis: resolved # Concern for UGIB Patient with hx of GERD and ___ esophagus and noted increasing abdominal discomfort over the last week. He reported episode of black emesis and noted to have coffee ground emesis from NGT in ED and ICU. was treated with IV PPI BID and his hemoglobin remained stable. GI was consulted and the patient underwent an EGD on ___ that did not find the source of the bleeding. He should follow-up with GI as an outpatient to consider capsule study. # Acute hypoxemic respiratory failure - resolved Patient with low level O2 requirement in ICU and transition to floor which resolved with use of incentive spirometer. This was likely secondary to PE vs. atelectasis from sedentary lifestyle. # Pneumobilia: noted to have pneumobilia on CT imaging as an inpatient and during EGD, per GI, he was noted to have a history of spinchterotomy in the past, which can help to explain the persistent pneumobilia. There was no further intervention indicated. # Irritant conjunctivitis: He was noted to have conjunctival injection/conjunctivitis, likely irritant in setting of eyelash given that patient notes history of prior episodes. He had no purulent drainage, visual changes, eye pain or headaches, and his irritant conjunctivitis improved prior to discharge. # Rosacea: Noted to have progression of his rosacea while inpatient. He would benefit from additional outpatient therapy. CHRONIC/STABLE ISSUES: ====================== # Hypothyroidism: Continued levothyroxine 88mcg daily # Bipolar disorder: continued risperidone 1mg qhs, carbamazepine 100mg qAM, 200mg qPM, clonazepam 0.25mg BID, buspirone 30mg BID # HTN: restarted home amlodipine # Insomnia: continued melatonin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 88 mcg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Benzonatate 200 mg PO TID:PRN cough 4. Pantoprazole 40 mg PO Q12H 5. RisperiDONE 1 mg PO QHS 6. CarBAMazepine 100 mg PO QAM 7. CarBAMazepine 200 mg PO QPM 8. ClonazePAM 0.5 mg PO BID 9. BusPIRone 30 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. amLODIPine 5 mg PO DAILY 12. melatonin 10 mg oral QHS 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q8H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #*13 Tablet Refills:*0 2. Enoxaparin (Treatment) 120 mg SC Q12H RX *enoxaparin 120 mg/0.8 mL 120 mg IM twice a day Disp #*20 Syringe Refills:*0 3. Warfarin 6.5 mg PO DAILY16 Take daily until instructed to change dose by a doctor 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. BusPIRone 30 mg PO BID 7. CarBAMazepine 100 mg PO QAM 8. CarBAMazepine 200 mg PO QPM 9. ClonazePAM 0.5 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. Furosemide 40 mg PO DAILY 12. Levothyroxine Sodium 88 mcg PO DAILY 13. melatonin 10 mg oral QHS 14. Pantoprazole 40 mg PO Q12H 15. RisperiDONE 1 mg PO QHS 16.Outpatient Lab Work ICD-9: 415.1 Please draw ___ on ___ Fax results to Dr. ___. FAX: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ==================== Acute pulmonary embolism Acute deep venous thrombosis Diverticulitis SECONDARY DIAGNOSIS: ==================== partial small bowel obstruction Acute hypoxemic respiratory failure Concern for upper GI bleed, coffee ground emesis Hypothyroidism Bipolar disorder Hypertension Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for trouble breathing, abdominal pain, and bloody vomit. What was done for me while I was in the hospital? - We found a blood clot in your leg and lungs. - You were started on medications (warfarin and lovenox) to help prevent further blood clots - You underwent an endoscope to evaluate the cause of your bloody vomit and you were started on a medication to help prevent any more episodes of bloody vomiting. - You had a tube placed in your nose to help relieve the obstruction in your bowels - You were started on antibiotics to help treat diverticulitis, an infection of the bowel What should I do when I leave the hospital? -Please take all of your medications as prescribed. Please go to all of your follow up appointments as scheduled. -Please have blood work drawn on ___ at the ___ lab (___) so your PCP can help adjust your dose of blood thinner medication (warfarin). -If you find you are not having a daily bowel movement, you may try taking Miralax (polyethylene gycol) which is available over the counter. Sincerely, Your ___ Care Team Followup Instructions: ___

10048001-DS-10

DS

2182-05-06 00:00:00

2182-05-06 15:59:00

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 Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with history of ___ disease c/b cirrhosis, esophageal varices and recurrent episodes of cholangitis and VRE bacteremia on suppressive medications presenting for low grade fever and dyspnea. Patient notes onset of dyspnea with dry cough on ___. Shortness of breath present while lying down or sitting up. No chest pain, pleuritic symptoms, lightheadedness/dizziness. No history of asthma or COPD but feels like he has been wheezing. Notes low grade fever 99.5 at home. Denies abdominal pain, chills, diarrhea, blood in stool or black stools. Has been eating and drinking well. No sick contacts. Of note, patient was recently admitted with concern for upper GI bleed form gastropathy with EGD only showing grade I varices and acute cholangitis with Enterococcus bacteremia treated with Daptomycin for 2 weeks. Patient had previously been on suppressive antibiotics with levofloxacin and cefpodoxime since ___ without infections. Given recurrent resistant bacterial infections and resistance profile of bacteria, prophylaxis regimen was changed to 1 month of cefpodoxime alternating with 1 month of Augmentin at recent ID visit. He was started on Augmentin on ___ at which point right arm PICC was also removed. He has started Augmentin on ___ as well though has previously taken this medication without issues. In the ED initial vitals: T 99.4 HR 82 BP 104/53 RR 20 100%RA -->94% 2L - Exam notable for: PULM: Mild end expiratory wheeze throughout, dry cough, no accessory mm. ABDOMINAL: Nontender, mildly distended, no rebound/guarding, no peritonitic signs - Labs notable for: WBC 5.3 Hgb 11.3/35.3 Plt 43 137/100/17 -----------<112 4.0/23/1.2 ATL 23, AST 48 AP 133 Tbili 2.2 Alb 3.1 Lipase 19 Trop <0.01 Lactate 2.6 Flu negative UA: negative - Imaging notable for: CXR: Low lung volumes with bibasilar atelectasis. abdominal U/s: No tappable pocket on abdominal u/s - Patient was given: 1L LR On the floor, patient appears to be in acute respiratory distress, sitting up at the side of the bed. Denies chest pain but confirms history above with worsening shortness of breath since ___. No recent travel or pain in the ___. Notes stable mild generalized abdominal pain that remains stable without other symptoms. Stat CTA obtained on the floor consistent with bilateral PE. REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS reviewed and negative. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: ther is alive with heart disease. Father died at ___ of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== T 98.6 BP 125/72 HR 92 RR 24 Sat 95% 3L NC GENERAL: sitting up in acute respiratory distress with use of accessory muscles, tripoding, able to complete full sentences, coughing intermittently HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: supple, no JVD HEART: tachycardic, regular rhythm, no murmurs, gallops, or rubs LUNGS: tachypneic, Diffuse wheezing bilaterally, no rhonchi or crackles, otherwise as above ABDOMEN: Mildly TTP diffusely, easily reducible umbilical hernia, +hepatomegaly, no rebound or peritoneal signs EXTREMITIES: no ___ edema, no calf tenderness, Right upper extremity without tenderness or swelling NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis DISCHARGE PHYSICAL EXAM: ======================== GENERAL: laying in bed comfortably, does not appear in respiratory distress. A&Ox3 HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: supple, no JVD HEART: RRR LUNGS: CTAB, breathing comfortably ABDOMEN: Mildly distended but soft, nontender. EXTREMITIES: no ___ edema, no calf tenderness, Right upper extremity without tenderness or swelling. Bilateral upper extremities appear symmetrical. NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis Pertinent Results: ADMISSION LABS: =============== ___ 08:54PM URINE HOURS-RANDOM ___ 08:54PM URINE UHOLD-HOLD ___ 08:54PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 08:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 07:50PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 06:39PM LACTATE-2.6* ___ 04:30PM GLUCOSE-112* UREA N-17 CREAT-1.2 SODIUM-137 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14 ___ 04:30PM estGFR-Using this ___ 04:30PM ALT(SGPT)-23 AST(SGOT)-48* ALK PHOS-133* TOT BILI-2.2* ___ 04:30PM LIPASE-19 ___ 04:30PM cTropnT-<0.01 proBNP-906* ___ 04:30PM ALBUMIN-3.1* ___ 04:30PM WBC-5.3 RBC-3.63* HGB-11.3* HCT-35.3* MCV-97 MCH-31.1 MCHC-32.0 RDW-19.7* RDWSD-69.0* ___ 04:30PM NEUTS-77.7* LYMPHS-7.4* MONOS-11.4 EOS-2.3 BASOS-0.4 IM ___ AbsNeut-4.08 AbsLymp-0.39* AbsMono-0.60 AbsEos-0.12 AbsBaso-0.02 ___ 04:30PM ___ PTT-31.1 ___ ___ 04:30PM PLT COUNT-43* PERTINENT STUDIES: ================== ___ Imaging CHEST (PA & LAT) Low lung volumes with bibasilar atelectasis. ___ Imaging CTA CHEST Large bilateral pulmonary emboli with evidence of right heart strain. No signs of associated pulmonary infarct. ___ Imaging BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ Imaging UNILAT UP EXT VEINS US Nonocclusive thrombus within the right axillary vein and proximal to mid right basilic vein. ___ Imaging DUPLEX DOPP ABD/PEL 1. Heterogeneous hepatic parenchyma with patent paraumbilical vein and retrograde flow of the right portal vein into the left portal vein. No evidence of thrombosis. 2. Splenomegaly, measuring 19.6 cm, previously 18.5 cm. ___ Imaging CHEST (PORTABLE AP) Mild pulmonary edema, new. ___ TTE IMPRESSION: Preserved biventricular systolic function. Mild to moderate tricuspid regurgitation. Mild mitral regurgitation. Moderate to severe pulmonary hypertension. Very small pericardial effusion. DISCHARGE LABS: =============== ___ 06:17AM BLOOD WBC-2.5* RBC-3.04* Hgb-9.5* Hct-29.7* MCV-98 MCH-31.3 MCHC-32.0 RDW-20.5* RDWSD-73.1* Plt Ct-39* ___ 06:17AM BLOOD ___ PTT-36.2 ___ ___ 06:17AM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-145 K-4.2 Cl-110* HCO3-22 AnGap-13 ___ 06:17AM BLOOD ALT-19 AST-26 AlkPhos-108 TotBili-1.0 ___ 06:17AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.4 Mg-1.6 Iron-31* ___ 06:17AM BLOOD calTIBC-203* Ferritn-95 TRF-156* ___ 05:52AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in Brief Hospital Course: ___ male with past medical history notable for Caroli disease complicated by recurrent episodes of cholangitis and VRE bacteremia on suppressive regimen, resultant cirrhosis with esophageal varices and portal gastropathy, presented with low grade fevers and dyspnea. Found on CTA to have acute bilateral PE with signs of RV strain but otherwise hemodynamically stable. Patient was anticoagulated first on heparin drip and then transitioned to rivoraxaban. TRANSITIONAL ISSUES: ==================== [ ] Please obtain repeat echocardiogram in ___ weeks to monitor pulmonary artery pressures. TTE from this admission showed estimated PA pressures were 52 mmHg likely from PE. [ ] Pulmonary embolus presumed to be provoked in setting of PICC associated DVT. Would reevaluate after 6 months of therapy if anticoagulation needs to be continued indefinitely. [ ] Patient's transferrin saturation was 15% (iron 31, calTIBC 203, ferritin 95, transferrin 156). Please consider outpatient iron supplementation ACUTE ISSUES: ============ #Hypoxia #Acute Submassive PE Patient presented with dyspnea and CTA ___ demonstrated acute bilateral PE. Patient recently had PICC removed on ___ after finishing IV daptomycin course for recent admission for enterococcus bacteremia. Doppler of right upper extremity demonstrating DVT, lower extremity dopplers negative. In this setting, PE presumed to be provoked. Surface echocardiogram with significant pulmonary hypertension with PA systolic pressure of 52mmHg. Cardiac biomarkers checked and BNP elevated to 900's. Patient Initially required 2L NC for hypoxia and weaned to room air at rest and ambulation by discharge. During admission, patient was initially started on heparin drip and transitioned to rivaroxaban for anticipated 6 month course of anticoagulation. #Fever Fever to 101.3 noted on ___ in absence of other clinical symptoms; was on suppressive daily augmentin at this time per outpatient infectious disease for bacteremia. He was started on vancomycin/cefepime. After 48 hours of negative cultures and negative CXR and chest CT, patient was trialed off antibiotics and was afebrile without any localizing symptoms. Fever presumed to be in setting of clot burden. ___ Presented with creatinine to 1.2 from baseline 0.9; resolved by discharge. Thought to be prerenal. CHRONIC ISSUES: ============= #___ Syndrome complicated by Cirrhosis EGD in ___ demonstrated portal gastropathy and duodenal ectasia (cauterized). Due to concern for possible bleeding while on anticoagulation, home diuretics and beta blockade were held. At discharge these were restarted - Restarted nadolol 20mg qdaily at discharge - Restarted furosemide 40mg qdaily and amiloride 10mg qdaily at discharge. # CODE: confirmed DNR/DNI # CONTACT: Wife, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Magnesium Oxide 400 mg PO DAILY 6. Nadolol 20 mg PO DAILY 7. Ursodiol 600 mg PO BID 8. Lactulose 30 mL PO Q2H 9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 11. Loratadine 10 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Sildenafil 50 mg PO DAILY:PRN sexual activity 14. rifAXIMin 550 mg PO BID 15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 2. Rivaroxaban 15 mg PO BID 3. aMILoride 10 mg PO DAILY 4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 8. Furosemide 40 mg PO DAILY 9. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Loratadine 10 mg PO DAILY 12. Magnesium Oxide 400 mg PO DAILY 13. Nadolol 20 mg PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. rifAXIMin 550 mg PO BID 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS #Acute Pulmonary Embolism SECONDARY DIAGNOSIS ___ disease complicated by recurrent episodes of cholangitis and VRE bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for coming to ___ for your care. Please read the following directions carefully: Why was I admitted to the hospital? -You were admitted to the hospital because were having difficulty breathing -We found that you had blood clots in your lungs What was done for me while I was in the hospital? -You were placed on blood thinners to prevent the blood clots from getting worse What do I need to do when I leave the hospital? -Your primary care doctor can help arrange for short term disability -Please take your medications as listed below -Please keep your appointments as below We wish you the best with your care! -Your ___ care team. Followup Instructions: ___

10048001-DS-11

DS

2182-05-18 00:00:00

2182-05-18 16:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypotension ugib Major Surgical or Invasive Procedure: EGD, colonoscopy ___ History of Present Illness: ___ with ___'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on anticoagulation now with hematemesis, fever, headache after fall. Pt was in his usual state of health until ___ (the day prior to admission) morning, when he woke up around ___ to go to the bathroom. He reports that his feet got tangled in the covers and he tripped getting out of bed - falling, and hitting the left side of his head on the wooden radiator cover. He had immediate pain, but went to the bathroom and then went back to bed. Wife reports that he slept more than usual on the day on ___. ___ evening, he felt feverish and reports taking his temperature, which was ___. Went to bed and slept normally. The morning of admission, he woke up and "felt weak." Carried a load of laundry downstairs and put laundry in the washing machine, at which point he became very nauseated. Dry heaved ___ times before vomiting a moderate amount of dark red blood with small clots. Shortly thereafter, he had a bowel movement, which he reports was black and soft. Several hours later, he had bright red blood per rectum. Called his PCP, who recommended that he come in to be evaluated. Of note, the patient was recently admitted on ___ for confusion and melena - treated for hepatic encephalopathy; found to have Enterococcus faecalis bacteremia and acute cholangitis. Underwent MRCP without any specific changes in biliary ducts. EGD showed portal hypertensive gastropathy with bleeding on contact as well as small duodenal vascular ectasia that was treated with APC. Completed two week course of daptomycin for cholangitis and was started on Augmentin for suppressive therapy. Patient had previously been on suppressive antibiotics (alternating between levofloxacin and cefpodoxime) since ___ without infections. Given recurrent resistant bacterial infections and resistance profile of bacteria, prophylaxis regimen was changed to 1 month of cefpodoxime alternating with 1 month of Augmentin at recent ID visit. He was started on Augmentin on ___ at which point right arm PICC was also removed. He was again admitted on ___ for hypoxia and found to have an acute submassive PE. At that time the patient recently had PICC removed on ___ after finishing IV daptomycin course for recent admission for enterococcus bacteremia. Doppler of right upper extremity demonstrating DVT, lower extremity dopplers negative. In this setting, PE presumed to be provoked. Discharged on rivaroxaban for anticipated 6 month course of anticoagulation. In the ED, Initial Vitals: T 97.5, HR 75, BP 90/48, RR1 8, O2 100% Exam: Unremarkable (including neuro exam), aside from guiaic positive stool. Labs: CBC: WBC 8.8 Hgb 9.8, Hct 29.8 Plt 58, LFT: ALT 59 ASt 140 AP 142 T bili 2.8 ALb 2.8 BMP Na 135 K 4.4 Cl 101 Bicarb 18 BUn 45 Cr 1.2 Lactate 3.7 Imaging: *CXR: Low lung volumes with mild bibasilar atelectasis. *Liver US: 1. Cirrhotic liver morphology with saccular intrahepatic biliary ductal dilatation in the right hepatic lobe consistent with patient's known ___'s syndrome. The portal veins are patent with redemonstration of reversed flow in the right portal vein. 2. Sludge within a distended gallbladder without evidence of acute cholecystitis. 3. Redemonstration of marked splenomegaly and patent umbilical vein. *CT Head w/out contrast: No acute intracranial abnormality. No acute fracture. Consults: Hepatology: no need for urgent scope, admit for monitoring and management of GI bleed Interventions: -Patient had 2 PIV placed, he recieved 1 U PRBC and 1 L fluid -Patient recieved 1 gram CTX IV, octreotide IV and pantoprazole 40mg IV VS Prior to Transfer: HR 66, BP 88/51, RR 20, SpO2 97% 2L NC On arrival to the MICU, he reports feeling "okay." Wants to know when he'll be able to eat. He denies lightheadedness, dizziness, shortness of breath, chest pain, abd pain, nausea. Had one episode of BRBPR in ED, but none since and no further vomiting. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: Mother has heart disease. Father died at age ___ from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: BP 96/60, HR 73, RR 26, SpO2 95%/RA GEN: tired-appearing man, sitting up in bed, NAD HEENT: mildly icteric sclera, PERRL. OP clear, dry MM. NECK: supple, no LAD. CV: RRR, S1+S2, no M/R/G RESP: CTAB, no W/R/C GI: non-distended, soft, non-tender MSK: WWP, no edema SKIN: bronzed skin, no skin lesions or breakdown NEURO: alert, oriented. No asterixis. PSYCH: pleasant, euthymic DISCHARGE PHYSICAL EXAM: ======================= VITALS: 24 HR Data (last updated ___ @ 1212) Temp: 97.9 (Tm 98.2), BP: 115/70 (99-122/61-75), HR: 80 (78-90), RR: 18, O2 sat: 95% (92-96), O2 delivery: Ra, Wt: 218.69 lb/99.2 kg GENERAL: Alert and interactive, in no acute distress. HEENT: Sclera anicteric and without injection. Moist mucous membranes 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. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Pertinent Results: ADMISSION LABS: ==================== ___ 02:56PM WBC-8.8 RBC-3.13* HGB-9.8* HCT-29.8* MCV-95 MCH-31.3 MCHC-32.9 RDW-19.2* RDWSD-67.0* ___ 02:56PM ___ PTT-39.3* ___ ___ 02:56PM ALT(SGPT)-59* AST(SGOT)-140* ALK PHOS-142* TOT BILI-2.8* ___ 02:56PM LIPASE-17 ___ 02:56PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-1.9 ___ 02:56PM GLUCOSE-128* UREA N-45* CREAT-1.2 SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-18* ANION GAP-16 ___ 03:10PM LACTATE-3.7* RELEVANT IMAGING: ==================== ___ EGD: portal hypertensive gastropathy, 3 grade I varices ___ ___: internal hemorrhoids without stigmata of bleeding ___ CT head w/o con: no acute intracranial process ___ TTE: CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 75 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Mildly dilated right ventricular cavity 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 trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images reviewed) of ___ , right ventricle is now dilated. Estimated pulmonary artery pressures are similar. Trivial aortic regurgitation is present. DISCHARGE LABS: ================= ___ 06:34AM BLOOD WBC-2.5* RBC-2.99* Hgb-9.3* Hct-29.4* MCV-98 MCH-31.1 MCHC-31.6* RDW-19.9* RDWSD-71.3* Plt Ct-50* ___ 06:34AM BLOOD ___ PTT-34.1 ___ ___:34AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-143 K-4.3 Cl-109* HCO3-20* AnGap-14 ___ 06:34AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6 MICRO: ====== ___ 6:08 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 3:05 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: PATIENT SUMMARY: ==================== ___ with ___'s disease (communicating cavernous ectasia, orcongenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on rivaroxaban, who presented with hematemesis, fever, and headache after fall. He remained hemodynamically stable while in house, with stable hemoglobin levels. His anticoagulation was switched to Lovenox (from rivaroxaban). TRANSITIONAL ISSUES: ==================== #GI Bleed #Acute Blood Loss Anemia: [] H/H check on ___: no active bleeding identified on ___ this admission, f/u H/H after starting lovenox for PE treatment on ___. #Cirrhosis [] Electrolyte check on ___: Lasix restarted at discharge, f/u K Mg Cr. [] F/u BP: home nadolol held in setting of GI bleed and hypotension, restarted nadolol for esophageal varices at discharge. BP 110s-120s/70s on day of discharge. #PE: [] AC switched to Lovenox, to be continued through ___, then discontinued. [] Consider TTE after completion of anticoagulation course, as RV was newly dilated on TTE ___. #CODE STATUS: DNR/DNI - if there was a treatable/fixable problem that would require temporary intubation, patient would be okay with intubation in that setting. #EMERGENCY CONTACT: Wife, ___, ___ ACTIVE/ACUTE ISSUES: ==================== # GI bleed # GAVE # Hypotension Patient presented with hematemesis x1, melena x1, BRBPR x2 - consistent with either very brisk UGIB or both UGIB and LGIB. Initially intermittently hypotensive in the ICU, blood pressure responsive to IV albumin and blood transfusions. Suspect that his hypotension was secondary to initial blood loss in combination with vasoplegia from underlying liver disease. Hemoglobin remained stable throughout admission and EGD and colonoscopy showed no identifiable source of bleeding, only showed his baseline GAVE. No other acute findings. Source of the GI bleed could be a small bowel source/AVMs vs. GAVE associated oozing. He was treated with IV pantoprazole 40mg BID, octreotide drip x72 hours, and ceftriaxone prophylaxis in setting of acute bleed (___). Transitioned back to home PPI at discharge. # ___ Baseline creatinine 0.9-1.2. Creatinine initially at baseline, but increased to 1.8 in setting of hypotension and bleed. Most likely pre-renal injury, resolved after volume resuscitation. # Coagulopathy Has some degree of coagulopathy at baseline in setting of cirrhosis, but presented with INR 4.9. Unknown etiology of this elevation, could have been mild elevation from rivaroxaban in combination with recent daptomycin and Augmentin causing some vitamin K malabsorption. Received IV vitamin K 10mg in the ED with normalization of INR. # PE # Catheter associated UE DVT Patient diagnosed with upper extremity DVT and submassive PE in ___. Planned for six months of anticoagulation for provoked thrombosis (through mid ___. Had been on rivaroxaban BID (loading dose) as an outpatient prior to admission. Rivaroxaban held during this admission in setting of GI bleed. After negative EGD/colonoscopy, patient was started on heparin gtt with stable Hgb. Vascular medicine was consulted for assistance with ongoing management of AC, recommended avoiding DOACs. He was transitioned from heparin gtt to lovenox BID (more rapid reversal than warfarin in event of recurrent bleeding) on ___. ___ TTE demonstrated dilated R ventricle, similar pulmonary artery pressures to most recent TTE on ___, no evidence of R heart failure. # Transaminitis Mild transaminitis, likely due to hypotension. Improving at time of discharge. # Fall Sounds mechanical in nature, per patient. No bleeding prior to fall, does not sound syncopal. CT head with no evidence of intracranial pathology or skull trauma. ___ was consulted, felt that there were no acute ___ needs. # ___ syndrome # Cirrhosis # Thrombocytopenia Childs class B cirrhosis; MELD-Na 31 on admission (largely driven by INR). History of hepatic encephalopathy, although none this admission. ___ EGD with one cord grade I varices, gastropathy, duodenal vascular ectasia status post APC, history of esophageal banding. EGD this admission with 3 cords of grade I varices in distal esophagus, nonbleeding, and portal hypertensive gastropathy. No tappable ascites pocket in the ED, no history of SBP. Continued home lactulose. Held nadolol and furosemide given recent GIB, restarted at time of discharge. CHRONIC ISSUES: ==================== # History of recurrent cholangitis Recurrent episodes of cholangitis due to biliary ductal dilation from ___'s disease. US on admission without evidence of cholangitis. History of CRE. Continued prophylactic Augmentin 850mg BID, ursodiol 600 mg BID. # Depression: continued citalopram 20mg daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Citalopram 20 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Loratadine 10 mg PO DAILY 7. Nadolol 20 mg PO DAILY 8. Ursodiol 600 mg PO BID 9. rifAXIMin 550 mg PO BID 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 11. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 13. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 14. Magnesium Oxide 400 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Rivaroxaban 15 mg PO BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H Duration: 5 Days RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*9 Tablet Refills:*0 2. Enoxaparin Sodium 100 mg SC Q12H RX *enoxaparin 100 mg/mL 1 ml SC every twelve (12) hours Disp #*60 Syringe Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 4. aMILoride 10 mg PO DAILY 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 6. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 7. Citalopram 20 mg PO DAILY 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 9. Furosemide 40 mg PO DAILY 10. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Loratadine 10 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Nadolol 20 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID 18.Outpatient Lab Work ICD-___ Please check CBC and chem ___ Fax results to Dr. ___ at ___ and Dr. ___ at ___ Discharge Disposition: Home Discharge Diagnosis: Primary: GI Bleed Secondary: ___ disease Childs class B cirrhosis Pulmonary embolism Catheter-associated upper extremity DVT Coagulopathy Thrombocytopenia ___ Fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure being a part of your care at ___! WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fall at home, fever, headache, and had blood in vomit and stool. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were found to have very low blood pressure. You were admitted to the ICU and given medications and blood transfusions to support your blood pressure and replace blood loss. - You were given medication to stop the bleeding. - You had an EGD and colonoscopy which did not identify any active sites of bleeding. - Your blood counts were monitored and remained stable. - Your home medication rivaroxaban was discontinued and you were started on enoxaparin (lovenox) to treat your pulmonary embolism and deep vein thrombosis (blood clots). WHAT SHOULD YOU DO WHEN YOU LEAVE? - You should get blood work checked on ___. - You should follow up with your PCP, ___, and Infectious Disease doctors in outpatient ___ as listed below. - Please seek medical attention immediately if you feel dizzy/lightheaded, notice bloody or black stools, or have any other symptoms that concern you. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10048001-DS-12

DS

2182-06-06 00:00:00

2182-06-06 17:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Midline placed ___ History of Present Illness: ___ M with PMH ___'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on lovenox who presents with dyspnea on exertion and dry cough. Patient reports symptoms began on ___. He reports dyspnea with walking around living room. He reports SOB improved with seating. He reports exacerbation of dry cough with lying flat but does not have worsening shortness of breath with lying flat. Patient reports that SOB worsened with walking to bathroom overnight. He denies fevers, chills, chest pain, productive cough, palpitations, lightheadedness. He denies blood in stool or black stool. - In the ED, initial vitals were: T 98.9 HR 86 BP 100/59 RR 22 SPO2 99% RA - Exam was notable for: JVP elevated to the mandible at 45 degrees, with HJR. Ext warm with 2+ pitting edema. No crackles appreciated - Labs were notable for: 136 | 103 | 23 -------------- 188 AGap=13 3.9 | 20 | 1.2 WBC 4.4 HGB 10.3 PLT 40 ___: 16.0 PTT: 46.9 INR: 1.5 LFTs not elevated. Tbili: 2.4 Lactate 3.2 to 2.3 proBNP: 775 Trop-T: <0.01 UA wnl - Studies were notable for: - CTA chest : improvement in pulmonary arterial thrombus burden, with persistent though small nonocclusive thrombus seen within the distal left main pulmonary artery and basal segmental branches. No substantial clot burden in the right pulmonary artery. Persistent dilatation of the left main pulmonary artery to 2.8 cm, otherwise no CT evidence of right heart strain. No evidence of underlying pulmonary infarction. - The patient was given: Furosemide 40 mg, Ipratropium-Albuterol Neb 1 NEB On arrival to the floor, the patient reports dyspnea on exertion but no positional component with orthopnea or platypnea. No subjective fevers/chills, abdominal pain, n/v/d, blood in the stool, confusion. Reports his weight at home has been stable at 205 lb. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: Mother has heart disease. Father died at age ___ from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 103.0 BP 99 / 62 HR 91 RR 18 SpO2 96 GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: JVP to jaw at 45 degrees CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: No rhonchi or rales. No increased work of breathing. expiratory wheezing noted bilaterally BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, mildly distended but no notable fluid wave, non-tender to deep palpation in all four quadrants. No ___ sign EXTREMITIES: No clubbing, cyanosis. 1+ edema in b/l calves. Pulses DP/Radial 2+ bilaterally. wwp SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. no asterixis. able to recite days of week backwards DISCHARGE EXAM: =============== PHYSICAL EXAM: ============== 24 HR Data (last updated ___ @ 707) Temp: 97.6 (Tm 98.7), BP: 109/72 (96-109/60-72), HR: 69 (64-92), RR: 17 (___), O2 sat: 95% (95-97), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. CARDIAC: RRR no m/r/g LUNGS: Bilateral wheezing ABDOMEN: Soft, NT, ND, +BS Pertinent Results: ADMISSION LABS: =============== ___ 01:40PM BLOOD WBC-4.4 RBC-3.27* Hgb-10.3* Hct-31.5* MCV-96 MCH-31.5 MCHC-32.7 RDW-18.9* RDWSD-67.6* Plt Ct-40* ___ 01:40PM BLOOD Neuts-77.4* Lymphs-7.8* Monos-13.9* Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.39 AbsLymp-0.34* AbsMono-0.61 AbsEos-0.01* AbsBaso-0.01 ___ 01:40PM BLOOD ___ PTT-46.9* ___ ___ 01:40PM BLOOD Glucose-188* UreaN-23* Creat-1.2 Na-136 K-3.9 Cl-103 HCO3-20* AnGap-13 ___ 01:40PM BLOOD ALT-17 AST-34 AlkPhos-97 TotBili-2.4* ___ 01:40PM BLOOD proBNP-775* ___:40PM BLOOD Albumin-3.3* Calcium-8.6 Phos-1.5* Mg-1.6 ___ 01:40PM BLOOD Lactate-3.2* IMAGING: ======== ___ Imaging CHEST (PA & LAT) IMPRESSION: No interval change in cardiac silhouette size, no evidence of substantial pulmonary vascular congestion or pulmonary edema. Overall slight improvement in lung aeration bilaterally. No focal consolidation. ___ Imaging CTA CHEST IMPRESSION: Overall improvement in pulmonary arterial thrombus burden, with persistent though smaller nonocclusive thrombus seen within the distal left main pulmonary artery and basal segmental branches. No substantial clot burden in the right pulmonary artery. Persistent dilatation of the left main pulmonary artery to 2.8 cm, otherwise no CT evidence of right heart strain. No evidence of underlying pulmonary infarction. ___ Imaging US ABD LIMIT, SINGLE OR FINDINGS: Targeted grayscale ultrasound images were obtained of the 4 quadrants of the abdomen, revealing no ascites. IMPRESSION: No ascites. ___ Cardiovascular Transthoracic Echo Report CONCLUSION: The left atrial volume index is normal. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 74 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Diastolic function could not be assessed. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images reviewed) of ___ , the estimated pulmonary artery systolic pressure is now lower. The right ventricular cavity size is smaller. ___ Imaging MRCP (MR ABD ___ IMPRESSION: 1. Cirrhosis with findings of portal hypertension, including marked splenomegaly and perigastric varices. Saccular dilatation of the intrahepatic bile ducts involving the right hepatic lobe, similar to prior exams, compatible with known ___'s syndrome. No suspicious hepatic lesion. No evidence of active cholangitis. DISCHARGE LABS: =============== ___ 07:00AM BLOOD WBC-2.4* RBC-2.93* Hgb-9.2* Hct-28.5* MCV-97 MCH-31.4 MCHC-32.3 RDW-18.4* RDWSD-66.0* Plt Ct-56* ___ 07:00AM BLOOD Glucose-88 UreaN-13 Creat-1.0 Na-144 K-3.9 Cl-107 HCO3-23 AnGap-14 ___ 07:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.5* Brief Hospital Course: ___ M with PMH ___'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on lovenox who presents with dyspnea/ cough found to have fever to 103 with blood cultures growing enterococcus. TRANSITIONAL ISSUES: ==================== [ ] Please continue your IV antibiotics until ___ [ ] Please follow-up with your physicians as scheduled [ ] Please reach out to your infectious disease doctor about restarting your prophylactic antibiotics once you finish your IV course. [ ] Follow-up platelet levels and consider decreasing enoxaparin dose. ACUTE/ACTIVE ISSUES: ==================== # Fever # History of recurrent MDR cholangitis Fever to 103 upon arrival to floor. No localized sx except cough, SOB but with recurrent episodes of cholangitis due to biliary ductal dilation from Caroli's disease. History of MDR infections with VRE bacteremia and Carbapenem resistant E. coli. Alternates suppressive augmentin with cefpodoxime at home. MRCP showed no evidence of cholangitis and was unrevealing for a cause, thus it was felt that the source of the bacteremia was transient gut translocation. Blood cultures returned positive for enterococcous. He was initially treated with Dapto/Cefepime/flagyl and then transitioned to zosyn for a ___, end date ___. # Dyspnea on Exertion # Pulmonary Hypertension Patient presenting with DOE/dry cough with JVP elevation, ___ edema without e/o of pulm edema on exam or CXR overall concerning for R heart failure. Known RV strain iso PE with PASP 50, however patient on AC with lovenox and CTPE with improved clot burden. TTE showed improvement in right heart strain. Symptoms improved with diuresis. # ___ syndrome # Cirrhosis # Thrombocytopenia Childs class B cirrhosis; MELD-Na 31 on admission (largely driven by INR). History of hepatic encephalopathy on lactulose, varices on Nadolol. No hx of ascites but on Lasix. EGD last admission ___ with 3 cords of grade I varices in distal esophagus, nonbleeding, and portal hypertensive gastropathy. His home furosemide and nadolol were initially held in the setting of infection but were restarted prior to discharge. # Lactic acidosis Lactic 3.2 downtrended to 2.3 in ED without fluid. Concern for infection given fever and hx of recurrent cholangitis. Improved. CHRONIC/STABLE ISSUES: ====================== # Depression: Continued home citalopram 20mg daily > 30 minutes spent on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 2. aMILoride 10 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Loratadine 10 mg PO DAILY 7. Ursodiol 600 mg PO BID 8. Sildenafil 50 mg PO DAILY:PRN sexual activity 9. Nadolol 20 mg PO DAILY 10. Magnesium Oxide 400 mg PO DAILY 11. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 12. Pantoprazole 40 mg PO Q24H 13. Enoxaparin Sodium 100 mg SC Q12H 14. Furosemide 40 mg PO DAILY 15. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 16. Cefpodoxime Proxetil 200 mg PO Q12H Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth q8hr Disp #*12 Tablet Refills:*0 2. Piperacillin-Tazobactam 4.5 g IV Q8H 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 4. aMILoride 10 mg PO DAILY 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. Enoxaparin Sodium 100 mg SC Q12H 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 9. Furosemide 40 mg PO DAILY 10. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Loratadine 10 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Nadolol 20 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID 18. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication was held. Do not restart Cefpodoxime Proxetil until you speak with your infectious disease doctor. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Enterococcus Bactermia Volume Overload Secondary Diagnoses: Caroli syndrome Cirrhosis Thrombocytopenia 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 because you had a fever and we were worried tat you had an infection due to your liver disease. WHAT HAPPENED TO ME IN THE HOSPITAL? - While you were in the hospital we did some imaging which showed you did not have an infection in your biliary system. - Some blood tests showed that you had bacteria in your blood. 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: ___

10048001-DS-13

DS

2182-09-28 00:00:00

2182-09-28 15:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ syndrome complicated by gram positive bacteremia Major Surgical or Invasive Procedure: TEE ___: No discrete vegetation or abscess seen. Mild mitral regurgitation. History of Present Illness: ___ yo M PMHx ___'s disease c/b cirrhosis with hx varices, HE, recurrent cholangitis and E. faecalis bacteremia, recent PE with RV strain on LMWH presented to ED with fevers that started ___ night and dry cough that started on ___ found to have GPCs in blood. The patient reports a 2 day history of fevers at home as well as a dry cough that started ___. He otherwise reports some mild nausea and chronic diarrhea ___ lactulose but otherwise no abdominal pain, chest pain, vomiting, headache, black/bloody stools. He takes suppressive Augmentin since his last infection in ___ and reports no missed doses. The patient has multiple hospitalizations for bacteremia and cholangitis, most recently in ___. He is on chronic suppression with Augmentin. He has also been hospitalized recently in ___ for a submassive PE ___ PICC-associated DVT, originally started on apixaban but had hematemesis, BRBPR, hypotension requiring a MICU admission. Now on Lovenox. He has a history of CRE E. Coli in ___ and reportedly VRE bacteremia per documentation review although not in ___ records. His recent E. faecalis species have been pan-sensitive. Regarding his cirrhosis, he has a history of HE on lactulose and grade I varices on nadolol as of his most recent EGD in ___. No clear history of ascites although he does take amiloride and furosemide as home medications. In the ED: - Initial vital signs were notable for: Temp 98.4, HR 81, BP 136/74, RR 16 satting 99% on RA Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: Mother has heart disease. Father died at age ___ from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 1835) Temp: 100.2 (Tm 100.2), BP: 116/67, HR: 95, RR: 18, O2 sat: 95%, O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. EOMI. Sclera anicteric. ENT: MMM. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Mild wheezes throughout. No rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, Non-distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: No CVA tenderness. No clubbing, cyanosis, or edema. Pulses DP/Radial 3+ bounding bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. CN2-12 grossly intact. Able to say days of the week backwards. No asterixis. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM: ============== 24 HR Data (last updated ___ @ 741) Temp: 98.2 (Tm 99.3), BP: 128/79 (118-129/72-79), HR: 93 (91-99), RR: 20 (___), O2 sat: 94% (93-95), O2 delivery: Ra, Wt: 218.3 lb/99.02 kg GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. Sclera anicteric. ENT: MMM. JVP elevated CARDIAC: Regular rhythm, normal rate. RESP: decreased breath sounds on R side. No increased work of breathing. ABDOMEN: Soft, Non-distended, non-tender to deep palpation in all four quadrants. +umbilical hernia MSK: No CVA tenderness. Trace peripheral edema. SKIN: Warm. No rash. NEUROLOGIC: AOx3. moving all extremities. Pertinent Results: ADMISSION LABS: =================== ___ 12:52PM BLOOD WBC-2.4* RBC-3.30* Hgb-9.3* Hct-30.4* MCV-92 MCH-28.2 MCHC-30.6* RDW-17.3* RDWSD-58.5* Plt Ct-60* ___ 12:52PM BLOOD Neuts-69.5 Lymphs-13.2* Monos-15.7* Eos-0.8* Baso-0.4 Im ___ AbsNeut-1.68 AbsLymp-0.32* AbsMono-0.38 AbsEos-0.02* AbsBaso-0.01 ___ 02:37PM BLOOD ___ PTT-41.2* ___ ___ 12:52PM BLOOD Glucose-135* UreaN-16 Creat-1.0 Na-138 K-4.7 Cl-106 HCO3-20* AnGap-12 ___ 07:49AM BLOOD ALT-14 AST-20 AlkPhos-149* TotBili-0.5 DirBili-0.2 IndBili-0.3 ___ 12:52PM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.4* Mg-1.9 ___ 07:36AM BLOOD CRP-101.7* ___ 01:20PM BLOOD Lactate-1.5 DISCHARGE LABS: ================== ___ 06:06AM BLOOD WBC-2.3* RBC-2.82* Hgb-7.9* Hct-25.9* MCV-92 MCH-28.0 MCHC-30.5* RDW-17.5* RDWSD-58.8* Plt Ct-49* ___ 06:06AM BLOOD Neuts-70.6 Lymphs-17.1* Monos-10.1 Eos-0.9* Baso-0.4 Im ___ AbsNeut-1.61 AbsLymp-0.39* AbsMono-0.23 AbsEos-0.02* AbsBaso-0.01 ___ 06:06AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-145 K-4.3 Cl-111* HCO3-24 AnGap-10 ___ 06:06AM BLOOD ALT-14 AST-20 AlkPhos-142* TotBili-0.6 ___ 06:06AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7 MICROBIOLOGY DATA: ====================== **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC OF 2 MCG/ML test result performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ ___ AT 8:40AM. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 11:14 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 11:14 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. TTE CONCLUSION: 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. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. There is no evidence for an atrial septal defect by 2D/color Doppler. Overall left ventricular systolic function is normal. The right ventricle has normal free wall motion. There are no aortic arch atheroma with no atheroma in the descending aorta to 30 cm 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 [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is trivial tricuspid regurgitation. There is no pericardial effusion. IMPRESSION: No discrete vegetation or abscess seen. Mild mitral regurgitation. Brief Hospital Course: BRIEF HOSPITAL COURSE: ==================== ___ yo M PMHx Caroli's disease c/b cirrhosis with hx varices, HE, recurrent cholangitis and E. faecalis bacteremia, recent PE with RV strain on LMWH admitted for fevers that started ___ night and dry cough, found to have ampicillin-resistant enterococcus. He was treated with IV Vanc 1000mg q12 hours. TRANSITIONAL ISSUES: ================== [ ] TTE showing mod-severe pulm hypertension (PAp 58; given concern for this contributing to DOE, was referred to cardiology to follow up outpatient. TTE will need to be repeated in future [ ] Midline placed for IV abx for gram positive bacteremia, will be followed by ___ Infectious Disease clinic, with projected end date ___. Will get weekly lab work for this. [ ] ___ at ___ will be the Primary Care Physician to write scripts for outpatient IV abx. HEPATOLOGY: [ ] Diuretics (Amiloride and Lasix) held on discharge given active infection, will restart after checking with Dr. ___ (___). [ ] Will plan to start Rifaxamin after IV daptomycin course for chronic suppressive therapy with Caroli Syndrome. Will need to follow up regarding insurance coverage past the end of this year. [ ] Stopped prophylactic Bactrim given he developed bacteremia on this. Will plan to use Rifaxamin as suppressive therapy after course of IV abx. ACUTE ISSUES: ============= #Ampicillin-resistant enterococcus #History of Cholangitis Given the patient's history of recurrent cholangitis and E. faecalis bacteremia, and now again with enterococcus in blood, there was high suspicion for biliary source. Of note, enterococcus was previously ampicillin sensitive, but grew ampicillin resistant this admission. Bacteremia occurred while on suppressive Amox/clav. TEE was performed and showed no evidence of endocarditis. He was changed from IV vancomycin (D1: ___ to IV Daptomycin due to medication-induced neutropenia, and was discharged on IV dapto to be followed by ___ clinic with projected end date ___. #Cirrhosis #___'s disease ___ A. Meld-Na 11. Well-compensated when not actively infected. - VARICES: EGD ___ with grade I varices in distal esophagus. Also PHGP noted in stomach. History of banded varices per patient. Will hold home nadolol for now given risk for decompensation iso bacteremia. - ASCITES: No ascites noted on RUQUS. Patient reports never requiring a paracentesis. Held home diuretics despite evidence of volume overload in setting of infection. Will continue to hold until following up with Dr. ___. - HE: Continued home lactulose. - Continued ursodiol #Pulmonary embolism History of PE with RV strain ___. Unable to tolerate DOAC due to bleeding. Switched to Lovenox which he is tolerating well. No chest pain, shortness of breath, hypoxia, or e/o bleeding. - Continued home LMWH 100 mg SC BID #Dry cough #Dyspnea upon exertion #Pulmonary HTN Patient is asymptomatic and not hypoxic or platypneic to suggest hepatopulmonary syndrome. No ascites for hepatic hydrothorax. CXR in ED unremarkable. Most recent ECHO with PASP 34 mmHg. TTE this admission with higher pulmonary artery pressure, which may explain DOE. Received duonebs PRN, will need to follow up with cardiologist. #Depression: Continued citalopram 20 mg daily #GERD Continued home pantoprazole #Glaucoma Continued home latanoprost #CODE: Full code (confirmed) #CONTACT: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 100 mg SC Q12H 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Ursodiol 600 mg PO BID 4. Nadolol 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Magnesium Oxide 400 mg PO DAILY 7. Citalopram 20 mg PO DAILY 8. aMILoride 5 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Furosemide 40 mg PO DAILY 11. Lactulose 30 mL PO Q8H:PRN encephalopathy Discharge Medications: 1. Daptomycin 600 mg IV Q24H 2. Heparin Flush (10 units/ml) 2 mL IV X1 PRN For Midline Insertion 3. aMILoride 5 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Enoxaparin Sodium 100 mg SC Q12H 6. Furosemide 40 mg PO DAILY 7. Lactulose 30 mL PO Q8H:PRN encephalopathy 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Nadolol 20 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Ursodiol 600 mg PO BID 13.Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK ICD9: 790.7 Bacteremia Discharge Disposition: Home Discharge Diagnosis: PRIMRARY DIAGNOSIS: ================= Ampicillin-resistant enterococcus bacteremia SECONDARY DIAGNOSIS: =================== Cirrhosis secondary to Caroli's Syndrome History of Pulmonary embolism Thrombocytopenia secondary to cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you were having fevers. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were diagnosed with bacteremia, or bacteria in your blood. - You were started on IV antibiotics. - You got imaging studies of your heart to rule out endocarditis(infection or inflammation of your heart valves) 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. -You will need to follow up with Infectious Disease doctors in ___, but should take your IV daptomycin until ___. After you finish this course, resume taking the oral medication called Rifaxamin for suppression of infection. - We are holding your diuretics (Amiloride and Lasix) on discharge because you have an active infection and it could make your blood pressure too low. Check with Dr. ___ resuming these. - Weigh yourself daily, and if your weight increases more than 3 lbs in 2 days or 5 lbs in 1 week, call Dr. ___ as you may need to restart antibiotics. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10048001-DS-4

DS

2175-02-13 00:00:00

2175-02-14 10:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever, pain Major Surgical or Invasive Procedure: ERCP with stent placement History of Present Illness: ___ h/o cirrhosis ___ Caroli syndrome, who presents to our ED as a transfer from OSH, w/ recent fever to 104, cough, dyspnea, diffuse abdominal pain, general malaise, headache. Patient has had a fever since ___ (five days ago). Fever has been variable, going up and down over the past few days. Saw PCP recently and was treated with a course of Tamiflu for suspected influenza. Since starting tamiflu has had diarrhea, with ___ BMs yesterday. Has had no appetite for a week. Very poor PO intake. Today went to outside hospital ED, was ill-appearing with multiple laboratory abnormalities including thrombocytopenia to 18, acute renal failure, and they were initially concerned for DIC. At OSH, received solumedrol (due to meningitis in ddx given his headache), CTX 2 g, vanc, Zosyn, acyclovir. BP stable en route here, received 4L IVF en route to ___ ED. In the ED inital vitals were: 97.8 111 116/76 24 96% 4L Pt received 4 L NS in total between OSH and here as of ___. -pCXR: limited AP w/ poor insp effort, but no obvious infiltrates. -Labs in ED: ARF, elevated LFTs/bili, tcp, no schistocytes, INCREASED fibrinogen. -ABG: pH7.40 pCO2 22 pO2 95 HCO3 14 primary anion gap metabolic acidosis -Foley: 800 cc UOP -R IJ, sterile, placed in ER, OK to use -scvO2: 80 -Discussed plan w/ ERCP: given h/o Caroli, high suspicion for cholangitis until proven otherwise, agree w/ non-con CT, though will be limited. please re-page if becomes more unstable, e.g. starting pressors, or if remarkable results on CT. will plan for ERCP first in AM, if crashing, can do ICU ERCP o/n. -CT torso: cirrhotic liver w/ large cysts c/w ___'s disease characterized on ___ MR; splenomegaly, patent umbilical vein, and small amt of ascites; R lung base atelectasis; can't r/o superimposed infection. - unlikely to be DIC, given no schistocytes, not decreased fibrinogen. his markedly worsened tcp is likely due to sepsis, on top of liver disease -VS on transfer: T 98.7 BP 132/75 HR 73 pOx 98 4L On arrival to the ICU, patient's initial vital signs were 97.9 96 ___ 96% 4L CVP 5. Patient awake, alert, conversant, in pain and in moderate respiratory distress. Family at bedside. Review of systems: (+) Per HPI (-) Denies sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ___ Syndrome Cirrhosis Inguinal hernia repair in ___. NKDA Social History: ___ Family History: He denies any history of kidney or liver disease in the family. No colitis in the family. His father died with "tumors" that ruptured. He does not know what type of cancer they were. His father was also diagnosed with diabetes right before he died. His mother has coronary artery disease and is ___. Two brothers with hip replacements and back problems. Physical Exam: Admission Physical Exam: 97.9 96 ___ 96% 4L CVP 5 General: Alert, oriented HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD, no tenderness to palpation of neck. negative Kernig and Brudzinski. FROM of neck. Lungs: Pt using some accessory muscles for breathing, rare crackles scattered CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly protuberant, umbilical herniation, hepatomegaly with 3cm liver palpable, no splenomegaly appreciated on exam, tenderness to palpation diffusely, mild guarding, no overt peritoneal signs, negative ___ sign GU: foley in place Skin: no spider angiomas appreciated; no bruising or rash Ext: warm, well perfused, 2+ distal pedal pulses, no clubbing, cyanosis or edema Neuro: PERRL, EOMI, strength of upper and lower extremities intact Pertinent Results: ___ 09:00PM BLOOD WBC-10.7# RBC-3.91* Hgb-13.2* Hct-37.2* MCV-95 MCH-33.8* MCHC-35.5* RDW-14.9 Plt Ct-31*# ___ 09:00PM BLOOD Neuts-70 Bands-6* Lymphs-4* Monos-15* Eos-0 Baso-0 ___ Metas-3* Myelos-1* Promyel-1* Other-0 ___ 03:36AM BLOOD WBC-8.8 RBC-3.59* Hgb-11.6* Hct-34.1* MCV-95 MCH-32.3* MCHC-34.0 RDW-15.1 Plt Ct-23* ___ 03:36AM BLOOD Neuts-87* Bands-2 Lymphs-4* Monos-6 Eos-0 Baso-0 ___ Metas-1* Myelos-0 ___ 05:53AM BLOOD WBC-8.1 RBC-3.49* Hgb-11.2* Hct-32.8* MCV-94 MCH-32.2* MCHC-34.2 RDW-15.4 Plt Ct-35* ___ 04:22AM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-1* ___ 04:22AM BLOOD WBC-14.0* RBC-3.97* Hgb-12.9* Hct-38.1* MCV-96 MCH-32.6* MCHC-34.0 RDW-15.3 Plt Ct-57* ___ 04:00AM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0 Baso-0 ___ Myelos-0 ___ 03:38AM BLOOD WBC-16.0* RBC-3.58* Hgb-11.7* Hct-33.4* MCV-93 MCH-32.6* MCHC-34.9 RDW-15.4 Plt Ct-50* ___ 04:00AM BLOOD WBC-17.5* RBC-3.57* Hgb-11.7* Hct-33.7* MCV-94 MCH-32.7* MCHC-34.6 RDW-15.4 Plt Ct-59* ___ 09:00PM BLOOD ___ PTT-30.8 ___ ___ 04:00AM BLOOD ___ PTT-33.3 ___ ___ 09:08PM BLOOD ___ ___ 09:00PM BLOOD Glucose-192* UreaN-119* Creat-4.1*# Na-137 K-3.6 Cl-105 HCO3-15* AnGap-21* ___ 05:45PM BLOOD Glucose-179* UreaN-82* Creat-1.9* Na-142 K-4.0 Cl-114* HCO3-17* AnGap-15 ___ 04:00AM BLOOD Glucose-118* UreaN-39* Creat-1.0 Na-140 K-4.0 Cl-112* HCO3-19* AnGap-13 ___ 09:00PM BLOOD ALT-189* AST-128* LD(___)-340* AlkPhos-119 TotBili-3.6* DirBili-3.2* IndBili-0.4 ___ 03:36AM BLOOD ALT-156* AST-104* LD(___)-322* AlkPhos-107 TotBili-3.0* ___ 05:53AM BLOOD ALT-131* AST-79* LD(___)-283* AlkPhos-131* TotBili-2.3* ___ 04:22AM BLOOD ALT-135* AST-86* AlkPhos-188* TotBili-2.4* ___ 03:38AM BLOOD ALT-136* AST-113* LD(___)-308* AlkPhos-222* TotBili-3.5* ___ 04:00AM BLOOD ALT-122* AST-85* LD(___)-321* AlkPhos-260* TotBili-3.6* ___ 09:00PM BLOOD Lipase-40 ___ 05:53AM BLOOD Lipase-79* ___ 09:00PM BLOOD Albumin-2.8* Calcium-7.4* Phos-2.8 Mg-2.2 UricAcd-7.9* ___ 03:38AM BLOOD Hapto-67 ___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:06PM BLOOD ___ pO2-108* pCO2-22* pH-7.39 calTCO2-14* Base XS--9 Comment-GREEN TOP ___ 08:57PM BLOOD Type-MIX pO2-72* pCO2-33* pH-7.35 calTCO2-19* Base XS--6 Comment-GREEN TOP ___ 09:06PM BLOOD Lactate-2.6* ___ 02:35PM BLOOD Lactate-1.5 OSH and ED Labs pH 7.40 pCO2 22 pO2 95 HCO3 ___ Fibrinogen 768 Na 137 K 3.6 Cl 105 Bicarb 15 Bun 119 Cr 4.1 Gluc 192 Ca 7.4 Mg 2.2 P2.8 Serum Tox Neg ALT: 189 AP: 119 Tbili: 3.6 Alb: 2.8 AST: 128 LDH: 340 Dbili: 3.2 Lip: 40 UricA:7.9 ___: 15.0 PTT: 30.8 INR: 1.4 WBC 10.7 Hct 37.2 Hgb 13.2 Plt 31 N:79 Band:0 ___ M:15 E:0 Bas:0 Promyel: 1 Other: 1 UA: 1.011 pH 5.5 Bact MOD WBC 7 RBC 11 Prt 30 Blood Sm MICRO: Direct Influenza Antigen (___): Negative Bloood Culture (___): NGTD Urine Culture (___): No growth ___ 10:41 am STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). ___ 4:18 pm THROAT FOR STREP R/O Beta Strep Group A (Pending): Images: CT Torso w/out contrast (___): 1. cirrhotic liver w/ large cysts c/w Caroli's disease characterized on ___ MR. 2. splenomegaly, patent umbilical vein, and small amt of ascites. 3. R lung base atelectasis; can't r/o superimposed infection. CXR (___): R IJ in place in the cavo-atrial junction CXR (___): The lung volumes are low with pronounced elevation of the right hemidiaphragm with bibasilar atelectasis, likely worse on the right than the left. There is no pneumothorax. The heart is of normal size. CXR (___): FINDINGS: In comparison with the study of ___, the right IJ line has been removed. Again they are extremely low lung volumes with atelectatic changes at the bases. No evidence of congestive failure or acute pneumonia on this quite limited study. CXR (___): Lung volumes are quite low. The right lung base is particularly elevated, most likely due to right upper quadrant mass effect or fluid and/or right subpulmonic pleural effusion. Heart is mildly enlarged. Mediastinal veins are engorged, but I doubt that there is pulmonary edema. No pneumothorax. CXR (___): The current study continues to redemonstrate low lung volumes. There is no evidence of pneumothorax. There is minimal amount of pleural effusion demonstrated. The lungs are essentially clear with no definitive evidence of new consolidation to suggest aspiration process. RUQ U/S (___): 1. Distended gallbladder, also seen on the ___ examination. No gallbladder wall thickening. Pericholecystic fluid and mild ascites. 2. No sonographic ___ sign. 3. If there is continued concern for cholecystitis, a HIDA scan can be obtained for further evaluation. HIDA (___): Heterogenous tracer uptake into the hepatic parenchyma and minimal amount of tracer excretion in the small bowel signifies underlying liver disease or obstruction. The findings are compatible with cholestasis. Given the poor excretion, the biliary system cannot be evaluated. EKG: sinus tachycardia at 101bpm; TWI III. nl axis. EKG unchanged from ___ MCRP ___: 1. No MR evidence for a hepatic abscess. 2. The two cystic lesions in the superior aspect of the right lobe of the liver which previously homogenously hyperintense on T2-weighted images now contain air indicative of continuity with the biliary tree given the recent ERCP. 3. The distended gallbladder contains gas, suggesting that air can travel from through the sphincterotomy and biliary tree. The gallbladder is unchanged in appearance since a prior study of ___. 4. Splenomegaly, increased since the prior study. 5. Moderate ascites. . FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: ___ h/o cirrhosis ___ ___ syndrome who presented with fever, cough, diffuse abdominal pain, concerning for cholangitis. Pt initially admitted to ___ and had ERCP with stent placement on ___. # Cholangitis: Initially, Pt presented with fever to 104, WBC 10.7 (no bands), upper quadrant abdominal pain. Considering abdominal pain and hx of Caroli disease, most likely source is cholangitis. Outside hospital cultures growing Rauoltella Planticola (an enteric GNR previously in the klebsiella family) that is pan-sensitive. Flu negative. s/p ERCP w/ stent placement on day of admission. Patient with increasing WBC since ___. No evidence of infection on CXR. UA negative. Patient did have one day of diarrhea, but was c. diff negative. HIDA scan unable to give any other definitive answer. MRCP performed on ___ to evaluate for intrahepatic abscess, which pt’s can be predisposed to with Caroli’s disease, was negative for abcess. No fevers since ___. Patient was continued on Meropenem, and transitioned to oral regimen of Cipro/flagyl per ID recommendations once afebrile for 3 days. . # Blepharitis: HSV possibly from immunocomprimise from sepsis. Per optho, no eye involvement. Pt received Bacitracin/Polymyxin B Sulfate Opht drops. Continue Acyclovir 400mg q8hrs x10 days. Continue artificial tears. . # Acute Renal Failure: Resolved from peak Cr of 4 now to Cr 1.0. Likely prerenal in addition to poor nutrition. Pt was fluid resuscitated and Cr resolved. Pt has had good urine output. . # Cirrhosis ___ ___ Disease: Pt with increased bilirubin during stay, discussed with Dr. ___, and thought to be secondary to infection and cholestasis. Pt was restarted on ursodiol while treating underlying infection. He also developed ascites with ___ edema after aggressive hydration in the FICU. He was started on diuretics with good response and will continue on current doses to be followed by Dr ___ week. . # Thrombocytopenia: Platelets initially 31K from most recent measurement of 86 in ___ on admission. Likely secondary to sepsis (marrow suppression) in the setting of underlying splenic sequestration ___ cirrhosis. Trended up appropiately, >100 on discharge. . #SOB: Persistent SOB, atelectasis and R hemidiaphrgam elevation on CXR, no evidence of pneumonia and no clinical suspicion of this. oxygenating well, no signs of PE. Symptoms are most likely related to atelectasis, increased ascites and hemidiaphragm elevation. Pt was given incentive spirometer and encouraged to use it 10 times an hr, with some improvement, while diuresing as above. On discharge, pt was feeling much better. . # Anemia: Hct 33.7 (stable from yesterday) from b/l 42. Current hct consistent with hospital range. Likely anemia from bone marrow suppression secondary to sepsis upon arrival. Remained stable, with no evidence of bleeding. Haptoglobin wnl. Unlikely hemolysis. Single positive guiac stool. Medications on Admission: Medications (per medical record): ursodiol 600 mg BID vitamin C vitamin D glucosamine loratadine Discharge Medications: 1. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: ___ Drops Ophthalmic PRN (as needed) as needed for dry eyes. 4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 5. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days. Disp:*42 Tablet(s)* Refills:*0* 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 8. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 hours) as needed for cough./wheeze. 9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Cepacol Sore Throat ___ mg Lozenge Sig: One (1) Mucous membrane twice a day as needed for sore throat. Discharge Disposition: Home Discharge Diagnosis: Cholangitis Cirrhosis due to Caroli Syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ were admitted with a severe infection of the biliary tree (cholangitis) and had a stent placed to improve the flow of bile as well as antibiotic treatment. ___ will continue treatment for this infection for 2 more weeks, when ___ will see the infectious disease doctors. ___ also had increased swelling and ascites and were started on diurectics. Dr. ___ continue to follow your ascites and will make any adjustments to the diurectics as needed. Followup Instructions: ___

10048001-DS-8

DS

2178-05-03 00:00:00

2178-05-06 20:29:00

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, fever Major Surgical or Invasive Procedure: Mid-line placement History of Present Illness: ___ yo M PMhx ___'s Disease complicated by cirrhosis and recurrent cholangitis with MDR E. coli presents with 1 day of fever 101.5 with rigors, diaphoresis, headache, generalized weakness, one episode of nonbloody/nonbilious emesis, dyspnea, nonproductive cough, and wheeze. Patient had sudden onset of dyspnea last similar similar to prior episodes of cholangitis. Of note, patient was previously doing well on suppressive/prophylaxis therapy of rifaxmin, recent switch to TMP-SMZ in late ___ due to high cost of rifaximin. On ___ night, patient awoke in middle of night drenched in sweat; he changed in pajamas and went back to bed. On ___ morning at 7:00, he went to put out trash and afterwards had to sit to rest for 101-5 minutes. His wife told him he looked terrible, took a temp of 101. Patient called Dr. ___ about above and was told to come to ___ ED for workup/culture/antibiotics. He has also had a brief headache for a few days (no neck stiffness) resolved with APAP in ED. He has had "wheeze" ("working to breath") without cough. He had ___ dry heaves in the ED. Patient has normally 2 BMs/day without notable change. ROS: Per HPI, positive for recent travel to ___ on ___, 2 weeks of tingling in left finger tips and bottom of food. Denies weight/appetite changes, chest pain/palpitations, abdominal pain, emesis/hematemesis, melena/hematochezia, dysuria/hematuria, change in color of stools or urine, visual or hearing changes, and focal weakness. In the ED, initial vitals were ___, 100.4, 105, 108/67, 24, SaO2 96% on ?NC/CPAP. Patient later had BP 85/52 and T102.7. His total bilirubin was near baseline, patient had no other foci of infection, CXR notable for mild volume overload felt to be secondary to hydration. A CVL was placed in his right femoral. He was given acetaminophen 1g, 3L NS, vancomycin/cefepime/metronidazole. He was briefly placed on NIPPV due to dyspnea but due to feeling better he was trialed on 4L NC. Vitals on transfer were ___, 98.6, 94, 97/67, 30, 95% on 4L NC. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Inguinal hernia repair in ___ -Depression -Osteopenia per patient -Seasonal allergies -Bee allergy Social History: ___ Family History: Mother is alive with heart disease. Father died at ___ of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ADMISSION EXAM: ================ Vitals: Afebrile, 86, 93/66, 20, 96% on 4L GENERAL: Tired, oriented, no acute distress HEENT: Sclera slightly icteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD, no meningeal signs LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, no signs of respiratory distress CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, mildly distended with air, bowel sounds present, no rebound tenderness or guarding, no organomegaly, umbilical hernia EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: R Fem Line in place C/D/I, no rashes, warm and well-perfused NEURO: A+Ox3, no asterixis, ___ ___ strength, sensation intact throughout DISCHARGE EXAM: ================ Vital Signs: T 97.9, HR 98, BP 118/68, RR 20, SaO2 95% RA General: Alert, oriented, no acute distress HEENT: Very mild conjunctival injection of R eye (improved from yesterday), open area on medial aspect of R lower eyelid, EOMI, no pain with eye movement, no periorbital swelling Neck: Supple, no JVD CV: Regular rate and rhythm, normal S1 + S2, no murmurs Lungs: Breathing comfortably, CTAB Abd: +BS, mildly distended, soft, nontender, no hepatomegaly. Umbilical hernia. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3, no asterixis Pertinent Results: ADMISSION LABS: ================ ___ 11:00PM BLOOD WBC-3.6* RBC-3.89* Hgb-13.2* Hct-38.0* MCV-98 MCH-33.9* MCHC-34.7 RDW-14.7 Plt Ct-25*# ___ 11:00PM BLOOD Neuts-88* Bands-4 Lymphs-4* Monos-4 Eos-0 Baso-0 ___ Myelos-0 ___ 01:44AM BLOOD ___ PTT-40.3* ___ ___ 09:58AM BLOOD ___ ___ 09:58AM BLOOD FacVIII-200 ___ 03:16PM BLOOD Glucose-142* UreaN-27* Creat-1.5* Na-136 K-3.6 Cl-101 HCO3-19* AnGap-20 ___ 03:16PM BLOOD ALT-37 AST-58* AlkPhos-57 TotBili-2.6* ___ 03:16PM BLOOD Lipase-22 ___ 03:16PM BLOOD cTropnT-<0.01 proBNP-363* ___ 03:16PM BLOOD Albumin-3.7 Calcium-8.7 Phos-0.8*# Mg-1.5* ___ 09:58AM BLOOD Hapto-28* ___ 02:56PM BLOOD pO2-88 pCO2-22* pH-7.53* calTCO2-19* Base XS--1 ___ 02:56PM BLOOD Lactate-3.6* ___ 03:10PM URINE Color-Amber Appear-SlHazy Sp ___ ___ 03:10PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 03:10PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1 ___ 03:10PM URINE CastGr-2* CastHy-3* ___ 03:10PM URINE Mucous-FEW DISCHARGE LABS: ================ ___ 04:00AM BLOOD WBC-3.6* RBC-3.30* Hgb-10.9* Hct-32.0* MCV-97 MCH-33.1* MCHC-34.2 RDW-16.5* Plt Ct-46* ___ 04:00AM BLOOD ___ PTT-35.5 ___ ___ 04:00AM BLOOD Glucose-99 UreaN-11 Creat-0.8 Na-141 K-3.7 Cl-107 HCO3-23 AnGap-15 ___ 04:00AM BLOOD ALT-25 AST-24 AlkPhos-71 TotBili-1.0 ___ 04:00AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8 MICROBIOLOGY: ============== ___ 1:30 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. ESCHERICHIA COLI. ___ MORPHOLOGY. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I 16 I CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0249 ON ___ - ___. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ 2:19 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ESCHERICHIA COLI. SECOND MORPHOLOGY. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0249 ON ___ - ___. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___: Blood culture negative ___: Blood culture negative ___: Blood culture negative ___: Blood culture pending ___: Blood culture pending ___: C diff negative IMAGING/STUDIES: ================= CTA (___): IMPRESSION: 1. No evidence of central or segmental pulmonary embolism. Evaluation of subsegmental pulmonary artery is limited due to motion artifact. 2. Slight interval increase in small bilateral pleural effusion with adjacent atelectasis. 3. ___'s disease with ductal dilatation, cirrhosis, and splenomegaly, better evaluated on ___ MRI. TTE (___): Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is 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 aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of ___, the findings are similar. TTE (___): Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No late contrast seen in left heart suggesting absence of intrapulmonary shunting. Conclusions No late contrast is seen in the left heart (suggesting absence of intrapulmonary shunting). Chest CT (___): IMPRESSION: 1. Bibasilar atelectasis and small bilateral non-hemorrhagic pleural effusion. 2. Sequelae of ___'s disease with biliary duct dilatation, cirrhotic liver, and splenomegaly as well as distended gallbladder, better characterized on prior MRI from ___. ___ (___): Negative CXR (___): IMPRESSION: No acute cardiopulmonary abnormality. RUQ US (___): IMPRESSION: 1. Cirrhosis with splenomegaly. No ascites. 2. Unchanged, marked distention of the gallbladder without specific evidence for acute cholecystitis. No intrahepatic biliary ductal dilation or gallstones. Brief Hospital Course: Mr. ___ is a ___ gentleman with a past medical history significant for ___'s syndrome complicated by cirrhosis and recurrent cholangitis with MDR E. coli who presented in septic shock and was found to have E. coli bacteremia, presumably from a biliary source. # Septic shock/E. coli bacteremia: Patient with a history of recurrent cholangitis presented with fever/tachycardia/leukopenia and ___ not responsive to 20mL/kg bolus in setting of suspected infectious source from biliary tree. TBili was elevated but CBD did not appear dilated on RUQ ultrasound. There were no signs or symptoms to suggest alternative source of infection. Patient was admitted to the ICU for pressors and was initially started on vancomycin/cefepime/Flagyl. Once blood cultures grew GNR (which later speciated to E. coli), vancomycin was discontinued. Patient was quickly weaned off pressors. Once E. coli sensitivities returned, patient was narrowed to ceftriaxone. A midline was placed so he could complete a 14 day course of ceftriaxone as an outpatient. # Cirrhosis: Patient with known cirrhosis secondary to Caroli syndrome. MELD 22 on admission. He has a history of esophageal variceal bleed in ___. No signs of bleeding, ascites, or encephalopathy on admission. TBili was 2.6 on admission but then normalized. RUQ ultrasound did not show any biliary ductal dilation. Home diuretics (Lasix 20 mg daily, amiloride 5 mg daily) and nadolol were initially held given septic shock, but these were later restarted after patient stabilized. # Dyspnea/hypoxia: Patient reported resting dyspnea and was initially hypoxic, requiring up to 4L O2. Work-up included CXR (limited study, mild pulmonary edema, no obvious infiltrate), chest CT (bibasilar atelectasis, small pleural effusions), TTE with bubble (normal EF, bubble study negative, no evidence of HPS), and CTA negative for PE. Diuresis was trialed. Patient's dyspnea resolved and he was able to be weaned off O2. # Pancytopenia: On review of OMR, patient has a chronic pancytopenia, likely secondary to cirrhosis. WBC and Hg were near baseline but thrombocytopenia was worse than baseline, likely a stress response in the setting of sepsis. There was no clinical or laboratory evidence of DIC. SQ heparin was held. All cell lines improved. # HSV lesions: Patient had three HSV lesions on his face, including one near his right eye with associated conjunctivitis. He was evaluated by ophthalmology and started on po acyclovir 400 mg tid. He will complete a 10 day course. He was also given erythromycin ointment and artificial tears for comfort. His conjunctivitis improved. # Depression: Citalopram was held given coagulopathy/thrombocytopenia. It was restarted on discharge. TRANSITIONAL ISSUES: ===================== -Patient recently changed his prophylactic antibiotics from rifaximin to Bactrim as his insurance change would not allow an affordable copay. Salix pharmaceuticals has given him a free 10 day supply while the liver transplant clinic tries to work with his insurance company to make this medication more affordable. He will resume prophylactic antibiotics once he finishes his course of ceftriaxone. -Pt's PCP wrote the ceftriaxone prescription and faxed it to the ___ where he will get his daily dose. They have coordinated with their ED to get him infusions on the weekend. First dose with their clinic will be 2 pm on ___. -Will complete 10 day course of acyclovir and erythromycin for conjunctivitis. If symptoms do not resolve he can follow up with ophtho as an outpatient. Erythromycin ointment finishes ___, acyclovir finishes ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid ___ mg PO BID 2. Citalopram 20 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Ursodiol 600 mg PO BID 5. Nadolol 20 mg PO DAILY 6. Amiloride HCl 5 mg PO DAILY 7. Loratadine 10 mg Oral daily 8. Magnesium Oxide 400 mg PO DAILY Discharge Medications: 1. Amiloride HCl 5 mg PO DAILY 2. Ascorbic Acid ___ mg PO BID 3. Furosemide 20 mg PO DAILY 4. Ursodiol 600 mg PO BID 5. Acyclovir 400 mg PO Q8H Duration: 10 Days Last day ___ RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*26 Tablet Refills:*0 6. Artificial Tear Ointment 1 Appl RIGHT EYE PRN pain irritation RX *artificial tears ointment [Artificial Tears] 1 drop daily Refills:*0 7. CeftriaXONE 2 gm IV Q24H 8. Citalopram 20 mg PO DAILY 9. Loratadine 10 mg Oral daily 10. Magnesium Oxide 400 mg PO DAILY 11. Nadolol 20 mg PO DAILY 12. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID Duration: 10 Days right eye and lower lid 3x/day. Last day ___ RX *erythromycin 5 mg/gram (0.5 %) 1 cm three times a day Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary -E. Coli bacteremia -Septic Shock Secondary -Caroli syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ for infection in your biliary tree. We gave you antibiotics and you improved. The infection spread to your blood which will require IV antibiotics for 2 weeks. We have set you up with the community clinic at ___ to continue your IV antibiotics through ___. During the weekends, you will go to the ___ room who will infuse the medication. If there is any problems with the mid-line (irritation, redness, pain), please call your pcp's office or go to the emergency room It was a pleasure taking care of you -___ Team Followup Instructions: ___

10048001-DS-9

DS

2182-04-19 00:00:00

2182-04-19 14:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Confusion, upper GI bleeding Major Surgical or Invasive Procedure: EGD ___: APC to vascular ectasia in the duodenum PICC line placement ___ History of Present Illness: Mr. ___ is a ___ year old man with a history of Caroli disease and well compensated cirrhosis who presents from ___ with confusion, abdominal pain and vomiting. He was just on vacation in ___ and approximately 3d ago his wife noticed that he wasn't acting like himself, was confused, and asking repetitive questions. He had diarrhea for one week, some of which was black of dark red. He also had some abomdinal pain that was not significantly different from normal, but did have some nausea and vomiting with bright red blood in the emesis. He has a history of cholangitis and typically has fevers and chills, which he hasn't had. He presented to the ___ ED. At ___ had WBc 13.8, INR 1.4, T bili 2.4, AST/ALT 143/123, Lactate 2.1, BNP 582, TropT 0.39. CTA without PE. CTAP with distended gallbladder with pericholecystic fluid and stone at gallbladder neck. A blood culture grew gram positive organisms in short chains. On arrival to the floor, he reports still feeling somewhat confused. He has not had further nausea/vomiting. He is very thirsty. EMERGENCY DEPARTMENT COURSE Initial vital signs were notable for: - T 96.9, HR 86, BP 129/71, RR 16, O2 95% RA Exam notable for: - Benign abdomen Labs were notable for: - ALT 108 - AP 246 - T bili 2.3 - AST 115 - Cr 1.3, BUN 43 - Lactate 2.3 Patient was given: - Zosyn - Protonix - Urosodiol 600mg - Lasix 40mg PO - Nadolol 20mg - Amliloride 10mg - Vancomycin Consults: - Hepatology ================= REVIEW OF SYSTEMS ================= Complete ROS obtained and is otherwise negative. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Inguinal hernia repair in ___ -Depression -Osteopenia per patient -Seasonal allergies -Bee allergy Social History: ___ Family History: Mother is alive with heart disease. Father died at ___ of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VITALS: T 98.9, BP 127/77, HR 78, RR 22, ___ GENERAL: Tired appearing, lying in bed, arousable to voice HEENT: Pupils equal and reactive, mild scleral icterus, dry mucous membranes, CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4 LUNGS: Poor air movement, bibasilar rales, diminished lung sounds bilaterally BACK: No CVA tenderness ABDOMEN: Soft, mildly tender to palpation diffusely, worse in LUQ. Umbilical hernia soft and reducible. EXTREMITIES: 2+ pitting edema to upper shins SKIN: Scattered superficial abrasions throughout abdomen NEUROLOGIC: A+Ox3, though slow to identify date. Mild asterixis. CNII-XII normal. ======================= DISCHARGE PHYSICAL EXAM ======================= General: Elderly gentleman, sitting up in chair HEENT: Sclera anicteric, mucous membranes moist Lungs: vesicular breath sounds bilaterally CV: Regular rate and rhythm, no murmurs Abdomen: obese, distended, no tenderness to palpation, reducible umbilical hernia Ext: Warm, well perfused, ___ bilateral pitting edema of lower extremities up to knees. Patient had removed compression stockings just prior to exam. Neuro: Alert, cranial nerves grossly intact Pertinent Results: ======================= ADMISSION LAB RESULTS ======================= ___ 04:13AM BLOOD WBC-12.5* RBC-3.55* Hgb-10.7* Hct-32.6* MCV-92 MCH-30.1 MCHC-32.8 RDW-18.6* RDWSD-56.5* Plt Ct-82* ___ 04:13AM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-2* Eos-0* ___ Myelos-6* NRBC-0.2* AbsNeut-11.00* AbsLymp-0.50* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00* ___ 04:13AM BLOOD ___ PTT-28.2 ___ ___ 04:13AM BLOOD Glucose-115* UreaN-43* Creat-1.3* Na-138 K-8.2* Cl-108 HCO3-20* AnGap-10 ___ 04:13AM BLOOD ALT-113* AST-175* AlkPhos-217* TotBili-2.1* ___ 04:13AM BLOOD Lipase-39 ___ 04:13AM BLOOD Albumin-2.6* ====================== DISCHARGE LAB RESULTS ====================== ___ 07:34AM BLOOD WBC-3.2* RBC-2.97* Hgb-9.1* Hct-29.1* MCV-98 MCH-30.6 MCHC-31.3* RDW-21.2* RDWSD-75.1* Plt Ct-72* ___ 07:34AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-142 K-4.6 Cl-109* HCO3-24 AnGap-9* ___ 07:34AM BLOOD ALT-27 AST-28 LD(LDH)-236 AlkPhos-130 TotBili-1.7* =============== MICRO DATA =============== ________________________________________________________ ___ 12:46 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:42 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:51 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 5:03 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. Identification and susceptibility testing performed on culture # ___ (___). Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS. __________________________________________________________ ___ 7:20 am BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. Identification and susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. __________________________________________________________ ___ 7:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC = 1.0 MCG/ML. Daptomycin test result performed by Etest. TETRACYCLINE Susceptibility testing requested per ___ (___) (___). TETRACYCLINE IS NOT INTENDED FOR THE PRIMARY TREATMENT OF BLOOD STREAM INFECTIONS. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- 2 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ @2149 ON ___. ===================== IMAGING AND REPORTS ===================== RUQ ULTRASOUND ___ IMPRESSION: 1. No biliary dilation or gallstones. Distended gallbladder without wall thickening, as seen previously. MRCP could further evaluate for cholangitis and the gallbladder distention. 2. Cirrhotic liver with stable splenomegaly and redemonstrated patent paraumbilical vein. Patent portal vein. CHEST X-RAY ___ IMPRESSION: Low lung volumes with mild pulmonary edema and trace left pleural effusion. Persistent bibasilar atelectasis. MRCP ___ IMPRESSION: 1. No MR evidence of acute cholangitis. Apparent 4 mm central filling defect in the distal CBD likely represents a flow void, without definite evidence of choledocholithiasis. 2. Well distended gallbladder without signs of acute cholecystitis, may be due to fasting state. 3. Overall stable saccular dilation of predominantly right-sided intrahepatic bile ducts, together with cirrhotic liver morphology and portal hypertension, consistent with known ___ syndrome. TRANSTHORACIC ECHO ___ IMPRESSION: No 2D echocardiographic evidence for endocarditis. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior TTE (images not available for review) of ___ , the estimated pulmonary artery systolic pressure is now increased. Tricuspid regurgitation is more prominent. UPPER ENDOSCOPY ___ 1. One cord of grade I varices in the distal esophagus. Not bleeding. 2. Diffuse congestion, petechiae and mosaic mucosal pattern of the stomach with contact bleeding in the fundus and body. Compatible with PHG. 3. Single small non bleeding localized angioectasia seen in the second part of the duodenum. Angioectasia was ablated completely. APC was successfully applied for hemostasis. Brief Hospital Course: Mr. ___ is a ___ year old man with a history of Caroli disease, cirrhosis, known esophageal varices who developed confusion and upper GI bleeding while on vacation in ___. He was treated for acute cholangitis, upper GI bleed likely from portal hypertensive gastropathy, and hepatic encephalopathy. He was discharged on his home medications with the addition of lactulose and daptomycin. He will follow up with PCP, infectious disease and hepatology for further management. ACUTE PROBLEMS: =============== # Acute cholangitis # Enterococcus faecalis bacteremia Patient has history of recurrent cholangitis due to intrahepatic biliary ductal dilation from ___'s disease. He has been on maintenance outpatient antibiotics and hasn't had any infections since about ___. Patient developed nausea, hematemesis and bloody bowel movement while on vacation with his wife in ___. ___. The episodes were self-limited, and they presented to nearest ER on return to ___ (which was ___. He was transferred to ___. Here, MRCP did not show any specific changes in biliary ducts. However, given that his disease is intra-hepatic, imaging may not be sensitive enough to identify changes. His blood cultures grew Enterococcus faecalis, and his initial broad antibiotic coverage was adjusted to Daptomycin with input from infectious disease team. He underwent placement of PICC line on ___ and was discharged with plan to follow up with ID. Routine TTE for bacteremia was normal. # Upper GI bleed Patient has history of bleeding esophageal varices that were previously banded. Most recent EGD was in ___ and showed grade I varices in the esophagus. Due to report of hematemesis and dark stool several days prior to admission, patient underwent EGD. This showed portal hypertensive gastropathy with bleeding on contact as well as small duodenal vascular ectasia that was treated with APC. There was no evidence of variceal bleeding on this exam. Colonoscopy was not done but should be pursued outpatient given that upper endoscopy findings were relatively underwhelming. He likely developed bleeding secondary to bacteremia from a biliary source. He was maintained on PPI and will follow up with hepatology at discharge, at which time colonoscopy should be discussed. # Acute decompensated cirrhosis: hepatic encephalopathy, volume overload, UGIB # ___'s disease Admission MELD-NA of 18. Patient has ___'s disease and subsequent liver cirrhosis for about ___ years. On this admission, his cirrhosis was decompensated by hepatic encephalopathy, volume overload and portal hypertensive gastropathy with GI bleeding. He likely developed bacteremia from cholangitis, which subsequently precipitated both GI bleed and hepatic encephalopathy. Patient was started on lactulose due to encephalopathy. Wife reported that over the last several weeks patient was showing signs of forgetfulness and confusion, and then developed altered sleep pattern while on vacation. This likely occurred in the setting of infection and GI bleeding. Patient will be discharged on lactulose titrated to ___ bowel movements daily (has not previously been on lactulose). GI bleeding was addressed as above. Underwent APC this admission, no varices. He was restarted on home nadolol at discharge. Home diuretics were initially held due to acute kidney injury. After EGD, he underwent IV diuresis due to worsening lower extremity edema and dyspnea. This improved and he was restarted on home diuretics at discharge. He was continued on home ursodiol. He will follow up with liver clinic (Dr. ___. # Acute kidney injury Baseline creatinine is about 1. On initial presentation to ___ it was elevated to 1.4. It improved with fluid and albumin for volume resuscitation. He likely was volume depleted after vomiting and diarrhea. Discharge creatinine was 0.9. CHRONIC PROBLEMS: ================ # Depression - Continue home citalopram ============================== TRANSITIONAL ISSUES ============================== [] Patient will be receiving Daptomycin once a day at the ___ at ___. ___ and ___, he will get it at their ___. The rest of the days of the week, he will need to go to the ___, located in the emergency room at ___. #CODE: Full, limited trial of life sustaining measures, confirmed #CONTACT: Wife, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Cefpodoxime Proxetil 200 mg PO Q12H 3. LevoFLOXacin 500 mg PO Q24H 4. Citalopram 20 mg PO DAILY 5. Nadolol 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Ursodiol 600 mg PO BID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Sildenafil 50 mg PO DAILY:PRN sexual activity 11. Furosemide 40 mg PO DAILY 12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 13. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 14. Loratadine 10 mg PO DAILY Discharge Medications: 1. Daptomycin 850 mg IV Q24H 2. Lactulose 30 mL PO Q2H RX *lactulose 20 gram/30 mL 30 ml by mouth once a day Disp #*1 Bottle Refills:*0 3. rifAXIMin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. aMILoride 10 mg PO DAILY 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 8. Furosemide 40 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Loratadine 10 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. Nadolol 20 mg PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Sildenafil 50 mg PO DAILY:PRN sexual activity 15. Ursodiol 600 mg PO BID 16. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication was held. Do not restart Cefpodoxime Proxetil until discussion with infectious disease team 17. HELD- LevoFLOXacin 500 mg PO Q24H This medication was held. Do not restart LevoFLOXacin until discussion with the infectious disease team Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Acute cholangitis -Enterococcus bacteremia -Acute decompensated liver cirrhosis SECONDARY: -Hepatic encephalopathy -Upper GI bleed -Acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for confusion, bleeding and concern for cholangitis. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You had an imaging study of your abdomen that did show some possibility of cholangitis. - Your blood cultures grew bacteria called Enterococcus. This was treated with IV antibiotics. - You had an endoscopy done which showed changes in your stomach due to your liver disease. You had a chemical treatment done to prevent from bleeding. No banding was done. - You had a PICC line placed so that you could get IV antibiotics at home. WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. - You are scheduled to get antibiotics at the ___ ___. ___ and ___, you will get it at their infusion center. The rest of the days of the week, you will need to go to the ___, located in the emergency room at ___ ___. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10048061-DS-4

DS

2169-04-24 00:00:00

2169-04-24 20:44:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Transfer for fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o female with a history of Still's disease who presented to OSH (___) with fevers to 104.8 and arthralgia and transferred for rheumatology evaluation. She first developed Still's symptoms in ___. Her symptoms were a fever to 103+ and rash. In ___, she was diagnosed with Still's disease and began following with Dr. ___ in Rheumatology (___, ___). She was initially started on prednisone 60 mg and a biologic. She was remained on the prednisone for ___ years but had several side effects including weight gain and osteoporosis, so this was stopped. She has also developed several infections as a result of her biologic therapy including a jaw infection and a breast abscess which required significant surgical intervention. Due to her infections on biologics, she was stopped on biologics by her rheumatologist. She has instead been maintained on hydroxychloroquine 400 mg qhs and sulfasalazine 1000 mg daily. At baseline, her Still's symptoms are: ___ pain in various joints (changes every day), morning nausea, morning sore throat, and fevers twice a day between 103.7 and 104s. A few days before this admission, she developed severe pain in her left wrist, right wrist, and left ankle along with a fever to 104.8 which is higher than normal for her. She took a cold shower for 8 minutes but the fever did not improve at all. She called her Rheumatologist who recommended presenting to the hospital. She presented to ___ in ___ on ___. While there, her vital signs were stable. Labs showed WBC 12.2, hgb 11.9, lactate 1.3, procal < 0.05, cr 0.63, UA bland, LFTs normal, albumin 4, trop negative, CRP 5.6, ESR 50, flu negative. She was transferred to ___ for specialist care. In the ED at ___, initial vitals were T 98.8, HR 70, BP 130/80, RR 16, O2 100% RA. Labs notable for WBC 9.5 (35% lymph), hgb 11.4, Cr 0.7, LFTs normal, lipase 15, INR 1.2, UA bland, lactate 0.9, CRP 5.1. A CT abd/pelvis with contrast did not show any intraabdominal pathology. She was given ketorolac x1 and oxycodone. Upon arrival to the floor, patient reports the above history. She feels significant pain in her wrists and left ankle. She says she hasn't had gabapentin in >24 hours. She denies dysuria, frequency, chest pain, cough, headache, visual changes. She does not feel she has an infection, and instead feels like this is an exacerbation of her underlying Still's. She denies any recent travel, changes in medication, changes in diet, or sick contacts. Past Medical History: Still's disease Social History: ___ Family History: Mother died from complications of RA. Father with plaque psoriasis and psoriatic arthritis. Sister with plaque psoriasis. Physical Exam: ADMISSION EXAM VITAL SIGNS: T 98.3, BP 145 / 86, HR 76, RR 20 99 RA GENERAL: Distressed appearing female sitting in bed HEENT: MMM, OP clear, external ear canal normal NECK: Soft, no masses CARDIAC: RRR, normal s1,s2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended EXTREMITIES: Right wrist is tender to palpation. Limited mobility of first three fingers due to pain. Left wrist tender to palpation. Both wrists with mild swelling and erythema. Left ankle is significantly tender to palpation and is swollen in the lateral aspect. Right ankle normal. NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation intact to light touch SKIN: No facial rashes noted DISCHARGE EXAM =========== ___ ___ Temp: 98.0 PO BP: 130/79 HR: 64 RR: 18 O2 sat: 99% O2 delivery: Ra GENERAL: resting comfortably in bed seated up right HEENT: anicteric sclera, no scleral injection NECK: Soft, no masses CARDIAC: RRR, normal s1,s2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended EXTREMITIES: Right wrist is tender to palpation. Limited mobility of first three fingers due to pain. Left wrist tender to palpation. Right wrist without marked overlying erythema or swelling in comparison to left wrist, no palpable synovitis or joint effusions. Left ankle with tender to palpation at the joint line but no overlying malleolus effusions, erythema or swelling NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation intact to light touch SKIN: No facial rashes noted Pertinent Results: ADMISSION LABS ___ 03:15AM BLOOD WBC-9.5 RBC-4.32 Hgb-11.4 Hct-35.4 MCV-82 MCH-26.4 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt ___ ___ 03:15AM BLOOD Neuts-56.1 ___ Monos-6.1 Eos-2.1 Baso-0.4 Im ___ AbsNeut-5.34 AbsLymp-3.33 AbsMono-0.58 AbsEos-0.20 AbsBaso-0.04 ___ 03:15AM BLOOD ___ PTT-29.4 ___ ___ 03:15AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-142 K-4.4 Cl-105 HCO3-24 AnGap-13 ___ 03:15AM BLOOD ALT-10 AST-16 AlkPhos-72 TotBili-0.3 ___ 03:15AM BLOOD Lipase-15 ___:15AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.7 Mg-2.0 Iron-67 ___ 03:15AM BLOOD calTIBC-432 Ferritn-21 TRF-332 ___ 03:15AM BLOOD CRP-5.1* ___ 03:21AM BLOOD Lactate-0.9 INTERVAL LABS ___ 09:00AM BLOOD RheuFac-<10 ___ ___ 03:15AM BLOOD CRP-5.1* DISCHARGE LABS MICROBIOLOGY IMAGING CT A/P With Contrast ___ 1. Soft tissue density just distal to the duodenal jejunal junction suspicious for small bowel mass for which further characterization can be obtained by endoscopy if amenable by location or MRE. 2. No acute intra-abdominal or pelvic abnormalities to correlate with patient's symptoms, specifically no evidence of intra-abdominal abscess. CXR ___ Heart size is normal. Mediastinum is normal. Lungs are clear. There is no pleural effusion. There is no pneumothorax ANKLE MRI: ___ IMPRESSION: -Thickening of syndesmotic ligaments with some adjacent tibial cortical irregularity posteriorly suggestive of prior syndesmotic ligament injury. The ATFL appears slightly irregular also most likely due to prior injury. No acute ligamentous injury is identified. -There is tibiotalar osteoarthritis with full-thickness cartilage loss along the superomedial aspect of the talar dome and the adjacent tibial plafond. There is associated associated subchondral bone marrow edema, osteophytosis and mild synovitis. -Some stranding of the fat with loss of normal signal in sinus tarsi is demonstrated, this may be seen in setting of sinus tarsi syndrome. -Plantar fasciitis with associated plantar calcaneal spur. -Mild atrophy of the abductor digiti minimi muscle which may be seen in the setting of Baxter neuropathy. -Minimal extensor digitorum tenosynovitis. ___, MD electronically signed on SUN ___ 8:15 ___ Microbiology: ========= ___ 5:10 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 3:26 am BLOOD CULTURE X2 Blood Culture, Routine (Pending): NGTD D/C Labs: ___ 06:20AM BLOOD WBC-7.1 RBC-4.20 Hgb-11.0* Hct-34.9 MCV-83 MCH-26.2 MCHC-31.5* RDW-14.7 RDWSD-44.6 Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-141 K-4.1 Cl-100 HCO3-27 AnGap-14 ___ 06:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 Brief Hospital Course: Summary: ======= Ms. ___ is a ___ year old female with a history of Still's disease, initially diagnosed in ___ previously on prednisone and biologics, currently maintained on hydroxychloroquine and sulfasalazine who initially presented with fever to 104+ and worsening arthralgias to ___, evaluated by rheumatology and ultimately per their assessment and negative laboratory and imaging findings determined not to have an acute flare of Adult onset Still's disease as a cause of her presentation. # Still's disease # Degenerative joint disease # Fever, joint pain Patient has a history of Still's disease initially diagnosed in ___, previously on prednisone and biologics, currently maintained on hydroxychloroquine and sulfasalazine. She previously did not tolerate biologics due to severe jaw and subsequent breast infection. At baseline has daily fevers measuring approximately 103-104, however presented with fever to 104.8 and severe worsening bilateral wrist and left ankle pain. Patient was evaluated by rheumatology, with recommendations including that she should follow up with her regular rheumatologist and could consider discontinuing her home regiment of sulfasalazine and plaquenil since it has not given her significant relief and worsened her nausea. Given severe left ankle swelling and pain, a left ankle MRI was obtained which showed largely degenerative joint disease without inflammatory changes. There was low suspicion for concomitant infection given low procalcitonin at OSH, no leukocytosis, or other localizing symptoms or signs consistent with infection. Given report of left-sided abdominal pain on admission, CT abdomen and pelvis was obtained which showed no obvious sources of infection, however did show soft tissue density distal to the duodenal-jejunal junction suspicious for small bowel mass. Patient was continued on home sulfasalazine and hydroxychloroquine. Pain was managed with Tylenol, ibuprofen, and oxycodone. Ultimately after a negative testing with a normal ferritin, negative ___, normal rheumatoid factor, their assessment was that this presentation was not consistent with a flair of her known Still's disease. # Possible small bowel mass - CT A/P on admission showed a soft tissue density just distal to the duodenal jejunal junction suspicious for small bowel mass. This will need further outpatient GI work up. TRANSITIONAL ISSUES =================== [ ] New/Changed Medications -None [ ] Discontinued medications -None [ ] patient with degenerative changes of left ankle, consider Ortho evaluation as an outpatient [ ] Recommend GI clinic visit for ongoing work-up of possible small bowel mass # CODE: full (presumed) # CONTACT: ___ Relationship: OTHER Phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydroxychloroquine Sulfate 400 mg PO QHS 2. SulfaSALAzine_ 1000 mg PO DAILY 3. Gabapentin 800 mg PO TID 4. Vitamin D ___ UNIT PO 1X/WEEK (MO) 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 6. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild 7. Methocarbamol 750 mg PO BID:PRN muscle spasm 8. Omeprazole 20 mg PO QAM 9. Zolpidem Tartrate 10 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 3. Nystatin Oral Suspension 5 mL PO QID Duration: 6 Days RX *nystatin 100,000 unit/mL 5 mL by mouth four times daily Refills:*0 4. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp #*28 Tablet Refills:*0 5. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #*60 Tablet Refills:*0 6. Gabapentin 800 mg PO TID 7. Hydroxychloroquine Sulfate 400 mg PO QHS 8. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 9. Methocarbamol 750 mg PO BID:PRN muscle spasm 10. Omeprazole 20 mg PO QAM 11. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild RX *oxycodone 5 mg 2 tablet(s) by mouth every six hours Disp #*16 Tablet Refills:*0 12. SulfaSALAzine_ 1000 mg PO DAILY 13. Vitamin D ___ UNIT PO 1X/WEEK (MO) 14. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Discharge Worksheet-Discharge ___, MD on ___ @ 1024 PRIMARY DIAGNOSIS Degenerative joint disease Chronic Still's disease Possible sinus tarsi syndrome 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 did you come to the hospital? -You initially presented to an outside hospital with worsening fever and joint pains -You were transferred to ___ for rheumatology evaluation - After the rheumatology evaluation it was determined that this round of pain was likely not due to a flare of your rheumatologic condition. - You also had an MRI of you left ankle which showed some degenerative changes of your ankle. What happened during her hospitalization? - You are evaluated by the rheumatology team and found not to have an acute exacerbation of your Still's disease - A MRI of your left ankle was obtained which showed degenerative changes - A Cat Scan of your abdomen showed a possible mass that will be further evaluated in the outpatient setting Which should you do when you leave the hospital? - Continue to take all your medications as prescribed - Follow-up with your primary care physician ___ 1 week - Please keep all the other scheduled healthcare appointments listed below Sincerely, Your ___ Care Team Followup Instructions: ___

10048244-DS-11

DS

2121-05-27 00:00:00

2121-05-28 11:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Attending: ___. Chief Complaint: Acute kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with history of HCV cirrhosis complicated by ___ s/p liver transplant ___, course c/b mild acute rejection ___ and recurrent HCV now s/p cure, recurrent cirrhosis, CVA in ___ with residual right sided weakness, and newly diagnosed focal segmental glomerulosclerosis, who is presenting with worsening renal function and chills. The patient was most recently discharged ___, for subcapsular/perinephric hematoma after renal biopsy was done for increasing creatinine and proteinuria. Although his renal function had moderately improved with decreasing tacrolimus level, final biopsy results showed FSGS. He went for routine follow up in primary care clinic yesterday (___) and labs showed creatinine had increased to 3.1, from 2.5 at discharge (baseline low 2s). He was sent to the ED when the labs resulted. Prior to coming to the ED, the patient was feeling well. He has had no fevers, nausea, vomiting, diarrhea, back/flank pain, dysuria, hematuria, or change in urine output, and no ___ swelling. He has had occasional chills. His wife also thought he was more fatigued than usual. In the ED initial vitals: 98.9 79 130/82 16 100RA. Exam was notable for shivering, sleepiness, bibasilar crackles, no ascites and residual RUE and RLE weakness. Labs were notable for Cr 3.2, H/H 8.1/26.1 (baseline), WBC 6.3, LFTs wnl. UA was notable for small blood, few bacteria, RBC 1, WBC 4, >300 protein. Urine protein/cr ratio was 3.8 (was 6.2 ___. Renal ultrasound showed no hydronephrosis, left perinephric hematoma measuring 7.3 x 3.7 x 3.1 cm. CXR had no acute processes. He was given 50 g albumin and 650mg acetaminophen. Upon arrival to the floor, the patient endorses headache, which has been persistent for some time. He denies new numbness or weakness. He denies chest pain, dyspnea, ___ edema, abdominal distension, decreased appetite, pruritus. REVIEW OF SYSTEMS: as per HPI. Past Medical History: # Liver Transplant (___) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented ___ -- c/b mild acute rejection (biopsy ___ -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD (___) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm (___) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation (___) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: ___ Family History: No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM VITAL SIGNS - 99.6 PO 163 / 74 R Lying 85 20 98 RA GENERAL - well appearing, no acute distress HEENT - MMM NECK - JVP not elevated CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops PULMONARY - clear to auscultation bilaterally, no wheeze, rales, rhonchi ABDOMEN - soft, NT, ND, NABS GENITOURINARY - no foley EXTREMITIES - no edema, WWP SKIN - no rash visualized NEUROLOGIC - baseline right arm and leg weakness PSYCHIATRIC - normal mood and affect DISCHARGE PHYSICAL EXAM VITAL SIGNS - 98.3, 150s/80s, 70s, 18, 97% RA GENERAL - well appearing, no acute distress HEENT - MMM CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops PULMONARY - clear to auscultation bilaterally, no wheeze, rales, rhonchi ABDOMEN - soft, NT, ND, NABS GENITOURINARY - no foley EXTREMITIES - no edema, WWP SKIN - no rash visualized NEUROLOGIC - baseline right arm and right leg weakness Pertinent Results: ADMISSION LABS ------------------ ___ 01:45PM BLOOD WBC-5.4 RBC-3.28* Hgb-7.9* Hct-24.4* MCV-74* MCH-24.1* MCHC-32.4 RDW-13.1 RDWSD-35.3 Plt ___ ___ 09:30AM BLOOD Neuts-73.1* Lymphs-18.1* Monos-7.3 Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.60# AbsLymp-1.14* AbsMono-0.46 AbsEos-0.05 AbsBaso-0.01 ___ 09:30AM BLOOD ___ PTT-33.3 ___ ___ 01:45PM BLOOD UreaN-36* Creat-3.1* Na-139 K-4.6 Cl-106 HCO3-19* AnGap-19 ___ 01:45PM BLOOD ALT-14 AST-24 AlkPhos-115 TotBili-0.3 ___ 01:45PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-1.9 ___ 01:45PM BLOOD tacroFK-2.3* ___ 10:15AM BLOOD Lactate-1.3 K-4.5 ___ EVEROLIMUS,LC/MS/MS,BLOOD 4.9 ___ 10:20AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:20AM URINE Blood-SM Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 10:20AM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 ___ 10:20AM URINE Hours-RANDOM UreaN-545 Creat-197 Na-20 K-41 Cl-<20 TotProt-750 Calcium-<0.8 Phos-47.7 Mg-1.7 Prot/Cr-3.8* ___ 10:20AM URINE Osmolal-383 DISCHARGE LABS: --------------- ___ 05:44AM BLOOD WBC-4.7 RBC-3.04* Hgb-7.5* Hct-22.7* MCV-75* MCH-24.7* MCHC-33.0 RDW-13.1 RDWSD-35.4 Plt ___ ___ 05:44AM BLOOD ___ PTT-30.9 ___ ___ 05:44AM BLOOD Glucose-137* UreaN-30* Creat-2.7* Na-138 K-4.6 Cl-106 HCO3-21* AnGap-16 ___ 05:44AM BLOOD ALT-14 AST-20 LD(LDH)-307* AlkPhos-104 TotBili-0.2 ___ 05:44AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 ___ 05:44AM BLOOD tacroFK-2.6* ___ 05:30AM BLOOD Hapto-318* IMAGING --------- RENAL ULTRASOUND ___: 1. No hydronephrosis. Left perinephric hematoma, extent of which is not clearly defined. Follow-up is recommended. RECOMMENDATION(S): Recommend follow-up. CXR (___): No acute cardiopulmonary process. Stable pleural calcifications. MICROBIOLOGY ---------------- ___ 10:20 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Brief Hospital Course: Mr. ___ is a ___ year old man with history of HCV cirrhosis complicated by ___ s/p liver transplant ___, course c/b mild acute rejection ___ and recurrent HCV now s/p cure, CVA in ___ with residual right sided weakness, and newly diagnosed focal sclerosing glomerulonephritis, presenting with worsening renal function and chills with concern for worsening FSGS, now with slightly improving renal function after stopping everolimus and decreasing the dose of tacrolimus. ___ on CKD, Focal segmental glumerosclerosis: Patient presenting with proteinuria and creatinine 3.2 above baseline low 2s, and discharge Cr of 2.5 (___). Given recent FSGS diagnosis, concerned for worsening disease, as it may be rapidly progressive in some people. Although his biopsy does not comment, suspect FSGS is secondary type and may be secondary to HCV. Patient denied decreased po intake and denies infectious symptoms. Renal ultrasound showing no hydronephrosis and stable left perinephric hematoma. Urine prot/cr worsening (6.5 from 3.8). Renal was consulted who felt that the acute worsening of his renal function could likely be attributed to his immunosuppressants so they recommended minimizing Everolimus and Tacrolimus. He was discharged on a decreased dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was initiated. #HCV cirrhosis c/b ___ s/p liver Transplant ___, with recurrent cirrhosis: Patient unfortunately developed recurrent cirrhosis despite HCV cure with simeprevir and sofosbuvir. He has had no identified liver lesions c/f HCC. He is currently on a study drug to treat fibrosis. He has no varices on recent EGD, no ascites, and no documentation of recent encephalopathy. He was continued on home study drug (per Dr. ___, and the following immunosuppressants: He was discharged on a decreased dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was initiated. He will follow up at transplant clinic on ___. #Hypertension: As above, BPs may be more elevated than in his past with the current FSGS and worsening renal function. Currently elevated BP most likely due to missed doses of home medications while in the ED, and BP stabilized but were still elevated to 150's systolic during the hospitalizations. We continue home labetolol 200 mg BID, amlodipine 10 mg PO daily on discharge. Would recommend eventually initiating ___ once kidney function stabilizes. Spironolactone 50 mg daily was held in setting of ___, and remained off on discharge. He should discuss this with his outside providers. # Anemia: Hgb 8 on admission, stable from prior discharge baseline. Last iron studies in ___ c/w AOCD with low retics suggestive of hypoproliferation. Hgb remained stable throughout discharge, Hgb 7.7 on discharge. #Chest pain: The night prior to discharge he developed L sided sharp chest pain which was completely new and happened at rest and resolved spontaneously after less than an hour with no intervention. His ECG and cardiac enzymes were negative and his chest pain did not recur. He was able to walk comfortably without recurrent pain so he was deemed safe for discharge. Discharge: # Esophagitis: Continued home omeprazole # Seizure Disorder: Continued home LevETIRAcetam 1500 mg PO BID. COncern that this dose is too high given recent worsening renal function. He should discuss this with his outpatient neurologist. # Ruptured Cerebral Aneurysm: Continued home Pravastatin 40 mg PO QPM. Transitional Issues: -Check creatinine at next visit. -Spironolactone held on discharge due to ___. Please consider restarting once kidney function stabilizes -Consider starting ___ once renal function stabilizes - Will need consultation with neurologist to discuss Levetiracetam dose. We feel that it is too high for his kidney function -Consider PCP prophylaxis given newly prescribed chronic prednisone. -Make sure he has not had recurrence of L sided chest pain he had the night prior to d/c Full Code Name of health care proxy: ___ Relationship: Wife Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. Everolimus 2.25 mg PO BID 3. LevETIRAcetam 1500 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Tacrolimus 3 mg PO Q12H 8. Vitamin D 1000 UNIT PO DAILY 9. IDN-___/Placebo Study Med ___ mg orally TWICE A DAY 10. amLODIPine 10 mg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 12. Spironolactone 50 mg PO DAILY 13. Labetalol 200 mg PO BID Discharge Medications: 1. PredniSONE 7.5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth twice daily Disp #*28 Tablet Refills:*0 RX *prednisone 2.5 mg 1 tablet(s) by mouth twice daily Disp #*28 Tablet Refills:*0 2. Tacrolimus 2.5 mg PO Q12H RX *tacrolimus 1 mg 2 capsule(s) by mouth twice daily Disp #*56 Capsule Refills:*0 RX *tacrolimus 0.5 mg 1 capsule(s) by mouth twice daily Disp #*28 Capsule Refills:*0 3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 6. IDN-___/Placebo Study Med ___ mg orally TWICE A DAY 7. Labetalol 200 mg PO BID 8. LevETIRAcetam 1500 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Pravastatin 40 mg PO QPM 12. Vitamin D 1000 UNIT PO DAILY 13. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until you speak to your transplant doctors on ___ Discharge Disposition: Home Discharge Diagnosis: Primary: ___ on CKD Secondary: HCV cirrhosis c/b ___ s/p liver Transplant ___, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Why were you admitted? You were admitted to ___ because your kidney function was slightly worse. We were concerned that this might have been because of your immunosuppressant medications so we stopped your Everolimus and decreased your Tacrolimus to 2.5 mg twice daily. We also started Prednisone 7.5 mg daily. What changes did we make? We changed your immunosuppressant medications to: Decreased Tacrolimus to 2.5 mg twice daily and we also started Prednisone 7.5 mg daily. We stopped your Everolimus. What do you need to do when you leave? -Please follow up with your PCP, your kidney specialist Dr. ___ your liver doctor Dr. ___ below) We wish you all the best. Sincerely, Your care team at ___ Followup Instructions: ___

10048244-DS-9

DS

2120-08-10 00:00:00

2120-08-10 16:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Attending: ___ Chief Complaint: fever, left leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with PMHx of hep C cirrhosis s/p liver transplant complicated by recurrent cirrhosis of transplanted liver, HCC, hx of CVA with residual right sided weakness presenting to the ED with left leg pain and fevers. Patient reports he developed left leg pain, over medial aspect of posterior knee 2 days ago. Pain worse when walking. He had no pain with passive R knee movement. He has been having associated fever and chills at home for the past 2 days. Has been taking Tylenol every ___ hours for pain and for fevers. Today fever went up to 102 so patient presented to ED. In the ED, initial vital signs were: T 102.7, ___, 18, 100% RA - Exam was notable for: AOx3. Mild tenderness over medial aspect of L knee, normal panless AROM and PROM of L knee - Labs were notable for: wbc 5.3, H/H ___, plt 109, 82% neutrophils. LFTs wnl. Na 141, K 3.7, Cl 104, Bicarb 26, BUN 18, Cr 2, gluc 108. INR 1.3. UA moderate blood, 600 protein. - ___ negative for DVT of left leg. - CXR Right upper lobe pleural plaque. No acute cardiopulmonary process. - RUQ US with no ascites. Only able to tolerate part of Doppler study, but patent hepatic arteries and right/main vein. - The patient was given: 1g Acetaminophen, 2L NS, Levofloxacin 750mg IV, Cefepime 2g IV, Vanc 1g, Morphine 4mg IV, 650mg - Consults: hepatology consulted, requesting admission to ___ 10 Vitals prior to transfer were: 98.2, HR 79, 133/67, 18, 99RA Upon arrival to the floor, patient febrile to 101.8, HR 107. Patient slightly confused. Having trouble getting words out. Unable to tell me full story. Says that he has had leg pain before, but usually due to edema. He has frequent urination, waking up 4x a night. Denies previous issues with prostate. Denies weak stream, or difficulty initiating urination. Missed both tacro doses today. Per wife, he has difficulty with speech since his surgery, but does all his own medications at home. He ambulates with cane. Of note, spironolactone was increased the beginning of ___ to 50mg from 25mg for persistent hypertension. No one is sick at home. Past Medical History: # Liver Transplant (___) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented ___ -- c/b mild acute rejection (biopsy ___ -- c/b recurrent HCV (biopsy ___ # HCV Cirrhosis -- Genotype 1A -- recurrent infection after transplant # Hepatocellular Carcinoma # Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD (___) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm (___) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation (___) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: ___ Family History: No family history of liver disease. Physical Exam: ================== ADMISSION EXAM ================== VITALS - 101.8, 150/91, 105, 18, 96RA WEIGHT: 95.8kg Bladder scan: 92cc post void GENERAL - middle aged, ___ man, lying in bed, confused, difficulty getting words out HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple CARDIAC - tachycardic, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - well healing scar from liver transplant, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema. No erythema of left leg, no warmth, nontender. No difference in size between left and right legs. SKIN - without rash NEUROLOGIC - A&Ox1-2 (name, hospital, not ___, right sided facial droop, ___ strength in right arm and leg (baseline). No asterixis. ================== DISCHARGE EXAM ================== VS: 98.3, 144/92, 86, 18, 98RA GENERAL - middle aged, ___ man, lying in bed, appears fatigued, slightly slurred speech HEENT - normocephalic, atraumatic CARDIAC - RRR, normal S1/S2, no murmurs rubs or gallops PULMONARY - CTAB ABDOMEN - well healing scar from liver transplant, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema. SKIN - without rash NEUROLOGIC - A&Ox3), right sided facial droop, ___ strength in right arm and leg (baseline). ___ strength in left arm and leg. No asterixis in left (cannot raise right arm). Pertinent Results: ADMISSION LABS =============== ___ 02:30PM WBC-5.3 RBC-4.68 HGB-12.0* HCT-37.2* MCV-80* MCH-25.6* MCHC-32.3 RDW-13.1 RDWSD-37.2 ___ 02:30PM NEUTS-82.0* LYMPHS-13.8* MONOS-3.8* EOS-0.0* BASOS-0.2 IM ___ AbsNeut-4.33 AbsLymp-0.73* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01 ___ 02:30PM PLT COUNT-109* ___ 02:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02:30PM CRP-66.3* ___ 02:30PM ALBUMIN-3.4* URIC ACID-5.4 ___ 02:30PM LIPASE-32 ___ 02:30PM ALT(SGPT)-17 AST(SGOT)-33 CK(CPK)-445* ALK PHOS-94 TOT BILI-0.4 ___ 02:30PM GLUCOSE-108* UREA N-18 CREAT-2.0* SODIUM-141 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15 ___ 02:39PM LACTATE-1.2 ___ 02:40PM ___ PTT-32.3 ___ DISCHARGE LABS ============== ___ 05:36AM BLOOD WBC-5.2 RBC-3.90* Hgb-9.8* Hct-30.6* MCV-79* MCH-25.1* MCHC-32.0 RDW-13.8 RDWSD-39.4 Plt ___ ___ 05:36AM BLOOD Plt ___ ___ 05:36AM BLOOD Glucose-118* UreaN-19 Creat-1.7* Na-142 K-3.5 Cl-108 HCO3-24 AnGap-14 ___ 05:36AM BLOOD ALT-35 AST-38 AlkPhos-68 TotBili-0.3 ___ 05:36AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9 PERTINENT LABS ============== ___ 05:05AM BLOOD tacroFK-5.0 ___ 05:05AM BLOOD tacroFK-3.4* ___ 05:05AM BLOOD tacroFK-4.0* ___ 05:05AM BLOOD tacroFK-4.1* ___ 10:24AM BLOOD tacroFK-4.5* MICRO ===== URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ 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. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ CMV Viral Load (Final ___: CMV DNA not detected. Blood Culture, Routine (Pending): __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ URINE CULTURE (Final ___: <10,000 organisms/ml. __________________________________________________________ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ Blood Culture, Routine (Final ___: NO GROWTH. STUDIES ======= -CXR Oblong opacity projecting over the right upper lung is compatible with calcified pleural plaque. The lungs are otherwise clear. No obvious effusion identified noting that there is exclusion of the right lateral costophrenic angle on the frontal view. The cardiomediastinal silhouette is stable given differences in projection. IMPRESSION: No acute cardiopulmonary process. -Left Lower Extremity Ultrasound No evidence of deep venous thrombosis in the left lower extremity veins. -RUQ Ultrasound Patent portal and hepatic veins. Patent hepatic arteries, the right and main hepatic artery not interrogated by Doppler ultrasound secondary to patient unable to remain still for the remainder of the study. Normal left hepatic artery waveform. No focal hepatic lesion. -CT A/P w/o Contrast 1. Although the exam is somewhat limited given the lack of IV contrast, peripancreatic fat stranding and fullness of the pancreatic head is compatible with pancreatitis. The chronicity of this finding is difficult to accurately assess, but is new since at least ___. 2. No focal fluid collection or intra-abdominal or pelvic abscess is identified. 3. Prior hepatic transplant, with persistent central periportal edema,. 4. Sequelae of portal hypertension includes persistent splenomegaly and perisplenic varices along with small volume intra-abdominal ascites. 5. Punctate, nonobstructing left lower pole renal stone. -CT Chest w/o Contrast No evidence of new infectious process. Chronic abnormalities including pleural effusion, pleural calcifications and bronchial wall thickening in the right lower lobe. Interval decrease in the right upper lobe pneumatoceles currently less than 5 mm in diameter. Brief Hospital Course: ___ year old man with PMHx of hep C cirrhosis s/p liver transplant complicated by recurrent cirrhosis of transplanted liver, HCC, hx of CVA with residual right sided weakness presenting to the ED with left leg pain and fevers, found to have ___. ACTIVE ISSUES ============== # Fever. He presented with fever to 103, with associated rigors and tachycardia, meeting criteria for SIRS. He was started on broad spectrum antibiotics with Vancomycin/Cefepime/Flagyl. He required scheduled APAP and cooling blankets but remainder persistently febrile for the first ___ hours of admission on antibiotics. He defervesced with last fever on ___ in the morning. Infectious work up was unrevealing, including CXR, Chest CT, CT A/P, and left knee xray. CMV VL was negative. Blood and urine cultures were negative. Antibiotics were discontinued after 4 days and he was monitored for 48 hours. He continued to improve without fevers and was discharged to home. The only other possible contributor to his fevers could have been the study drug he has been receiving. # Left knee pain. He presented with left knee pain, however this resolved spontaneously without intervention. Xray was without fracture. Lower extremity ultrasound was without DVT. # ___. Cr on admission was 2, elevated from recent baseline around 1.6. Cr downtrended with holding spironolactone and giving IV albumin. Spironolactone was restarted prior to discharge and Cr was at baseline 1.7. CHRONIC ISSUES ============== # HTN: Initially held amlodipine and spironolactone given SIRS, but restarted prior to discharge. # Hep C cirrhosis s/p extended criteria liver transplant, complicated by recurrent hep C cirrhosis. HCV of transplanted liver cleared with simeprevir and sofosbuvir and he was enrolled in a trial of antifibrotic therapy. He was continued on this study drug while inpatient. His cirrhosis was compensated with no LFT abnormalities, ascites ___ edema. He was continued on home tacrolimus dosing 3mg BID. # Seizure disorder. Continued keppra 1500mg BID # HLD. Continued pravastatin 40mg QHS TRANSITIONAL ISSUES =================== Immunosuppression - Tacrolimus 3mg BID - Resume standing transplant lab order on discharge # CONTACT: Patient, Taunia (Wife, HCP) ___ ___ # CODE STATUS: Full code confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Pravastatin 40 mg PO QPM 4. Spironolactone 25 mg PO DAILY 5. Tacrolimus 3 mg PO Q12H 6. Acetaminophen 325-650 mg PO Q8H:PRN pain 7. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Pravastatin 40 mg PO QPM 5. Spironolactone 25 mg PO DAILY 6. Tacrolimus 3 mg PO Q12H 7. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. IDN-___/placebo Study Med 25 MG PO 2X DAY Discharge Disposition: Home Discharge Diagnosis: Fever, unknown origin Left knee pain Encephalopathy ___ HTN Hep C cirrhosis s/p extended criteria liver transplant Seizure disorder HLD 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 during your hospitalization. Briefly, you were hospitalized with fevers and left knee pain. You were started on antibiotics and your fevers improved. You did not have any factures in your left knee on xray. We watched you in the hospital for 48 hours after stopping antibiotics and you continued to improve. We did not find any bacterial cause for your fevers in the blood or urine. We wish you the best, Your ___ Treatment Team Followup Instructions: ___

10048262-DS-18

DS

2168-08-29 00:00:00

2168-08-29 21:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aloe / apple / egg Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: =================== ___ 06:45PM BLOOD WBC-9.3 RBC-5.11 Hgb-15.2 Hct-44.8 MCV-88 MCH-29.7 MCHC-33.9 RDW-13.6 RDWSD-43.7 Plt Ct-UNABLE TO ___ 06:45PM BLOOD Neuts-88.0* Lymphs-4.0* Monos-7.0 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.22* AbsLymp-0.37* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.02 ___ 06:45PM BLOOD ___ PTT-32.8 ___ ___ 06:45PM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-140 K-3.2* Cl-98 HCO3-22 AnGap-20* ___ 06:45PM BLOOD ALT-30 AST-24 AlkPhos-60 TotBili-0.5 ___ 06:45PM BLOOD cTropnT-<0.01 ___ 06:45PM BLOOD Albumin-4.2 Calcium-9.1 Phos-1.9* Mg-1.6 ___ 06:51PM BLOOD ___ pO2-121* pCO2-30* pH-7.50* calTCO2-24 Base XS-1 Comment-GREEN TOP ___ 06:51PM BLOOD Lactate-3.8* ___ 10:10PM BLOOD Lactate-3.1* ___ 02:52AM BLOOD Lactate-4.3* ___ 06:37AM BLOOD Lactate-2.6* PERTINENT LABS: ================== ___ 09:07AM BLOOD WBC-3.6* RBC-3.46* Hgb-10.2* Hct-31.0* MCV-90 MCH-29.5 MCHC-32.9 RDW-14.3 RDWSD-46.5* Plt Ct-67* ___ 05:10AM BLOOD WBC-8.0 RBC-3.43* Hgb-10.2* Hct-32.2* MCV-94 MCH-29.7 MCHC-31.7* RDW-14.2 RDWSD-48.0* Plt ___ ___ 09:07AM BLOOD ___ PTT-32.3 ___ ___ 05:10AM BLOOD ___ PTT-28.0 ___ ___ 02:28AM BLOOD ALT-34 AST-34 AlkPhos-52 TotBili-0.7 ___ 04:41AM BLOOD ALT-193* AST-161* AlkPhos-66 TotBili-0.4 ___ 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3 ___ 06:45PM BLOOD cTropnT-<0.01 ___ 09:07AM BLOOD calTIBC-168* ___ Ferritn-1202* TRF-129* ___ 09:07AM BLOOD ___ 09:07AM BLOOD Ret Aut-1.1 Abs Ret-0.04 ___ 04:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 04:12AM BLOOD HCV Ab-NEG ___ 05:38PM BLOOD Lactate-4.2* ___ 09:46AM BLOOD Lactate-1.3 MICRO: =========== ___ 6:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ___ ___. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ___ | AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 R TRIMETHOPRIM/SULFA---- <=1 S ___ 11:55 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:05 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ====================================== CTA CHEST Study Date of ___ 7:54 ___ 1. Nonspecific 1.4 cm nodular left upper lobe opacity which may represent pneumonia. Recommend follow-up CT chest in 3 months to assess for resolution. Pulmonary nodule not excluded. 2. Malpositioned Foley catheter with balloon in the base of the penis. 3. Moderate amount stool in the distal sigmoid colon/rectosigmoid. Equivocal associated mild wall thickening, possible early stercoral colitis. 4. Chronic appearing left hip dislocation with adjacent soft tissue thickening, adjacent joint effusion not excluded. KUB ___: There are diffusely air-filled dilated loops of large bowel involving the right and transverse colon with moderate descending and sigmoid colonic stool burden. No dilated loops of small bowel visualized. There is no evidence of free intraperitoneal air. Right lower abdominal wall battery pack and single spinal stimulator lead noted overlying the right lower abdomen and pelvis. Surgical clips in the right upper quadrant again noted. At least moderate bilateral hip degenerative changes, incompletely assessed. IMPRESSION: 1. No evidence of pneumoperitoneum. 2. Nonobstructive bowel gas pattern with moderate stool burden. RUQ US ___: LIVER: The left lobe of the liver is not adequately visualized due to overlying bowel gas. Otherwise, the hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm GALLBLADDER: The gallbladder is not definitively visualized. However, there is a rounded structure in the area of the gallbladder fossa measuring 1.2 x 1.6 x 1.0 cm, which may represent a contracted gallbladder. IMPRESSION: 1. No evidence of intrahepatic or extrahepatic biliary dilatation. 2. Likely contracted gallbladder. 3. Splenomegaly. DISCHARGE LABS: ================== No labs collected ___ 05:21AM BLOOD WBC-8.5 RBC-3.52* Hgb-10.5* Hct-32.7* MCV-93 MCH-29.8 MCHC-32.1 RDW-14.6 RDWSD-48.3* Plt ___ ___ 05:21AM BLOOD Plt ___ ___ 05:21AM BLOOD Glucose-109* UreaN-11 Creat-0.4* Na-142 K-4.4 Cl-101 HCO3-26 AnGap-15 ___ 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3 ___ 05:21AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0 DISCHARGE EXAM: ================== VITALS: ___ 0809 Temp: 97.9 PO BP: 108/70 L Lying HR: 86 RR: 18 O2 sat: 94% O2 delivery: RA HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm with 2+ pulses, trace pitting edema in the feet bilaterally, boots on Skin: No rashes or lesions Neuro: responds appropriately to questions and follows commands, unable to move ___ bilaterally. LABS: Reviewed in ___ Brief Hospital Course: SUMMARY: ===================== Mr. ___ is a ___ man with a history of advanced secondary progressive multiple sclerosis with cognitive decline, who presented from his group home with sepsis and lactic acidosis requiring brief MICU admission (<24h) and found to have Providencia stuartii bacteremia. On presentation to the ED, his UA was consistent with possible UTI, but his urine cultures remained without growth during his hospital course. He had a CT torso that showed a possible L lingular pneumonia and he was briefly on CTX/azithro in the setting of new oxygen requirement (___) but he was quickly weaned off of oxygen and did not have other symptoms of pneumonia/URI and it was stopped. Additionally, CT torso showed possible stercoral colitis and he was briefly on flagyl. His hospital course was complicated by constipation requiring manual disimpaction in the ED after which he remained constipated and his bowel regimen was escalated until he had several large bowel movements after 5 days without any. On presentation to the ED, he had hematuria from a traumatic foley in his urethera that was placed at the group home. The foley was removed and he was voiding well with a condom catheter although retaining ~500cc before urinating, which per the patient and his family is what he usually uses. For treatment of his Providencia stuartii bacteremia, he underwent ___ guided R PICC placement and ID was consulted and he was started on cefepime to complete a 2 week course from his last negative blood culture (___) with a plan to switch to ertapenem at discharge for ease of dosing. He was noted to have transaminitis on ___ and RUQ US showed no evidence of structural causes and his transaminitis was thought to be secondary to cephalosporins and he was switched to meropenem on ___ with improvement of his transaminitis. He remained hemodynamically stable and afebrile on IV antibiotics with negative surveillance cultures and with resolution of his thrombocytopenia, which was thought to be secondary to sepsis, and he was discharged back to his group home on ertapenem to complete his course of IV antibiotics (last day ___. TRANSITIONAL ISSUES: ====================== [] He will need to continue IV antibiotics with ertapenem 1g q24 hours until ___ (last day ___. Okay to remove PICC line after course of IV antibiotics completed. [] He is due for a refill of his baclofen pump on ___. Confirmed with group home that they will be able to refill it there when he gets back. [] Have physician at ___ home check CBC and LFTs in ~1 week (___) to make sure that his thrombocytopenia and transaminitis have resolved. [] Please follow-up with his neurologist about management of his possible early urinary retention/neurogenic bladder. Please avoid foley as he is voiding well with a condom catheter but he usually doesn't void until he is retaining 500-600ccs. [] Please order a repeat CT chest in 3 months to evaluate for resolution of L lingular opacity. [] His CT imaging demonstrated left hip fluid collection/joint effusion. Ortho reviewed the imaging and it appears chronic since ___ based on prior Xray. [] He is not immune to Hep B (surface ab neg) but has an egg allergy (?sneezing). If allergy not severe, he should receive the Hep B vaccine. ACUTE ISSUES ======================= #Fever #Sepsis #?UTI #?L lingula pneumonia #Provide___ bacteremia Patient was febrile to 105 at outpatient facility and was 104 on presentation to the ___ ED. His UA was grossly positive with prior dysuria c/f UTI in the setting of recent foley (possibly placed on ___ for possible chronic urinary retention although usually urinates well with a condom cath. Of note, his urine culture from the ER without growth. CT chest concerning for possible L lingula pneumonia but patient clinically without symptoms of pneumonia and stopped CTX/azithro (___) as penumonia unlikely. BCx from ___ growing Providencia ___, which is usually from a urinary source, but of note all his urine cultures remained negative. ID was consulted and recommended a 2 week course of abx from first negative culture (___) with Cefepime 2 mg IV q12h while inpatient and plan to discharge on ertapenem 1 g IV daily for ease of once daily dosing. However, due to elevated transaminases thought to be due to cephalosporins, he was changed from cefepime to meropenem ___ with improvement in his transaminitis. He remained afebrile and hemodynamically stable with negative blood cultures on IV antibiotics and was discharged back to his group home on ertapenem 1 g q24h through ___. #Elevated LFTs #Transaminitis #Drug induced liver injury Elevated ALT/AST with normal alk phos and bili c/w hepatocellular pattern. Notably LFTs were normal upon presentation. Hepatitis panel with Hep B non-immune but otherwise negative. RUQUS with poorly visualized left liver lobe but otherwise normal hepatic parenchyma. Given no structural deficits, transaminitis thought to be due to cephalosporins and he was switched to meropenem on ___ with gradual improvement in his LFTs. #?Urinary retention #Hematuria #Traumatic foley placement He has a questionable history of urinary retention and it is unclear why he had a foley on presentation to the ED as he is usually able to void okay with a condom catheter per the patient and his family but notes from the OSH state it was placed for urinary retention. On CT A/P in the ED, his foley was misplaced in his urethra and likely was the cause of his hematuria. The foley was replaced in the ED and removed in the ICU and a condom cath was placed. We paged urology several times about if he could be straight cathed if necessary or if he would require another foley if he was retaining urine but we did not get a response. His hematuria resolved and he was voiding well with the condom cath and did not require straight cath. Of note, he was retaining 500-600 cc on bladder scan before voiding. #?Stercoral colitis #Constipation CT A/P was concerning for stercoral colitis and he was manually disimpacted in ED. In one of the notes from the group home, there was mention of ulcerative colitis but per patient and family there is no diagnosis of UC and he is not on treatment for it. He has chronic constipation at baseline and his bowel regimen was escalated, including miralax, senna, lactulose, bisacodyl, and multiple enemas, until he finally had several large bowel movements on the 5 day without any. He developed nausea and abdominal cramping from his constipation and KUB at that time showed moderate stool burden without evidence of ileus, obstruction, or perforation. #Multiple Sclerosis #Baclofen pump Patient has a history of advanced progressive MS with cognitive decline and has a baclofen pump. He stated that his pump needs to be refilled soon and anesthesia was consulted for baclofen pump interrogation (on 299mcg/day) and he is due for a refill on ___. Before discharge, we confirmed with his group home that they will be able to refill his pump when he returns. #Dislocated Hip w/ Effusion CT A/P demonstrated chronic appearing left hip dislocation with complex fluid collection c/f hematoma vs. infection within the hip joint without evidence of bone erosion. Ortho reviewed the images and thought it was most likely chronic dislocation (since ___ in a patient that is mostly bedbound. We had low clinical suspicion for a septic joint as he did not have any pain and remained stable on antibiotics for treatment of his ___ bacteremia. #Thrombocytopenia (resolved) Patient presented with thrombocytopenia (plt 67 at lowest) and initially it was unclear if it was chronic but was not present as of ___ and his labs were negative for hemolylsis or DIC. With treatment of his sepsis/bacteremia, his platelet count gradually recovered and was normal on day of discharge (199) and was thought to be secondary to sepsis. #Lactic Acidosis (resolved) He presented with lactic acidosis in the ED likely iso sepsis as above. He was initially fluid responsive to 2L IVF, but his lactic acidosis uptrended upon arrival to the ICU likely in the setting of insufficient fluid resuscitation. His lactic acidosis then resolved on ___ (1.3) after adequate fluid resuscitation with an additional 2L of LR. CHRONIC ISSUES ======================= #Vitamin D deficiency #Osteoporosis He was continued on his home vitamin D and calcium. #CODE STATUS: Full confirmed (MOLST in chart) #CONTACT: HCP: ___ (Mother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1500 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO BID 4. Senna 17.2 mg PO DAILY 5. Naproxen 440 mg PO Q12H:PRN Pain - Mild 6. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 8. Clotrimazole Cream 1 Appl TP BID:PRN rash 9. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 10. Loratadine 10 mg PO DAILY:PRN allergy 11. Vitamin D 3000 UNIT PO DAILY 12. Lioresal (baclofen) 2,000 mcg/mL injection DAILY 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose 2. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Calcium Carbonate 1500 mg PO BID 5. Clotrimazole Cream 1 Appl TP BID:PRN rash 6. Docusate Sodium 100 mg PO BID 7. Lioresal (baclofen) 2,000 mcg/mL injection DAILY 8. Loratadine 10 mg PO DAILY:PRN allergy 9. Multivitamins 1 TAB PO BID 10. Naproxen 440 mg PO Q12H:PRN Pain - Mild 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 12. Senna 17.2 mg PO DAILY 13. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 14. Vitamin D 3000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ======================= # Providencia ___ bacteremia # Sepsis SECONDARY DIAGNOSIS: ====================== # Fever # L lingular opacity without evidence of pneumonia # Transaminitis # Drug induced liver injury # Hematuria secondary to traumatic foley placement # Possible stercoral colitis # Constipation # Multiple sclerosis with baclofen pump # Chronically dislocated left hip with effusion # Thrombocytopenia (resolved) # Lactic acidosis (resolved) # Vitamin D deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital because you had a fever (105 degrees) WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were found to have an infection in your blood (___ ___) and were started on IV antibiotics - The foley catheter in you bladder wasn't in the correct place and it was removed and you were voiding okay without it - You were not having bowel movements and you finally had a bowel movement after lots of medications WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___

10048986-DS-18

DS

2127-04-10 00:00:00

2127-04-12 21:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: Emesis Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old male with AAA, BPH, GERD who presents from home with one day of nausea and vomiting. He was in his normal state of health until the day prior to admission when he developed sudden nausea and 4 episodes of dark but non-bloody emesis. He was at a ___ service commemorating ___ anniversary of son's death at the time. He ate food with family, drank a very small amont of wine. He describes upper abdominal discomfort with the vomiting. He had one episode of loose stool yesterday. He denies antibiotic use during the past six months. He denies dyspnea, chest pain. In the ED, initial vs were: 98.6 72 150/72 16 99% RA. CTA abd: no SBO, stable appearance of infrarenal aorta. Patient was given zofran x 3 with improvement in symptoms. Vitals on Transfer:97.8 71 140/75 16 97% RA He feels that his nausea and vomiting are improving. He feels that he may need to have a bowel movement. Past Medical History: -GERD -knee osteoarthritis -AAA -BPH -spinal stenosis -? hx of pancytopenia per PCP, MDS ___ hernia -insomnia -lower extremity edema wearing compression stockings Social History: ___ Family History: coronary artery disease Physical Exam: Vitals: T: 97.7 BP:104/58 HR:58 RR:18 O2: 98%R General: comfortable, NAD HEENT: anicteric sclera Lungs: CTA bilaterally, unlabored CV: S1, S2 regular rhythm, normal rate Abdomen: soft, mild TTP epigastric area, no rebound, not distended Ext: 1+ edema, not wearing compression stockings Neuro: alert, oriented, speech fluent Pertinent Results: ADMISSION LABS: ___ 12:50AM BLOOD WBC-16.7*# RBC-3.43* Hgb-10.9* Hct-33.8* MCV-99* MCH-31.8 MCHC-32.3 RDW-14.8 Plt ___ ___ 12:50AM BLOOD Neuts-86.4* Lymphs-6.9* Monos-4.3 Eos-1.9 Baso-0.6 ___ 12:50AM BLOOD Glucose-121* UreaN-26* Creat-0.9 Na-136 K-4.0 Cl-102 HCO3-23 AnGap-15 ___ 12:50AM BLOOD ALT-31 AST-43* AlkPhos-61 TotBili-0.8 ___ 12:50AM BLOOD Lipase-60 ___ 12:50AM BLOOD cTropnT-<0.01 ___ 12:50AM BLOOD Albumin-4.5 ___ 05:20AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9 . DISCHARGE LABS: ___ 09:10AM BLOOD Hct-30.7* ___ 06:30AM BLOOD Plt ___ ___ 09:10AM BLOOD Glucose-106* UreaN-11 Creat-1.0 Na-141 K-3.9 Cl-108 HCO3-25 AnGap-12 ___ 06:30AM BLOOD calTIBC-218* VitB12-687 Ferritn-213 TRF-168* ___ 06:30AM BLOOD TSH-3.0 ___ 06:30AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.8 Iron-24* . 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. CT ABDOMEN: The imaged lung bases demonstrate bibasilar dependent atelectasis without pleural effusions. Heart is top normal in size without pericardial effusion. Small hiatal hernia is noted. The liver demonstrates homogeneous enhancement without suspicious focal lesions. There is no evidence of intrahepatic or extrahepatic biliary ductal dilatation. The gallbladder is incompletely distended. There is no gallbladder wall edema or pericholecystic fluid collection to suggest acute inflammation. No calcified gallstones are seen within its lumen. The spleen is unremarkable. The pancreas enhances homogeneously without ductal dilatation or peripancreatic fluid collection. The adrenal glands are normal. The kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or renal masses. Multiple renal hypodensities bilaterally are too small to characterize and are likely cysts. The largest hypodense lesion arising from the lower pole of the left kidney measures 5.1 x 4.8 cm with 12 Hounsfield units in attenuation, compatible with a simple cyst, unchanged. The small and large bowel loops are normal in caliber without evidence of bowel wall thickening or obstruction. The appendix is not visualized; however, there are no secondary signs to suggest inflammation in the right lower abdomen. There is no mesenteric or retroperitoneal lymphadenopathy. The imaged intra-abdominal aorta and its branches demonstrate moderately severe calcified atherosclerotic disease. Infrarenal aorta measures 2.8 cm in maximum dimension, with stable-appearing focal dissection. CT OF THE PELVIS: The bladder, distal ureters, rectum and sigmoid colon are unremarkable. The prostate gland appears enlarged. There is no free air or free fluid within the pelvis. Post-surgical changes related to bilateral inguinal hernia repair are noted. There is no pelvic wall or inguinal lymphadenopathy. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion is seen. IMPRESSION: 1. No acute CT findings to account for the patient's clinical presentation. 2. Calcified atherosclerotic disease of the aorta. Stable appearance of the dilated infrarenal aorta measuring 2.8 cm in maximum dimension with stable focal dissection. 3. Bilateral renal hypodensities, most compatible with cysts. 4. Small hiatal hernia. . CXR: FINDINGS: Frontal and lateral views of the chest demonstrate low lung volumes. There is no focal consolidation, pleural effusion or pneumothorax. A 6-mm nodular opacity projecting over the right upper lung is stable since priors. Hilar and mediastinal silhouettes are unchanged. The descending aorta appears tortuous. Heart size is top normal. Perihilar vascular congestion is noted. There is mild intersitial pulmonary edema. IMPRESSION: No focal consolidation. Mild interstitial pulmonary edema. Brief Hospital Course: #GASTROENTERITIS: The patient symptoms of emesis and loose stool were most consistent with viral gastroenteritis. There was no evidence on labs or imaging of hepatitis, pancreatitis, colitis, appendicitis, or bowel obstruction. Infectious stool studies - C. difficile and stool culture - were negative. He was managed supportively with bowel rest, IVF, and anti-emetics. His symptoms were already improving at the time of admission. At the time of discharge, he was tolerating a regular diet and bowel movements had improved. #GERD:Continue PPI #HX AAA: stable on CT #Anemia: Patient with history of macrocytic anemia, presumed MDS #BPH:Continue finasteride and tamsulosin #RENAL CYST: Stable on CT abdomen #PULMONARY NODULE: Stable on CXR Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO HS 3. Omeprazole 20 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. Lorazepam 0.5 mg PO HS:PRN insomnia Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Tamsulosin 0.4 mg PO HS 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. Lorazepam 0.5 mg PO HS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Viral gastroenteritis 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: It was a pleasure to participate in your care. You were admitted to the hospital with vomiting and loose stool. This was likely due to a viral gastroenteritis. Your symptoms improved and you were discharged. Please follow up with your primary care physician. Happy holidays! Followup Instructions: ___

10048986-DS-19

DS

2127-10-13 00:00:00

2127-10-14 23:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: Right lower leg pain on ambulation Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx spinal stenosis presents with RLE pain, which began today, and is present only on walking/standing. He feels that his pain is throughout his leg. He denies weakness, notes that his ability to walk is limited by pain. He denies n/v/d, no fevers or chills, no hx of cancer. He thinks his RLE may be more swollen than usual. No new numbness, weakness or incontinence. He denies any international travel, long car rides, immoblization for >1wk, ortho surgerys (carpal tunnel ___, but he was back to normal routine same day). He denies night sweats, weight loss, change in bowel habits, bloodly stools, or smoking. Past Medical History: -GERD -knee osteoarthritis -AAA -BPH -spinal stenosis -? hx of pancytopenia per PCP, MDS ___ hernia -insomnia -lower extremity edema wearing compression stockings Social History: ___ Family History: coronary artery disease Physical Exam: Admission: GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, NECK: nontender supple neck, no LAD, no JVD CARDIAC: Irregular, distant 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: moving all extremities well, no cyanosis or clubbing, 2+ edema to mid lower extremity. RLE cool to touch, LLE warm to touch. Sensation to touch decreased in both L and R ___. Signs of PVD present. PULSES: Could not appreciate in Right, faint in left. NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes LABS: see below Discharge: 97.5 117/62 60 18 99RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, NECK: nontender supple neck, no LAD, no JVD CARDIAC: Irregular, distant 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: moving all extremities, no cyanosis or clubbing, 2+ edema to mid lower extremity now resolving with ___, worse on the L. RLE cool to touch, LLE warm to touch. Sensation to touch decreased in both L and R ___. Signs of PVD present. PULSES: Could not appreciate in Right, faint in left. NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ___ 03:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL ___ 03:45PM WBC-6.3 RBC-3.11* HGB-10.3* HCT-31.8* MCV-102* MCH-33.2* MCHC-32.4 RDW-14.4 ___ 03:45PM estGFR-Using this ___ 03:45PM ___ PTT-30.2 ___ ___ 03:45PM PLT SMR-NORMAL PLT COUNT-128* Brief Hospital Course: ___ with hx spinal stenosis presents with RLE pain, which began today, and is present only on walking/standing. In the ED: RLE u/s reveals + DVT. Pt's pain likely d/t contribution from DVT. No evidence of cauda equina syndrome, no evidence of cord compressiion. In the ED, initial vitals were: 97.3 66 138/67 18 97% ra On the floor, Pt has stable vitals and no complaints. He notes mild pain in the RLE with walking. #DVT: Pt. started on Enoxoparin 70 mg SQ q12H and Warfarin 4 mg PO DAYS (___). Education nurse attempted education for ___ shots at home; however, pt did not feel comfortable giving. VMA can only come once a day and with twice daily shots, Mr. ___ had to stay with us until his INR reached therapeautic levels. We monitored his INR and labs daily. No signs of PE developed. On ___ his INR reached 1.9, and outpatient ___ was arranged to follow INR ___ ___ therapy saw and suggested in-home ___ ___ weekly. ___ visited him several times inpatient for evaluation and early ambulation. -For pain: TraMADOL (Ultram) 50 mg PO Q6H:PRN pain. # BPH - We Continued his home regimen of Tamsulosin 0.4 mg PO HS and Finasteride 5 mg PO DAILY #GERD -We continued his home dose of Omeprazole 20 mg PO DAILY Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Omeprazole 20 mg PO DAILY 4. Tamsulosin 0.4 mg PO HS 5. Aspirin 81 mg PO DAILY 6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID bug bites 7. Acetaminophen 500 mg PO Q8H:PRN pain 8. melatonin 1 mg oral QHS 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit) 500-400 mg oral daily 11. flaxseed oil 1,000 mg oral daily Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Omeprazole 20 mg PO DAILY 4. Tamsulosin 0.4 mg PO HS 5. Acetaminophen 650 mg PO Q8H:PRN pain 6. Docusate Sodium 100 mg PO DAILY:PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hr Disp #*20 Tablet Refills:*0 8. Warfarin 4 mg PO DAILY RX *warfarin 2 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID bug bites 10. Fish Oil (Omega 3) 1000 mg PO DAILY 11. flaxseed oil 1,000 mg oral daily 12. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit) 500-400 mg oral daily 13. melatonin 1 mg oral QHS 14. Outpatient Lab Work Check INR on ___. ___ will schedule after this date. ICD-9: 453.4 Please fax results to ___ clinic fax: ___ (responsible provider ___, phone, ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: DVT 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 while at ___. You came to us with pain in your lower leg while walking and we found a blood clot in your deep leg veins. The treatment for this is to thin your blood to prevent the clot from enlarging. Over time, your body will dissolve the clot. The oral medication, Warfarin, takes a few days to start working, so we had to give you a few days of a medication called Lovenox (shots), which works much faster. You are taking warfarin at the same time, so the lovenox is a bridge to a therapuetic warfarin level. We had physical therapy see you while here, and they would like to work with you at home. Followup Instructions: ___

10049041-DS-21

DS

2164-01-11 00:00:00

2164-01-11 20:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex Attending: ___ ___ Complaint: Date of ICU Admission: ___ Reason for ICU Admission: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, who re-presents from LTACH with altered mental status. Patient was recently admitted from ___ to ___ for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. The day of admission he was noted to be minimally responsive, with hypercarbia (et CO2 ___ was transferred here. In the ED, initial vitals notable for HR 110s-120s, BPs ___, RR 24. 97-100% vent/trach. Exam was notable for minimal reactivity (grimaces to noxious stimuli but does not withdraw to pain), distended abdomen, trach and PEG sites c/d/I. VBG showed pH 7.3, PCO2 88. CBC WBC 12.7, Hgb 8.7, Plts 337. LFTs 51/80. BMP notable for HCO3 of 37. BUN/Cr ___. Troponins <0.01, flu negative. CXR without focal consolidation or edema. He was placed on assist control with improvement in mental status to baseline. Patient was given vancomycin/Zosyn and 2L fluid. Due to abdominal distention, CT A/P was obtained which showed no acute process. He communicated to the ED team that people "are trying to kill me at rehab." On arrival to the MICU, the patient is awake and alert, denies pain, shortness of breath. Notes that he has been constipated. No chest pain. Mildly short of breath. No new rashes or lesions. Appears somewhat disoriented and paranoid. ROS: Positives as per HPI; otherwise negative. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: reviewed GEN: alert, trach in place HENNT: sclera anicteric CV: RRR, nl s1, s2 RESP: Mild bilateral wheezes GI: distended, mildly tender to palpation EXTREM: no ___ SKIN: WWP NEURO: Alert, responding to questions appropriately, moving all extremities DISCHARGE PHYSICAL EXAM: VS: reviewed GEN: alert + oriented, trach in place HENNT: sclera anicteric CV: RRR, nl s1, s2 RESP: Mild bilateral wheezes GI: distended, mildly tender to palpation EXTREM: no ___ SKIN: WWP NEURO: Alert, responding to questions appropriately, moving all extremities. Appears in better spirits. Pertinent Results: ADMISSION LABS =============== ___ 03:55PM BLOOD WBC-12.7* RBC-2.70* Hgb-8.7* Hct-29.1* MCV-108* MCH-32.2* MCHC-29.9* RDW-15.9* RDWSD-62.0* Plt ___ ___ 03:55PM BLOOD ___ PTT-25.8 ___ ___ 03:55PM BLOOD Glucose-148* UreaN-26* Creat-0.6 Na-142 K-4.4 Cl-91* HCO3-37* AnGap-14 ___ 03:55PM BLOOD ALT-80* AST-51* AlkPhos-101 TotBili-0.2 ___ 03:55PM BLOOD proBNP-285* ___ 03:55PM BLOOD cTropnT-<0.01 ___ 03:55PM BLOOD Lipase-16 ___ 03:55PM BLOOD Albumin-3.3* Calcium-9.7 Phos-5.5* Mg-2.1 ___ 04:02PM BLOOD ___ pO2-52* pCO2-88* pH-7.30* calTCO2-45* Base XS-12 ___ 04:02PM BLOOD Lactate-0.8 Creat-0.6 K-3.9 ___ 04:02PM BLOOD Hgb-9.1* calcHCT-27 DISCHARGE LABS =============== ___ 02:32AM BLOOD WBC-11.8* RBC-2.27* Hgb-7.3* Hct-24.7* MCV-109* MCH-32.2* MCHC-29.6* RDW-16.0* RDWSD-63.0* Plt ___ ___ 02:32AM BLOOD ___ PTT-20.8* ___ ___ 02:32AM BLOOD Glucose-87 UreaN-20 Creat-0.6 Na-140 K-3.6 Cl-91* HCO3-36* AnGap-13 ___ 02:32AM BLOOD Calcium-9.6 Phos-3.1 Mg-1.9 IMAGING/STUDIES ================ ___ CXR: COPD/pulmonary emphysema. No focal consolidation. ___ CT Head: 1. No evidence of acute intracranial process. 2. Air-fluid levels in the sphenoid and maxillary sinuses, which can be seen with acute sinusitis in the appropriate clinical setting. Correlation with clinical circumstances is recommended. ___ CT a/p: 1. No acute findings. No findings to account for abdominal distension. 2. PEG tube in place. 3. Areas of hepatic hypodensity, not fully characterized the thought to represent benign cysts and likely focal fat deposition. Brief Hospital Course: Mr. ___ is a ___ with history of COPD, HTN, and recent admission for hypercarbic respiratory failure ___ COPD exacerbation and MSSA pneumonia, s/p trach placement ___, who presents from his LTAC with altered mental status, ultimately attributed to sedating medications. ACUTE ISSUES: # Toxic metabolic encephalopathy Initial concern for infection but ultimately, infectious work-up negative. No evidence of metabolic derangements. Ultimately contributed to sedation from home methadone. Mental status improved after this medication was held, and patient was transitioned to oxycodone PRN for pain control. CHRONIC ISSUES: # Anxiety: Continued home Seroquel at reduced dose (see discharge med list) # Acute sinusitis: Identified on CTH during prior admission. Continued agumentin (last day ___. # Constipation: Likely secondary to chronic opioid use. Continue home standing bowel regimen and also trialed methylnaltrexone with some improvement. # Pain Held home methadone on discharge, as above. Treated pain with oxycodone PRN. TRANSITIONAL ISSUES: [] Noted to have hematuria - please consider further evaluation if this continues [] Consider PJP prophylaxis given long-term steroid use [] Monitor blood sugars which were noted to be high in the setting of steroid use [] Watch out for adrenal insufficiency given long-term steroid use and recently initiated taper 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 may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 3. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 4. Bisacodyl ___AILY 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 6. Heparin 5000 UNIT SC BID 7. Ipratropium Bromide Neb 1 NEB IH Q6H 8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 9. LORazepam 0.5 mg PO BID:PRN agitation 10. Lactulose 30 mL PO QD:PRN Constipation - Third Line 11. Methadone 10 mg PO Q6H Tapered dose - DOWN 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Polyethylene Glycol 17 g PO DAILY 14. PredniSONE 10 mg PO DAILY 15. QUEtiapine Fumarate 50 mg PO QHS 16. QUEtiapine Fumarate 50 mg PO QID:PRN agitation 17. Senna 8.6 mg PO BID 18. Simethicone 40-80 mg PO QID:PRN gas 19. Nystatin Oral Suspension 5 mL PO QID 20. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 21. Tiotropium Bromide 1 CAP IH DAILY 22. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q6hr Disp #*5 Tablet Refills:*0 3. QUEtiapine Fumarate 25 mg PO QID:PRN agitation 4. Acetaminophen 650 mg PO Q6H 5. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB 6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 7. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H 8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 9. Bisacodyl ___AILY 10. Heparin 5000 UNIT SC BID 11. Ipratropium Bromide Neb 1 NEB IH Q6H 12. Lactulose 30 mL PO QD:PRN Constipation - Third Line 13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14. LORazepam 0.5 mg PO BID:PRN agitation 15. Multivitamins W/minerals 1 TAB PO DAILY 16. Nystatin Oral Suspension 5 mL PO QID 17. Polyethylene Glycol 17 g PO DAILY 18. PredniSONE 10 mg PO DAILY 19. Senna 8.6 mg PO BID 20. Simethicone 40-80 mg PO QID:PRN gas 21. Tamsulosin 0.4 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: - Toxic metabolic encephalopathy SECONDARY DIAGNOSIS: - Constipation - COPD - HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, You were admitted to the intensive care unit because you were confused. While you were in the hospital, you had imaging and labs to look for signs of infection or electrolyte disturbances. Your pain medications were adjusted and your mental status improved. We are concerned that your methadone likely contributed to your confusion, and recommend that you stop taking this medication. When you leave the hospital, you will be going to the ___ ___ facility to help work on improving your strength. Continue taking all your medications as prescribed, and follow-up with your primary care physician as needed. Followup Instructions: ___

10049041-DS-22

DS

2164-01-21 00:00:00

2164-01-21 15:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Precedex Attending: ___. Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who re-presents from LTACH with vomiting and abdominal pain. Patient was recently admitted from ___ to ___ for refractory hypercarbic respiratory failure with failure to wean off the ventilator, ultimately requiring a tracheostomy and PEG tube placement. That course was c/b MSSA pneumonia, acute sinusitis, severe constipation. He was discharged to rehab. He was re-admitted on ___ for altered mental status (sedation) and hypercarbia, both of which improved with adjustment of his ventilator. Initial concern for was for infection, but work-up for infection and metabolic derangements were unremarkable. Ultimately, this period of altered mental status was contributed to sedation from home methadone and seroquel. Last night, he developed vomiting x3. This was non-bloody, non-bilious and associated with LLQ and LUQ pain with diarrhea. Normal bowel movment yesterday. Also with Tmax of 99.9. Denies HA, CP, SOB, dysuria. He was sent to the ED from his rehab for concerns of intestinal ischemia/obstruction/perf. In the ED, a CTA ABD & PELVIS was performed which was unremarkable. He was noted to have worsening copious secretions from trach and had episodes of satting into the ___. Diaphoretic. Given no intra-abdominal infection, initial suspicion is that it is possible pulmonary etiology. Portable CXR initially read with RML PNA and was started on vancomycin and Zosyn. CXR read finalized with no evidence of pneumonia. Admitted to the ICU due to ventilation with trach. Past Medical History: COPD HTN Appendectomy Social History: ___ Family History: No family history of cardiovascular disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: Temp: 98.3, BP: 188/128, HR: 121, RR: 16, 97% O2 vent General: Patient lying in bed, pleasant, no apparent distress, awake aware and oriented Ãâ€"3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach in place, attached to ventilator Cardiovascular: Regular rate and rhythm no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Minimally tender, abdomen distended Extremities: 2+ pulses bilaterally Neuro: ___ strength bilaterally in UE and ___. SLTIT. DISCHARGE PHYSICAL EXAM Mental status: He is alert. He resonds appropriately to questions though has a delayed response. He will either write our mouth words. At times, he does not respond and then will say that he is tired of talking. He is agitated at times though admits to feeling anxious. General: Patient sitting upright in chair, pleasant, no apparent distress, awake aware and oriented X3. nonverbal at baseline. communicates with writing on paper and reading his lips HEENT: Trach in place, attached to ventilator Cardiovascular: Regular rate and rhythm, no murmurs rubs or gallops Lungs: Clear to auscultation bilaterally Abdomen: Non-tender, mild distension with tympani to percussion Extremities: 2+ pulses bilaterally Neuro: ___ strength bilaterally in UE and ___. SLTIT. Pertinent Results: Admission labs: =============== ___ 03:49PM BLOOD WBC-15.9* RBC-2.97* Hgb-9.6* Hct-31.9* MCV-107* MCH-32.3* MCHC-30.1* RDW-17.6* RDWSD-67.5* Plt ___ ___ 03:49PM BLOOD Glucose-110* UreaN-4* Creat-0.4* Na-145 K-4.1 Cl-99 HCO3-36* AnGap-10 ___ 03:49PM BLOOD ALT-97* AST-53* AlkPhos-108 TotBili-0.2 ___ 03:58PM BLOOD ___ pO2-36* pCO2-65* pH-7.39 calTCO2-41* Base XS-10 Discharge labs: =============== ___ 03:04AM BLOOD WBC-9.0 RBC-2.69* Hgb-8.7* Hct-28.4* MCV-106* MCH-32.3* MCHC-30.6* RDW-17.0* RDWSD-65.3* Plt ___ ___ 03:04AM BLOOD ___ PTT-30.1 ___ ___ 03:04AM BLOOD Plt ___ ___ 03:04AM BLOOD Glucose-121* UreaN-5* Creat-0.4* Na-140 K-3.6 Cl-97 HCO3-31 AnGap-12 ___ 03:04AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7 Pertinent labs: =============== ___ 12:48PM BLOOD ___ pO2-46* pCO2-66* pH-7.36 calTCO2-39* Base XS-8 ___ 09:43PM BLOOD ___ pO2-59* pCO2-59* pH-7.42 calTCO2-40* Base XS-10 ___ 11:33AM BLOOD ___ pO2-78* pCO2-58* pH-7.41 calTCO2-38* Base XS-9 ___ 06:19AM BLOOD ___ pO2-46* pCO2-68* pH-7.34* calTCO2-38* Base XS-7 ___ 01:11AM BLOOD ___ pO2-42* pCO2-79* pH-7.30* calTCO2-40* Base XS-8 ___ 03:58PM BLOOD ___ pO2-36* pCO2-65* pH-7.39 calTCO2-41* Base XS-10 IMAGING: ========= ___ Imaging CTA ABD & PELVIS FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 1.2 x 0.9 cm hypoattenuating lesion at the hepatic dome may reflect a simple hepatic cyst or biliary hamartoma (03:18). There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Bilateral renal cortical hypodensities are too small to fully characterize. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Patient is status post PEG tube placement. Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder is decompressed with Foley catheter in place. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. Seminal vesicles are grossly unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Small foci of gas in the left upper abdomen may be related to prior injection (3:100). IMPRESSION: No acute findings in the abdomen or pelvis to account for patient's symptoms, specifically no convincing signs of bowel ischemia. ___ Imaging PORTABLE ABDOMEN IMPRESSION: There is a percutaneous gastrostomy tube projecting over the left upper quadrant of the abdomen. The stomach is slightly distended with air, similar to prior CT. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. Brief Hospital Course: ASSESSMENT ========== Mr. ___ is a ___ with a history of COPD and HTN, recently here with severe refractory hypercarbic respiratory failure ___ COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, ventilator dependent, who re-presents from LTACH with vomiting and abdominal pain. ACUTE ISSUES ======================= #Trach and vent dependent #Hypercarbic respiratory failure #Primary Respiratory Acidosis with Secondary Metabolic Alkalosis: No current concern for infection. Per history, he has COPD, however he does not necessarily present as COPD, though unclear what the underlying process is. Tolerated vent mask for approximately 20 min on ___ before requiring PSV. However PSV decreased from ___ to ___ which he is tolerating well. Unfortunately, we had to scale back to ___ at 30% an hour prior to discharge due to an elevated CO2 (66). Moving forward, we recommend daily trach mask trials as long as patient can tolerate. #Constipation Tympanic abdominal percussion on exam, and has not had BM since he was admitted. History of severe constipation which was attributed to opioid use. With resolution of his initial GI symptoms, he was restarted on tube feeds and his home bowel regimen was slowly added back on. He had one bowel movement on the day prior to discharge. #Tachycardia #HTN Noted to have initially low UOP. Gave 1L of fluids with improvement of UOP but only mild improvement of HR. ___ his baseline HR or iso of anxiety. We recommend treating anxiety appropriately though if pressures remain elevated, initiation of anti-HTN therapy. #Vomiting - resolved #Diarrhea - resolved #Leukocytosis - improving Acute presentation of vomiting x3, diarrhea, abdominal pain, and leukocytosis. However, he is now stating he had no abdominal pain. Remainder of symptoms fully resolved by time he arrived to ICU. Unclear exactly why he has been repeatedly sent in. CTA abdomen and pelvis unremarkable for any acute etiology. Likely gastroenteritis (given leukocytosis) vs constipation with overflow vs medication overuse (Bisacodyl PR, Docusate BID, Lactulose, miralax, Senna). He was restarted on tube feeds. #Pain #Anxiety During recent admission, patient was on prolonged fentanyl drip iso of extended intubation. He was thus transitioned to methadone, dilaudid, seroquel due to concern with potential opioid withdrawal, and tapered to just Seroquel QHS and a methadone at discharge. The methadone was then switched to oxycodone PRN for pain control, and the Seroquel dose was reduced on the most recent admission on ___ for concerns of over sedation. He was continued on home home QUEtiapine Fumarate 25 mg PO QID + 25mg QHS. Currently getting a total of 125mg/25. Per rehab documentation, they have been slowly tapering the Seroquel off. He was continued on home OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN and home TraZODone 25 mg PO BID:PRN agitation, anxiety. CHRONIC ISSUES ======================= #RUE DVT Ultrasound on ___ revealed acute DVT in right internal jugular vein. Lovenox was started on ___. He was continued on home lovenox. #Abnormal liver tests Persistently mildly elevated in hepatocellular pattern with highLDH as well. Improved since prior admission one month ago. LDH high but normal hemolysis labs and CK on prior admission. #Hematuria Noted on prior admissions and present during this hospitalizations. #BPH Continue home Tamsulosin 0.4 mg PO QHS TRANSITIONAL ISSUES: ===================== [ ] Continue to taper his ventilation as tolerated. We were initially able to reduce pressure support to ___ at 30% with no change in VBG but had to scale back to ___ at 30% an hour prior to discharge due to an elevated CO2 (66). His CO2 was 58 on prior day. Please perform daily trach mask trials. [ ] Follow up his bowel movements. He had one bowel movement on the day prior to discharge. [ ] Noted to have hematuria - please consider further evaluation if this continues [ ] Continue to taper his steroid [ ] Continue to taper his Seroquel [ ] Consider PJP prophylaxis given long-term steroid use [ ] He is iron deficient. Suggest PO iron supplementation Q48H for increased absorption and less constipation. [ ] Recommend treatment of blood pressure if continually elevated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl ___AILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 5. Ipratropium Bromide Neb 2 NEB IH Q6H 6. Lactulose 10 mL PO DAILY 7. melatonin 3 mg oral QHS 8. Multivitamins 1 TAB PO DAILY 9. Nystatin Oral Suspension 5 mL PO QID 10. Omeprazole 40 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Potassium Chloride (Powder) 40 mEq PO DAILY 13. QUEtiapine Fumarate 25 mg PO QID 14. QUEtiapine Fumarate 25 mg PO QHS 15. senna leaf extract ___ mg oral BID 16. Tamsulosin 0.4 mg PO QHS 17. Thiamine 100 mg PO DAILY 18. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 19. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 21. Simethicone 80 mg PO QID:PRN gas 22. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 23. TraZODone 25 mg PO BID:PRN agitation, anxiety 24. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 25. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/WHEEZING/COUGH 4. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH 5. Bisacodyl ___AILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Docusate Sodium (Liquid) 100 mg PO BID 8. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 9. Ipratropium Bromide Neb 2 NEB IH Q6H 10. Lactulose 10 mL PO DAILY 11. melatonin 3 mg oral QHS 12. Multivitamins 1 TAB PO DAILY 13. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous Q8H 14. Nystatin Oral Suspension 5 mL PO QID 15. Omeprazole 40 mg PO DAILY 16. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 17. Polyethylene Glycol 17 g PO DAILY 18. Potassium Chloride (Powder) 40 mEq PO DAILY Hold for K > 19. PredniSONE 5 mg PO DAILY 20. QUEtiapine Fumarate 25 mg PO QID 21. QUEtiapine Fumarate 25 mg PO QHS 22. senna leaf extract ___ mg oral BID 23. Simethicone 80 mg PO QID:PRN gas 24. Tamsulosin 0.4 mg PO QHS 25. Thiamine 100 mg PO DAILY 26. TraZODone 25 mg PO BID:PRN agitation, anxiety Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: ========= # Gastroenteritis # Hypercarbic respiratory failure SECONDARY: =========== # Chronic constipation # COPD # Anxiety # DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You had vomiting and abdominal pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You had imaging which did not show any issues with the bowels - Your symptoms improved - You were given fluids - You were continued on the ventilator 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: ___

10049095-DS-15

DS

2128-10-09 00:00:00

2128-10-09 15:56:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / desipramine / verapamil Attending: ___. Chief Complaint: Agitation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with history of bipolar disease, depression, ___ disease, vascular dementia, bilateral knee replacements, peripheral neuropathy, diabetes, CKD, episodes of falls with head injury, bipolar disorder, heart block status post PPM, DVT on Coumadin, who presents with wife and son with complaint of 2 weeks of worsening mental status, anxiety, and depression. of note, he was referred to the ED from his psychiatrist for concern of worsening mood due to organic etiology. They state that he does have baseline dementia, but this is been particularly bad over the past 2 weeks. He has been very anxious and depressed. He has been complaining of pain in the lower extremities, particularly around the left heel, where he has an ulcer. He denies fevers or chills. He has not been complaining of any chest pain, shortness of breath, abdominal pain, vomiting, diarrhea, urinary symptoms. He has been eating and drinking well. His blood sugars have been well controlled at home. No recent falls. He uses a walker but is very limited in his ability to ambulate, he also uses a transfer chair at home. He does have some visiting nurse resources. Wife states that she spoke with his psychiatrist today who sent him to the emergency department. Of note, Mr. ___ follows with psychiatry here for post concussive syndrome as well as dementia related to ___ and vascular dementia. He last saw psych on ___ where his psychiatrist mentioned that the patient has had a turbulent course over the past year, characterized by episodes of falls with head injury. Mr. ___ has been confined to a wheelchair for some time and has been cared for by his extended family. His recent course has been complicated by periods of delirium, impaired cognitive status. His baseline mental status is noted to be the following: "subdued, sad faced, not overtly tearful, complaining of depression. Speech is reduced in rate, productivity. There is a paucity of thought. No evidence of spontaneous tearfulness during mental status evaluation. He appears to be somewhat disoriented, not fully oriented in all spheres." Past Medical History: Bipolar disorder ___ disease Vascular Dementia Social History: ___ Family History: Noncontributory Physical Exam: Admission Exam: General: Elderly male lying in bed, no acute distress HEENT: PERRL. EOMI. MMM. No regional lymphadenopathy. No erythema of the oropharynx. Neck: No regional lymphadenopathy or thyromegaly. Lungs: Clear to auscultation bilaterally. CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD. GI: BS present. Soft, nontender, nondistended. No hepatomegaly. Ext: No peripheral edema. Heel of the left lower extremity has a well-healed 1x1 cm ulcer without any evidence of erythema, purulence, or drainage. Neuro: Patient states that he is at ___. He is not alert to day of the week, month, or year. He states that he lives with his parents. Cranial nerves II through XII intact. Strength 5 out of 5 in the upper extremities B/L. Strength ___ in the lower extremities b/l). Discharge Exam: Vitals: Per OMR General: Elderly male lying in bed, no acute distress HEENT: Pupils small, reactive to light Lungs: Clear to auscultation bilaterally. CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD. GI: BS present. Soft, nontender, nondistended. Ext: No peripheral edema. Heel of the left lower extremity has a well-healed 1x1 cm ulcer without any evidence of erythema, purulence, or drainage. Pulses present by palpation bilaterally. Neuro: Patient states that he is at ___. He is not alert to day of the week, month, or year. He states that he lives with his parents. Cranial nerves II through XII intact. Strength 5 out of 5 in the upper extremities B/L. Strength ___ in the lower extremities b/l). Pertinent Results: Labs: ___ 08:55AM BLOOD WBC-6.3 RBC-5.39 Hgb-14.6 Hct-45.9 MCV-85 MCH-27.1 MCHC-31.8* RDW-15.3 RDWSD-47.3* Plt ___ ___ 06:55AM BLOOD WBC-5.2 RBC-5.26 Hgb-14.1 Hct-44.7 MCV-85 MCH-26.8 MCHC-31.5* RDW-15.5 RDWSD-47.4* Plt ___ ___ 07:15AM BLOOD WBC-4.9 RBC-5.01 Hgb-13.4* Hct-43.4 MCV-87 MCH-26.7 MCHC-30.9* RDW-15.4 RDWSD-48.6* Plt ___ ___ 07:02AM BLOOD WBC-8.5 RBC-4.99 Hgb-13.5* Hct-44.1 MCV-88 MCH-27.1 MCHC-30.6* RDW-15.3 RDWSD-49.1* Plt ___ ___ 05:59AM BLOOD WBC-4.9 RBC-4.91 Hgb-13.3* Hct-42.3 MCV-86 MCH-27.1 MCHC-31.4* RDW-15.7* RDWSD-48.9* Plt ___ ___ 06:30AM BLOOD WBC-6.3 RBC-4.78 Hgb-12.9* Hct-42.0 MCV-88 MCH-27.0 MCHC-30.7* RDW-15.8* RDWSD-49.3* Plt ___ ___ 08:55AM BLOOD Glucose-89 UreaN-34* Creat-2.4*# Na-149* K-4.4 Cl-103 HCO3-27 AnGap-19* ___ 06:55AM BLOOD Glucose-133* UreaN-35* Creat-2.4* Na-144 K-4.3 Cl-101 HCO3-27 AnGap-16 ___ 06:48AM BLOOD Glucose-117* UreaN-32* Creat-2.3* Na-150* K-4.1 Cl-107 HCO3-29 AnGap-14 ___ 07:15AM BLOOD Glucose-97 UreaN-32* Creat-2.0* Na-146 K-4.2 Cl-107 HCO3-26 AnGap-13 ___ 07:02AM BLOOD Glucose-151* UreaN-29* Creat-1.8* Na-150* K-4.7 Cl-111* HCO3-28 AnGap-11 ___ 08:55AM BLOOD ALT-10 AST-19 AlkPhos-44 TotBili-0.6 ___ 06:48AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 ___ 07:02AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.1 ___ 05:59AM BLOOD Glucose-128* UreaN-32* Creat-1.7* Na-146 K-4.7 Cl-106 HCO3-29 AnGap-11 ___ 04:03PM BLOOD Glucose-119* UreaN-32* Creat-1.7* Na-143 K-4.7 Cl-104 HCO3-27 AnGap-12 ___ 06:30AM BLOOD Glucose-169* UreaN-35* Creat-1.8* Na-145 K-5.2 Cl-106 HCO3-27 AnGap-12 INR: ___ 07:20PM BLOOD ___ PTT-35.5 ___ ___ 07:15AM BLOOD ___ PTT-31.8 ___ ___ 07:02AM BLOOD ___ PTT-25.1 ___ ___ 06:30AM BLOOD ___ PTT-35.9 ___ ___ 05:59AM BLOOD ___ PTT-37.6* ___ ___ 06:30AM BLOOD ___ PTT-37.1* ___ Brief Hospital Course: ASSESSMENT/PLAN: Mr. ___ is a ___ male with history of bipolar disorder, depression, peripheral neuropathy, diabetes, CKD, who presented with 2 weeks of worsening mental status, anxiety, and depression and was found to have mild hypernatremia and and ___ that improved with hydration. Mental status also improved with correction of sodium and fluid balance. Please see below for medication changes. Acute Issues: ============ #Worsening mental status #Anxiety #Depression The patient has a ___ year history of bipolar disorder, which is characterized by periods of hypomania, irritability, but a more chronic course of depression. Psychiatry evaluated patient and got collateral from Psychiatrist Dr. ___. Psychiatry confirmed his medications as below. Acute on chronic agitation likely due to dehydration, and hypernatremia as his symptoms resolved with resolution ___ and Hypernatremia. As per Dr. ___ sertraline and donepezil was discontinued. Home ___ will be held in the setting of initiation of gabapentin to avoid over sedation. Dr. ___ will reinitiate ___ as appropriate. The patient was discharged on the following medications: -Olanzapine 2.5 mg daily -Olanzapine 2.5mg daily PRN agitation. -Trazodone 100 mg QHS -Depakote 500 mg Daily #Bilateral Lower extremity pain The patient has a history of diabetes and has a history of pain in bilateral legs. Workup inpatient has included foot XR (neg for fx), ___ dopplers (no evidence of DVT or ___ cyst). Most likely etiology either diabetic neuropathy or osteoarthritis. In coordination with outpatient psychiatrist Dr. ___ was started on gabapentin 200mg TID with good effect. #Hypernatremia ___ Cr 2.4 (previous Cr in ___ at ___ was 1.7). the creatinine improved with oral hydration. The patient should continue to drink at least four 16 oz glasses of water (64oz) a day. The hypernatremia resolved with oral hydration. He should have his CMP checked by his PCP on follow up in ___. CHRONIC ISSUES ============== #Hypertension -Continueed home amlodipine and hydrochlorothiazide #Vascular dementia Continued home ASA 81 #History of DVT -Continue home warfarin 2 mg daily #Diabetes Continued home regimen insulin Transitional Issues: ==================== [] Please check INR next appointment and make adjustments as needed [] Re-evaluation for re-initiation of ___ as well as increasing olabnzapine 2.5mg as per Dr. ___ ___ Changes: NEW: Olanzapine 2.5mg daily Olanzapine 2.5mg Daily PRN agitation Gabapenitn 200mg TID DOSE CHANGES: Depakote 500mg BID to ___ daily DISCONTINUED MEDICATIONS: Sertraline 25mg daily HELD MEDICATIONS: Lamictal 100mg daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 2.5 mg PO DAILY 2. TraZODone 100 mg PO QHS 3. Divalproex (DELayed Release) 500 mg PO BID 4. Warfarin 3 mg PO DAILY16 5. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 6. FoLIC Acid 1 mg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Thiamine 100 mg PO DAILY 11. Cyanocobalamin 1000 mcg PO DAILY 12. melatonin 3 mg oral qhs 13. Atorvastatin 20 mg PO QPM 14. LamoTRIgine 100 mg PO DAILY Discharge Medications: 1. Gabapentin 100 mg PO TID 2. OLANZapine 2.5 mg PO DAILY:PRN agitation 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Divalproex (DELayed Release) 500 mg PO BID 8. FoLIC Acid 1 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. melatonin 3 mg oral qhs 11. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin aspart) 100 unit/mL (70-30) subcutaneous BID 12. OLANZapine 2.5 mg PO DAILY 13. Thiamine 100 mg PO DAILY 14. TraZODone 100 mg PO QHS 15. Warfarin 3 mg PO DAILY16 16. HELD- LamoTRIgine 100 mg PO DAILY This medication was held. Do not restart LamoTRIgine until directed by Dr. ___ ___ Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypernatremia Acute Kidney Injury 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 caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - Because you were not feeling well. WHAT HAPPENED TO ME IN THE HOSPITAL? - We checked you labs and found that you were dehydrated. - We gave you fluids and your got better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please drink at least four 16oz containers of water a day to prevent dehydration -Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10049334-DS-16

DS

2183-07-17 00:00:00

2183-07-18 20:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: hip fracture Major Surgical or Invasive Procedure: Orthopedic Surgery ___: Intramedullary nailing with a long TFN System, 10 x ___ mm, with 105 mm lag screw. History of Present Illness: ___ with dementia, atrial fibrillation not on anticoagulation, and history of traumatic subdural hematoma due to fall and resulting TBI presents from home after a mechanical fall. The patient was unable to provide history due to very poor mental status. In discussion with the patient's daughter-in-law, the patient is reported to have poor mental status at baseline. He has moments of lucidity but often he has difficulty carrying on conversation or following basic instructions. He does ambulate at baseline. He is totally dependent in iADLs and now in most ADLs (assistance with bathing, dressing, and toileting; able to feed self if food provided). Of note, he had been on hospice a year ago and was expected to survive days-weeks; however, recovered surprisingly and has been living at home with wife (also with advanced dementia) and his son and daughter, who are their primary caretakers. He was in the living room with his wife when he had a fall. It was only witnessed by his wife, but his daughter-in-law says that it appeared he most likely was turning and tripped, falling next to a table that he tried to grab as he landed close to it. In the ED, initial vitals were: 98.7 68 186/100 16 93% RA. Exam was notable for: "Tender over right hip and femur only. right leg mildly rotated, no appreciable limb length shortening." Labs notable for Hgb 9.6 (from baseline ___, and CXR notable for moderate pulmonary edema. Hip XR showed R intertrochanteric fracture. Patient received: IV Furosemide 20 mg, IV Morphine Sulfate 2.5 mg x2. Orthopedics was consulted and recommended operative management. He was admitted to medicine for optimization of volume status. Vitals prior to transfer were: 79 163/97 16 96% Nasal Cannula. On arrival to the floor, patient was not interactive or conversant. Past Medical History: - Atrial fibrillation not on warfarin - Hypertension - Hyperlipidemia - BPH (benign prostatic hyperplasia) - Gout - History of traumatic subdural hemorrhage s/p evacuation - Peripheral neuropathy - Osteoarthritis - Non-convulsive status epilepticus - History of Clostridium difficile infection - Urinary tract infection - Edema - Congestive heart failure - Urinary incontinence - Bullous disorder Social History: ___ Family History: Unable to be obtained due to patient's mental status. Physical Exam: ADMISSION Vitals: 99.4 133-180/72-100 68-107 18 96% on 2L Gen: Elderly gentleman lying in bed, asleep but rousable to sternal rub, does not follow commands HEENT: PERRL, pupils contracted 3mm to 2mm, head appears atraumatic Neck: supple, JVP difficult to appreciate but visibly distended external jugular vein up 6-7 cm above clavicle Cardiac: RRR, normal S1 and S2, no murmurs Pul: CTAB, no wheezes or crackles Abd: +BS, soft, non-tender, non-distended Ext: warm, well perfused, +RLE 1+ pitting edema to knee, RLE foreshortened and externally rotated Skin: Multiple skin tears on arms and legs, as well as old desquamated bullae. Neuro: Patient does not follow commands, resists passive extension of all extremities. DISCHARGE VS 98.0 143 83 18 98/ra Gen: elderly, chronically ill, NAD HEENT: EOMI, MMM Neck: supple, JVP difficult to appreciate but visibly distended external jugular vein up 5cm above clavicle Cardiac: RRR, NMRG Pul: Anterior crackles to midlung, improved from yesterday. Breathing comfortably. NC in place. Abd: soft, ntnd Ext: wwp. +RLE 1+ pitting edema to knee Skin: Multiple skin tears on arms and legs, as well as old desquamated bullae. Neuro: Alert. Nonverbal. Does not follow commands, resists passive extension of all extremities. Pertinent Results: ====================== LABS ====================== Admission: ___ 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt ___ ___ 04:00PM BLOOD ___ PTT-30.4 ___ ___ 04:00PM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-137 K-3.8 Cl-103 HCO3-26 AnGap-12 ___ 07:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2 H/H trend: ___ 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt ___ ___ 07:00AM BLOOD WBC-7.1 RBC-2.76* Hgb-8.8* Hct-27.0* MCV-98 MCH-31.9 MCHC-32.6 RDW-14.1 RDWSD-49.6* Plt ___ ___ 05:21AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.0* Hct-24.9* MCV-97 MCH-31.3 MCHC-32.1 RDW-14.2 RDWSD-50.5* Plt ___ ___ 10:28AM BLOOD WBC-11.7*# RBC-2.70* Hgb-8.4* Hct-27.5* MCV-102* MCH-31.1 MCHC-30.5* RDW-14.3 RDWSD-53.1* Plt ___ ___ 06:57AM BLOOD WBC-6.1 RBC-2.23* Hgb-7.0* Hct-22.3* MCV-100* MCH-31.4 MCHC-31.4* RDW-14.4 RDWSD-51.6* Plt ___ ___ 07:35PM BLOOD WBC-6.2 RBC-2.56* Hgb-7.9* Hct-25.2* MCV-98 MCH-30.9 MCHC-31.3* RDW-15.9* RDWSD-56.5* Plt ___ ___ 07:02AM BLOOD WBC-4.6 RBC-2.41* Hgb-7.3* Hct-24.8* MCV-103* MCH-30.3 MCHC-29.4* RDW-16.1* RDWSD-60.2* Plt ___ ___ 01:28PM BLOOD WBC-4.9 RBC-2.61* Hgb-8.0* Hct-26.3* MCV-101* MCH-30.7 MCHC-30.4* RDW-15.9* RDWSD-57.1* Plt ___ DISCHARGE LABS: ___ 06:15AM BLOOD WBC-4.5 RBC-2.80* Hgb-8.6* Hct-28.6* MCV-102* MCH-30.7 MCHC-30.1* RDW-15.4 RDWSD-56.9* Plt ___ ___ 06:15AM BLOOD Glucose-107* UreaN-35* Creat-0.7 Na-148* K-3.7 Cl-110* HCO3-27 AnGap-15 ___ 06:15AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.4 ====================== MICRO ====================== ___ CULTURE-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTURE-FINAL {PROTEUS MIRABILIS}INPATIENT URINE CULTURE (Final ___: PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 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 ====================== IMAGING/STUDIES ====================== ___ LOWER EXT VEINS ___ ___ 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Right calf subcutaneous edema. ___ (PORTABLE AP) ___ ___ Previous moderate pulmonary edema has improved, moderate bilateral pleural effusions have redistributed dependently, but probably not enlarged, and nowobscure the right heart border. Opacification at the lung bases is probably a combination of atelectasis, dependent edema overlying pleural effusion. No pneumothorax. ___ UNILAT MIN 2 VIEWS ___ ___ Images from the operating suite show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. ___ EXTREMITY FLUORO ___ ___ Images from the operating suite show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. ___. Atrial fibrillation with a moderate ventricular response. Occasional ventriclar premature beats with one couplet. Left axis deviation consistent with left anterior fascicular block. Non-specific repolarization abnormalities. Possible old anteroseptal myocardial infarction. Compared to the previous tracing of ___ no change except for ventricular ectopy now present. ___ (PORTABLE AP) ___ ___ In comparison with the study of ___, there again is enlargement of the cardiac silhouette with asymmetric pulmonary edema. As previously, it would be difficult to unequivocally exclude superimposed pneumonia, especially in the absence of a lateral view. Hazy opacifications bilaterally with poor definition of the hemi diaphragms suggests layering pleural effusion with underlying compressive atelectasis. No interval change. No evidence of pneumothorax. ___. Atrial fibrillation with a moderate ventricular response. Left anterior fascicular block. Possible old anteroseptal myocardial infarction. Non-specific repolarization abnormalities. Compared to the previous tracing of ___ the rate is slower without other significant change. ___ (AP & LAT) RIGHT ___ No acute fracture seen of the mid to distal right femur. ___ (SINGLE VIEW) ___ Prominent right greater than left perihilar is opacities worrisome for severe pulmonary edema. Asymmetric increased opacity on the right as compared to the left could be due to asymmetric pulmonary edema versus underlying infection and/ or aspiration. Pulmonary hemorrhage not excluded. Subtle posterolateral right-sided rib deformities including right fourth through seventh ribs consistent with rib fractures ; the right fourth and seventh rib fractures appear old. The right fifth and sixth rib fractures are of indeterminate age, but could be acute to subacute. Correlate with clinical history and site of point tenderness. Findings are new since ___ ___ (UNILAT 2 VIEW) W/P ___ Comminuted right intertrochanteric fracture with varus angulation of the right femoral head. Moderate to severe right hip osteoarthritic changes. ___ C-SPINE W/O CONTRAST ___ 1. No acute fracture of the cervical spine. Multi-level degenerative changes. 2. Partially imaged right greater than left pleural effusions. Pulmonary edema. ___ HEAD W/O CONTRAST ___ Some patient motion limits the exam. No definite acute intracranial process seen. ___. Baseline artifact limits the sensitivity of interpretation. The rhythm is probably atrial fibrillation with rapid ventricular response. Occasional ventricular premature contraction and aberrantly conducted complexes. Left axis deviation. Possible inferior wall myocardial infarction of indeterminate age. Poor R wave progression in leads V1-V3. Possible anteroseptal myocardial infarction of indeterminate age. Delayed R wave transition. Diffuse non-specific ST segment changes with biphasic T waves in lead V6. Cannot exclude possible myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of ___ the ventricular rate has increased by about 20 beats per minute and the lateral ST-T wave changes are slightly more pronounced. Brief Hospital Course: ___ with dementia, atrial fibrillation not on anticoagulation, and history of traumatic subdural hematoma due to fall and resulting TBI presents from home after a mechanical fall, found to have a right intertrochanteric fracture. This was repaired by orthopedic surgery. # s/p R intertrochanteric fracture: Hip was repaired ___, complicated by mild bleeding into R thigh (R more swollen than L, dopplers negative for DVT). His enoxaparin was stopped ___ and restarted ___. # Anemia: Pt developed acute blood loss anemia from bleeding into R thigh; he received 2u PRBCs and was monitored for development of compartment syndrome. His H/H stabilized, by day of discharge Hbg 8.6. # dCHF: Patient had an episode of hypoxemia in the PACU that resolved with diuresis, most likely a mild exacerbation of his diastolic CHF. He was restarted on home diuretics but then these were stopped as the patient was no longer volume overloaded and developed hypernatremia (likely secondary to poor PO intake). The patient was discharged off home Lasix, will need daily weights to determine whether these should be restarted. # Hypernatremia: Patient developed mild hypernatremia (Na on day of discharge 148) likely secondary to poor PO intake. Received mIVF of D5W. Consider need to continue D5W for hypernatremia. # UTI: Pt developed UTI, tx'ed w/ cipro 500 bid x7d, which he completed on ___. # HTN: Patient's home carvedilol was continued, lisinopril held but restarted on day of discharge given SBPs 120s-150s. # Dementia: Of note, he is totally dependent in iADLs and now in most ADLs (assistance with bathing, dressing, and toileting; able to feed self if food provided). Of note, he had been on hospice a year ago and was expected to survive days-weeks; however, recovered surprisingly and has been living at home with wife (also with advanced dementia) and his son and daughter, who are their primary caretakers. # Malnutrition: Nutrition provided recommendations. Pt discharged on multivitamin. Likely contributing to INR of 1.3. TRANSITIONAL ISSUES: [] Please check CBC on ___. Discharge Hgb was 8.6. Transfuse for Hbg <7 [] Patient was started on enoxaparin for prophylaxis; consider continued need for this at outpatient follow up appointment. [] F/u with orthopedics scheduled for ___. [] Patient's home diuretics (Lasix 40 mg PO BID) were held in the setting of hypernatremia. Please weigh the patient daily to assess need to restart diuretics. Weight on ___: 71.67 kgs [] The patient's sodium on day of discharge was 148 (likely secondary to poor PO intake) and he was given D5W; please check sodium regularly (every other day or so) and give D5W at a slow rate PRN for hypernatremia. [] Patient with minor coagulopathy (INR 1.3 on day of discharge) likely secondary to malnutrition, consider nutritional supplements. Pt started on multivitamin. [] Patient's home BP lisinopril was restarted on day of discharge; SBPs were 120s-150s and he had normal renal function and normal K. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Potassium Chloride 10 mEq PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Carvedilol 12.5 mg PO BID 4. Furosemide 40 mg PO BID 5. Terbinafine 1% Cream 1 Appl TP DAILY Discharge Medications: 1. Carvedilol 12.5 mg PO BID 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 4. Lactulose ___ mL PO BID:PRN constipation 5. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia 6. Acetaminophen 1000 mg PO TID Pain 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 30 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - R hip fracture - acute blood loss anemia - diastolic CHF, acute on chronic - UTI, complicated - ___ Secondary: - coagulopathy - malnutrition - advanced dementia - hypertension 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 Mr. ___, You were seen at ___ for hip fracture. This was repaired by orthopedic surgery, and we gave you blood to treat some expected postsurgical thigh bleeding. Please see your appointments and medications below. You have a follow up appointment with orthopedic surgery. Sincerely, Your ___ Medicine Team Followup Instructions: ___

10049681-DS-15

DS

2117-11-22 00:00:00

2117-11-22 11:08:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Demerol Attending: ___. Chief Complaint: Right arm pain Major Surgical or Invasive Procedure: Open reduction and internal fixation right upper extremity fracture History of Present Illness: ___ transferred from OSH after mechanical fall today in which she likely fell onto her R elbow, sustaining a comminuted fx of the medial epicondyle. Lives alone, normally walks with walker. No head strike, no LOC. Past Medical History: -"large heart since birth" - per ___: HTN, herniated disc Social History: ___ Family History: Non contributory Physical Exam: Admission Exam T=97.7 BP=158/52 HR=69 RR=16 O2=94RA PHYSICAL EXAM GENERAL: Pleasant, well appearing in NAD HEENT: Normocephalic, atraumatic. No scleral icterus. PERRLA/EOMI. membranes are dry. OP clear CARDIAC: Regular rhythm, normal rate. Normal S1, S2. ___ SEM heard best at the ___ RICS with carotid radiation LUNGS: CTAB, good air movement biaterally, no wheezing ABDOMEN: NABS. Soft, NT, ND EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. Diffuse nontender erythema over the lower right leg, but no edema, palpable cords. RUE in splint. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ___ 05:10PM GLUCOSE-125* UREA N-30* CREAT-1.1 SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 ___ 05:10PM estGFR-Using this ___ 05:10PM WBC-11.6* RBC-3.78* HGB-12.4 HCT-37.3 MCV-99* MCH-32.7* MCHC-33.2 RDW-12.9 ___ 05:10PM NEUTS-92.3* LYMPHS-4.6* MONOS-2.6 EOS-0.2 BASOS-0.3 ___ 05:10PM PLT COUNT-216 ___ 05:10PM ___ PTT-28.9 ___ ___ 05:10PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: The patient was admitted to the Orthopaedic Trauma Service for repair of her right upper extremity fracture. The patient was taken to the OR and underwent an uncomplicated repair. The patient tolerated the procedure without complications and was transferred to the PACU in stable condition. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. The patient tolerated diet advancement without difficulty and made steady progress with ___. Weight bearing status: Non weight bearing right upper extremity. The patient received ___ antibiotics as well as Lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 4 weeks post-operatively. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: -Norvasc 5mg daily -tylenol #3 with codeine, 2 tabs TID PRN pain -Atenolol 25mg daily -Celebrex ___ daily PRN -furosemide 30mg daily -calcium 600+D twice daily -centrum silver +zinc daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: ___ Tablets PO HS (at bedtime). 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Dyspepsia. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous QPM (once a day (in the evening)). 8. furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours) as needed for pain: Do not drink alcohol or drive while taking this medication. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right medial epicondyle 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: ******SIGNS OF INFECTION********** Please return to the emergency department or notify MD if you should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed can be removed 2-week after your surgery. This can be done at your rehabilitation facility or by a ___. No dressing is needed if wound continued to be non-draining. ******WEIGHT-BEARING******* Non-weight bearing Right upper extremity Range of motion as tolerated at elbow. ******MEDICATIONS*********** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink ___ glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on ___. *****ANTICOAGULATION****** - Take Lovenox for DVT prophylaxis for 4 weeks post-operatively. Physical Therapy: Non weight bearing right upper extremity Treatments Frequency: Please assess wound daily for signs of infection. If has staples/sutures that need to be removed, please take out at post-operative day 14. Followup Instructions: ___

10049736-DS-5

DS

2139-10-25 00:00:00

2139-10-26 06:33:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins Attending: ___. Chief Complaint: RLQ pain Major Surgical or Invasive Procedure: Laparoscopic paratubal cystectomy detorsion History of Present Illness: ___ yo G4P4 dx with R ovarian vs paratubal cyst after presenting to ___ with RLQ pain ~1 mo ago. She had severe pain which improved after narcotics and rest. Was back to her usual state of health until last night. Began having dull RLQ pain @ 1030pm, subsequently had severe pain beginning @ 130am. Presented to ___ initially and was transferred ___ concern for torsion. On arrival to ___, she was very uncomfortable. Vital signs were normal. Got 2x morphine 5mg IV and had a pelvic US. Ate crackers at 930am. Currently states pain is ___, achy, RLQ, non-radiating Past Medical History: OB/GYN Hx: - LTCS x 4 - denies h/o pelvic infections - remote h/o cervical dysplasia, nl f/u - diagnosis of R adnexal cyst ~1mo ago - no current contraception PMH: Denies PSH: - LTCS x4 - LSC appy Social History: ___ Family History: non-contributory Physical Exam: T 97.3, HR 57, BP 100/52, RR 20 100% NAD Abd soft, ND, +TTP RLQ/suprapubic region, no r/g Pelvic: small av uterus with limited mobility. + soft, moblie mass appreciated post to uterus, fairly uncomfortable with palpation of the mass. Discomfort on R with mvmt of cervix ext NT, NE Pertinent Results: ___ 05:40AM BLOOD WBC-9.2 RBC-4.03* Hgb-12.2 Hct-35.2* MCV-87 MCH-30.3 MCHC-34.7 RDW-12.8 Plt ___ ___ 05:40AM BLOOD Neuts-85.5* Lymphs-11.0* Monos-3.1 Eos-0.2 Baso-0.3 ___ 05:40AM BLOOD Glucose-122* UreaN-14 Creat-0.7 Na-140 K-3.9 Cl-106 HCO3-25 AnGap-13 ___ 07:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 07:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 07:00AM URINE UCG-NEG PELVIC ULTRASOUND ___: Transabdominal and transvaginal examinations performed, the latter to further evaluate the endometrium and adnexal structures. The uterus is anteverted and retroflexed and measures 10.8 x 4.4 x 6.0 cm. The endometrium is homogeneous in echogenicity measuring 8 mm. A C-section scar is noted. Within the right adnexa, there is a large simple cyst measuring 6.4 x 5.0 x 6.6 cm. This likely represents a paraovarian cyst. The adjacent ovary appears slightly edematous and measures 2.6 x 3.2 x 3.3 cm. The left ovary measures 2.6 x 2.2 x 3.1 cm. Small follicles are noted. There is normal arterial and venous Doppler waveforms within both ovaries. There is trace pelvic free fluid. IMPRESSION: 1. Slightly edematous right ovary with normal arterial and venous Doppler waveforms. Findings are indeterminate with ovarian torsion not excluded. Gynecologic consultation with clinical correlation is recommended. 2. Large 6.6 cm right paraovarian cyst. Follow-up pelvic ultrasound in 3 months is recommended. Brief Hospital Course: Ms. ___ presented to the emergency department with RLQ pain. Ultrasound was performed showing a large 6.6 cm right paraovarian cyst and slightly edematous right ovary. Due to concern for torsion, patient was taken to the operating room. She was found to have a 10cm paratubal necrotic cyst causing adnexal torsion and underwent laparascopic paratubal cyst excision after adnexal detorsion. She had an uncomplicated recovery and was discharged home on postoperative day #0 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication. Medications on Admission: None Discharge Medications: 1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain: do not administer more than 4000mg acetaminophen in 24 hrs. Disp:*30 Tablet(s)* Refills:*0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: paratubal cyst adnexal torsion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Followup Instructions: ___

10049746-DS-22

DS

2137-01-10 00:00:00

2137-01-10 18:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pravachol / Darvon / Carrot Attending: ___. Chief Complaint: Broken femur, newly diagnosed DLBCL Major Surgical or Invasive Procedure: ___ line placement History of Present Illness: ___ w/ PMH hemochromatosis, hypothyroidism, anemia presents from ___ with a femur fracture s/p fall. She had a previous hip fracture in ___ with replacement at that time. Patient says that 6 weeks ago she began feeling weak and tired, with intermittent nausea causing a 20 pound weight loss. She was admitted to ___ as a result of these issues and found to be severely anemic at the time and given 2 units of blood. CT showed multiple liver masses and lymphadenopathy which was recently discovered to be Non-Hodgkin Lymphoma. Regarding her fall, she does not recall the entire circumstances of the events leading up to the fall, but she notes that she felt a little bit lightheaded. Denies loss of consciousness. Denies head strike. Landed on her left side after striking the bathtub. She was found wedged between the bathtub in the toilet. She denied CP, SOB, or palpitations preceding the fall. Denies recent urinary symptoms, abdominal pain, N/V/D. Her Hb at ___ was 7. She was given 1 pRBC. Foley in place from OSH. She also has a new diagnosis of Non Hodgkin's lymphoma with liver lesions and no evidence of lymphoma elsewhere. Daughter, husband, and patient are aware of the diagnosis, she has not yet seen an oncologist. She was informed by her primary care physician. She was seen in the ED by trauma surgery and orthopedics. Trauma surgery recommended touchdown weightbearing on the left lower extremity in that she does not need operative repair. They stated that the hardware appears well-positioned given her periprosthetic femur fracture. In the ED, initial vitals: T: 99.6 HR: 104 BP: 138/80 RR: 18 Sp02: 2L 95% Nasal Cannula Labs notable for: - Leukocytosis to 11.7, H/H 8.7/25.5 (given 1 u for 7.0 ___ -Coags wnl - Lactate 1.3 - UA with mod leuks, neg nitrites - Chem 7 wnl (Cr 0.7) - BNP 655 - Trop 0.01 @ 0703 on ___. - Urine culture and blood cultures drawn. - Active blood bank specimen. Imaging notable for: ___ EKG: Sinus rhythm at 86, no ischemia or arrhythmia, nonspecific TWI in V1, similar to prior EKG from ___. QTc: 425. Possible ___. ___ CTA CHEST: 1. Left upper lobe segmental pulmonary embolism. Questionable left lower lobe subsegmental pulmonary embolism which is likely real given slight hypoenhancement of the lung supplied by this branch which could represent component of infarct. No right heart strain. 2. Rib fractures at the costovertebral junctions of the left eighth and ninth ribs posteriorly to be correlated clinically regarding acuity as these may be recent in nature. 3. Evidence of metastatic disease in the partially visualized abdomen. ___ CT C-spine: Degenerative changes without fracture or acute malalignment. ___ CT Head W/O contrast: No acute intracranial process.Complete opacification of the left frontal sinus and ethmoid air cells. Given demineralized left ethmoid septa and soft tissue extension into the left orbit, underlying mass lesion with secondary obstruction would be of concern. A mucocele is less likely given lack of expansion. Dedicated nonurgent MRI suggested. ___ Left Hip IMPRESSION: Acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. Pt given: - 2 mg IV morphine for pain x 3 (approx. Q4-6H) - IVF w/ NS @ 100 ml/hr. - CTX 1g x 1 at 13:16 - Lovenox 70 mg @ 14:35 - Levothyroxine 50 mcg 15:10 - Fluticasone/Salmeterol @ 15:17 - Zofran 4 mg @ 16:15 Vitals prior to transfer: T: 98.1 HR: 86 BP:108/56 RR:22 Sp02:97% Nasal Cannula On the floor, she was seen with her husband ___ and ___ daughter ___. She has some discomfort in her left leg she points to her distal femur. She denies any chest pain or tightness, she does endorse some mild shortness of breath. She denies any abdominal pain, constipation, diarrhea, dark or bloody stools, dysuria. Of note, she does endorse that she had increased urinary frequency prior to the Foley placement. She is anxious about the new cancer diagnosis. Review of systems is otherwise negative. Past Medical History: Osteoarthritis Hypothyroidism Hemochromatosis Asthma HCV- resolved Basal cell ca- forehead Non-Hodgkin's lymphoma located in liver. Social History: ___ Family History: Her brother was diagnosed with kidney cancer at ___ and died shortly thereafter. Her father died of a heart attack at ___. Her mother died of coronary artery disease at ___. Her sister died of COPD and she was a heavy smoker. She otherwise denies any other history of cancer, hypertension, stroke in her family. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= VITALS: T: 98.2 BP: 144/80 HR: 97 RR: 18 Sp02: 90% 4L General: Alert, oriented, no acute distress, nasal cannula in place. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. distal pulses intact. Lungs: On 4L (patient could not tolerate sitting up due to leg pain), good air exchange, no increased work of breathing, no wheezes, rales or rhonchi. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place. Ext: No peripheral edema, some minor bruises on lower extremities bilaterally, able to move toes on both sides, exam limited by pain on LLE, able to move RLE normally. Neuro: CNII-XII grossly intact, normal sensation. DISCHARGE PHYSICAL: =================================== VS: 0332 98.0 PO 131/62 86 19 95 Ra tmax 98.5 ACCESS: Dual Lumen Non-Heparin Dependent Right Brachial PICC (placed ___ PHYSICAL EXAM: General: Sitting up in bed. NAD. A&Ox3. Very pleasant. HEENT: Mucosa pink, moist, non-inflammed. No conjunctival pallor. CV: Tachycardic, Regular rhythm. No murmurs, rubs, gallops. Lungs: Lungs CTAB. No wheezes, rales, rhonchi. Abdomen: Soft, nontender, non distended. Ext: 1+ edema of bilateral lower extremities, L>R. Neuro: A&O x3. Conversant. Remainder of neuro exam is non-focal. Skin: Multiple ecchymoses. no rashes, lesions, or petechiae noted. B/l LEs with hyperpigmented patches and shiny taut patches. Pertinent Results: ADMISSION LABS: = ================================================================ ___ 09:28PM GLUCOSE-136* UREA N-17 CREAT-0.7 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16 ___ 09:28PM ALT(SGPT)-20 AST(SGOT)-52* LD(LDH)-541* ALK PHOS-68 TOT BILI-3.6* ___ 09:28PM CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-2.0 URIC ACID-4.2 ___ 09:28PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG ___ 09:28PM HCV VL-NOT DETECT ___ 09:28PM WBC-13.5* RBC-3.08* HGB-9.5* HCT-28.7* MCV-93 MCH-30.8 MCHC-33.1 RDW-21.0* RDWSD-58.8* ___ 09:28PM PLT COUNT-357 ___ 09:28PM ___ PTT-30.2 ___ ___ 03:40PM WBC-11.1* RBC-2.76* HGB-8.7* HCT-25.5* MCV-92 MCH-31.5 MCHC-34.1 RDW-20.5* RDWSD-57.5* ___ 03:40PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-7 EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-8.66* AbsLymp-1.67 AbsMono-0.78 AbsEos-0.00* AbsBaso-0.00* ___ 03:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 03:40PM PLT SMR-NORMAL PLT COUNT-318 ___ 01:23PM LACTATE-1.3 ___ 08:04AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:04AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-2* PH-6.0 LEUK-MOD* ___ 08:04AM URINE RBC-42* WBC-35* BACTERIA-NONE YEAST-NONE EPI-0 ___ 08:04AM URINE MUCOUS-RARE* ___ 07:03AM GLUCOSE-117* UREA N-19 CREAT-0.7 SODIUM-134 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15 ___ 07:03AM ALT(SGPT)-21 AST(SGOT)-66* LD(LDH)-656* ALK PHOS-67 TOT BILI-5.8* DIR BILI-1.0* INDIR BIL-4.8 ___ 07:03AM cTropnT-<0.01 proBNP-655* ___ 07:03AM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.1 URIC ACID-5.5 ___ 07:03AM HAPTOGLOB-36 ___ 07:03AM WBC-12.0* RBC-2.89* HGB-9.0* HCT-26.5* MCV-92# MCH-31.1 MCHC-34.0 RDW-19.3* RDWSD-56.6* ___ 07:03AM NEUTS-76* BANDS-1 LYMPHS-16* MONOS-5 EOS-0 BASOS-0 ___ MYELOS-2* AbsNeut-9.24* AbsLymp-1.92 AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00* ___ 07:03AM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+* ___ 07:03AM PLT SMR-NORMAL PLT COUNT-331 ___ 07:03AM ___ PTT-23.6* ___ DISCHARGE LABS: =============================================================== ___ 12:00AM BLOOD WBC-5.2# RBC-2.77*# Hgb-8.4*# Hct-25.8*# MCV-93 MCH-30.3 MCHC-32.6 RDW-17.8* RDWSD-57.4* Plt ___ ___ 12:00AM BLOOD Neuts-62 Bands-2 Lymphs-15* Monos-10 Eos-4 Baso-7* ___ Myelos-0 AbsNeut-1.60 AbsLymp-0.38* AbsMono-0.25 AbsEos-0.10 AbsBaso-0.18* ___ 12:00AM BLOOD Plt ___ ___ 12:00AM BLOOD ___ ___ 12:00AM BLOOD Glucose-87 UreaN-11 Creat-0.5 Na-138 K-3.9 Cl-99 HCO3-26 AnGap-13 ___ 12:00AM BLOOD ALT-9 AST-12 AlkPhos-115* TotBili-0.5 ___ 12:00AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1 IMAGING/STUDIES: =============================================================== ___: NCHCT:IMPRESSION: No acute intracranial process. Complete opacification of the left frontal sinus and ethmoid air cells. Given demineralized left ethmoid septa and soft tissue extension into the left orbit, underlying mass lesion with secondary obstruction would be of concern. A mucocele is less likely given lack of expansion. Dedicated nonurgent MRI suggested. ___ CTA:IMPRESSION: 1. Left upper lobe segmental pulmonary embolism. Questionable left lower lobe subsegmental pulmonary embolism which is likely real given slight hypoenhancement of the lung supplied by this branch which could represent component of infarct. No right heart strain. 2. Rib fractures at the costovertebral junctions of the left eighth and ninth ribs posteriorly to be correlated clinically regarding acuity as these may be recent in nature. 3. Evidence of metastatic disease in the partially visualized abdomen. ___: CT C-Spine: Degenerative changes without fracture or acute malalignment. ___: Hip XR: Acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. ___: ECHO:IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mildly dilated aortic arch Mild mitral regurgitation. Moderate pulmonary hypertension. ___: CT 1. No acute intracranial process. 2. Re-demonstration of complete opacification of the left frontal sinus and ethmoid air cells with apparent demineralization of the left ethmoid septa and extension into the left orbit, again concerning for underlying mass lesion. Nonurgent MRI is again recommended for further evaluation. 1. No infectious source identified in the abdomen and pelvis. 2. Upper abdominal lymphadenopathy, the largest conglomerate measuring up to 2.6 x 2.4 cm in the gastrohepatic ligament, compatible with provided history of lymphoma. 3. Multiple hypoenhancing hepatic masses, the largest measuring up to 5.5 x 4.4 cm, likely representing lymphomatous involvement. 4. Signs of excess fluid including small bilateral pleural effusions, trace pelvic free fluid, and mild body wall edema. 1. Oblique, mildly displaced left femoral periprosthetic fracture is re-demonstrated. Asymmetry of the muscle bulk surrounding the periprosthetic fracture suggesting a component of intramuscular hematoma, however no large hematoma is seen separate to this region. No retroperitoneal hematoma. 2. Please refer to CT of the abdomen and pelvis performed with contrast earlier on the same day for additional details of intra pelvic structures. 1. Oblique, mildly displaced left femoral periprosthetic fracture is re-demonstrated. Asymmetry of the muscle bulk surrounding the periprosthetic fracture suggesting a component of intramuscular hematoma, however no large hematoma is seen separate to this region. No retroperitoneal hematoma. 2. Please refer to CT of the abdomen and pelvis performed with contrast earlier on the same day for additional details of intra pelvic structures. ___: CT Chest: 1. Persistent small bilateral non hemorrhagic pleural effusions, similar to ___ chest radiograph given difference of technique, though increased since ___ chest CTA 2. Bibasilar pulmonary opacities most consistent with compressive atelectasis. Clinical correlation for superimposed infection is recommended. 3. Small airways disease with bronchial wall thickening. No mucus plugging. 4. 0.3 cm right upper lobe pulmonary nodule, unchanged since ___. 5. Innumerable hepatic masses, better characterized on CT abdomen/pelvis from ___, most consistent with lymphomatous involvement. ___ Video Swallow: IMPRESSION: Transient penetration with thin and nectar liquids. No aspiration. ___ FEMUR (AP & LAT) LEFT: IMPRESSION: Unchanged periprosthetic left femur fracture. Degenerative changes in the left knee. ___ LLE Ultrasound: IMPRESSION: -No evidence of deep venous thrombosis in the left lower extremity veins. -2 small fluid collections in the popliteal fossa are likely continuous with each other, likely representing a ruptured ___ cyst. ___ ECHO: Conclusions There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the left ventricular cavity appears smaller, c/w underfilling. Other findings are similar. ___ MRI brain with and without contrast: IMPRESSION: 1. The imaging findings are overall concerning for central pontine myelinolysis. Differential considerations subacute infarct or other demyelinating process is considered much less likely given the symmetric bilateral appearance of the abnormality with classic sparing of the peripheral pons and cortical spinal tracts. 2. Scattered foci of gradient echo susceptibility artifact, compatible with prior micro hemorrhages in a distribution suggestive of underlying amyloid angiopathy. 3. Prominent periventricular subcortical T2/FLAIR white matter hyperintensities the subcortical and periventricular white matter are nonspecific and nonenhancing, commonly seen in setting of chronic microangiopathy in a patient of this age. 4. No evidence of abnormal enhancement to suggest intracranial metastatic disease at this time. 5. Additional findings described above. ___ CTA CHEST: IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level or aortic abnormality. Assessment of subsegmental pulmonary arteries is limited due to respiratory motion artifact. 2. Interval resolution of pleural effusions. 3. Enlarged right and left main pulmonary arteries suggests pulmonary arterial hypertension. 4. Known hepatic masses are better assessed on prior CT abdomen and pelvis dated ___ due to timing of the contrast bolus. ___ FEMUR (AP & LAT) LEFT IMPRESSION: Compared to the prior study there has been no significant interval change. The left total hip arthroplasty is again visualized. A periprosthetic oblique fracture through the proximal feet femoral diaphysis is again noted. This is unchanged in alignment compared to the prior study. No callus formation is identified. No periprosthetic loosening is visualized. Degenerative changes are again visualized in the left knee. ___ MRI without contrast: IMPRESSION: 1. Previously identified periprosthetic fracture appears slightly more distracted than prior CT on ___ but likely similar to x-ray from ___. 2. There is a large fluid collection posterior to the left total-hip replacement primarily centered deep to the gluteus maximus muscle with apparent extension to the neck of the femoral component and insinuating between the fracture fragment and the prosthesis. 3. Ovoid lesion centered within the proximal vastus intermedius/vastus lateralis demonstrating internal STIR heterogeneity with central T1 hypointensity but peripheral T1 hyperintensity most likely represents a hematoma. Follow-up imaging should be performed to ensure resolution. 4. There is a small amount of fluid deep to the hamstring insertion at the Left ischial tuberosity which may represent sequela of partial tearing and/or calcific tendinitis as seen on prior CT RECOMMENDATION: ___ week follow-up MRI to ensure resolution of presumed hematoma in the proximal thigh. PATHOLOGY: ================ ___ CSF cytology report: No malignant cells. ___ CSF Flow cytometry INTERPRETATION: Non-diagnostic study. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells for analysis. Correlation with clinical, morphologic (see separate cytology report ___-___) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. MICRO: ========================================================== ___ 12:15 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 1710 ON ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ (___) @ ___, ___. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. ___ 8:23 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ Enterovirus Culture (Final ___: No Enterovirus isolated. ___ 8:23 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ___ 5:28 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 12:15 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 1710 ON ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ (___) @ ___, ___. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. Brief Hospital Course: Ms. ___ is a ___ woman with a history of COPD, hypothyroidism, and hemochromatosis who presented as a transfer from an outside hospitalwith a new left femoral fracture, as well as fatigue, nausea, anemia, and new liver lesions on outside hospital abdominal CT, now biopsy-proven diffuse large B-cell lymphoma. She also had new PEs (now on Lovenox). She started treatment for DLBCL with mini R-CHOP. Her course was complicated by persistently elevated bilirubin (likely due to liver disease and hemolysis), warm hemolytic anemia (on Rituxan), steroid psychosis/delirium, and hypoxia that ultimately required a stay in the FICU. Her mental status ultimately improved and she was weaned off oxygen. On the floor she continued to improve, worked with ___ and was deemed stable to continue chemo. She is now being discharged on C3D10 of R-mini-CHOP. ACUTE ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ # Diffuse Large B- Cell Lymphoma: During an outpatient workup for anemia, a CT scan that showed numerous liver lesions. Biopsies show high-grade diffuse large B-cell lymphoma with high nuclear proliferation index (>90%). She was initially started on treatment with only cyclophosphamide on ___ and Solu-Medrol on ___ and ___ due to an elevated bilirubin. The patient then developed severe delirium and hypoxia from volume overload and was transferred to the FICU on ___. While in the ICU the patient briefly required BIPAP support and improved with diuresis. Her delirium improved with the discontinuation of dilaudid and olanzapine 10 mg twice per day. Following discharge from the ICU she subsequently received dose-reduced vincristine and Adriamycin on ___ and Rituxan on ___. Over the course of the next week the patient was weaned to room air, her mental status returned to baseline, and she began to work with ___. Per the recommendations of her primary oncologist, it was decided to start her next cycle of chemo inpatient. On ___ she received R-CHOP w/ a dose-reduced prednisone regimen. She started a cycle of R-mini-chop on ___, which she tolerated well. She started G-CSF on ___ and is being continued on it upon discharge. # Pulmonary embolism # COPD # Hypoxia (resolved) On admission, CTA was notable for new segmental and subsegmental PEs. She was started on therapeutic Lovenox. The patient was stable on ___ NC/facemask and intermittently off of additional oxygen. After receiving 4L of IVF during prep for her chemo, she developed new onset increasing tachypnea, hypoxia and tachycardia to the 140s. Her hypoxia and tachycardia significantly improved in the ICU with diuresis. The patient progressively was able to be weaned off of O2 on the ___ service, and returned to her baseline respiratory status. She has been maintained on therapeutic Lovenox and will be discharged on Lovenox. # Femoral fracture: The patient initially presented to an OSH w/ a left femoral fracture in the setting of a mechanical fall. X-rays showed an acute periprosthetic fracture at the midportion of the femoral stem of the left hip arthroplasty. Orthopedic surgery determined she could have surgery if desired but non-operative management is fine as well. The pt did not wish to have surgery. The patient received pain control initially with Tylenol, oxycodone, and morphine with good effect. She worked with physical therapy when she returned from the ICU and was reevaluated by ortho who recommended no interventions and ___ until discharge to an acute rehabilitation facility. She will continue getting ___ at her rehab facility. # Urinary retention: Pt was not requiring a foley prior to this admission. Foley has been present for almost entire admission; several voiding trials during the week prior to discharge were unsuccessful. Discontinued olanzapine, which was felt to be the only drug contributing to urinary retention. She is being discharged with a foley catheter to rehab. This will be a transitional issue for the rehab facility to work on, and if the pt is unable to void, she should follow up with outpatient urology. # Hemolytic anemia: The patient was noted to have an elevated indirect bilirubin. Labs showed a warm hemolytic anemia with Coombs (+), anti-C3 (+), and haptoglobin <10. Her LFTs and LDH remained stable. An eluate test was negative. Given that she was receiving Rituxan as part of her DLBCL regimen, there was no need for additional treatment. It was suspected that this was secondary to the patient's hematologic malignancy. # Psychosis (resolved: The patient became psychotic/delirious after receiving high dose steroids on ___, ultimately requiring ICU transfer due to a lack of response to Haldol and increased nursing requirements. She was started on standing Olanzapine and Dilaudid in the ICU, which ultimately led to better control of agitation and pain. However, she became non-responsive to questions and commands. On transfer back to the ___ service, her mental status progressively improved once Dilaudid was discontinued. Of note, the patient underwent an EEG that showed epileptiform discharges, but no organized seizure activity. When she underwent her second cycle of chemotherapy w/ R-CHOP her prednisone dose was modified to 4mg PO QD x3 days and she was started on Olanzapine 10mg PO QD for 3 days for prophylaxis of steroid induced delirium. This regimen worked and she underwent her second round of chemo without issue. She was then continued on Olanzapine 2.5mg thereafter. Olanzapine was eventually discontinued several days prior to discharge(due to concern for urinary retention), and the pt did not have any further sx of psychosis or AMS once off the olanzapine. # ?GPC bacteremia (determined to be contaminant). Labs in the ICU showed a lactic acidosis and new leukocytosis. She was started on Cefepime and Vancomycin. 1 culture bottle grew coag negative staph and corynebacterium, which was deemed to likely be a contaminant. She received a course of linezolid for growth of GPC in the setting of vancomycin. Ultimately, she was transitioned off of antibiotics on the ___ service without incident. CHRONIC ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ # Tachycardia Baseline is 100-120s, was diagnosed w/sinus tachycardia as outpatient and put on metoprolol XL 50mg PO. Also had new PEs on admission w/ assoc tachycardia. EKGs showed NSR. Cardiology was consulted and felt this is consistent with atrial tachycardia; they agreed on continuing metoprolol. Her dose was increased to 100mg daily. #Hypothyroidism: The patient was maintained on her home levothyroxine. TRANSITIONAL ISSUES = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ []Will need follow up w/ Ortho w/Dr. ___ ___ -- this is scheduled for ___ []Will need CBCs to monitor her blood counts. Please check them on ___ and ___ and fax them to ___ to Dr. ___ for monitoring. []Will need Oncology follow up w/ Dr. ___ to discuss further treatment -- this is scheduled for ___ []Please monitor platelets while the pt is on lovenox. She is on this for her pulmonary emboli. Should her plts drop to between ___, please reduce the dose in half (from 60bid to 30bid). If plts drop below 30K, please stop lovenox. DNR/DNI Contact: ___ (daughter) ___, ___ (daughter, current location of husband, ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Montelukast 10 mg PO DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. DiphenhydrAMINE ___ mg PO QHS:PRN insomnia 7. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea Discharge Medications: 1. Acyclovir 400 mg PO TID 2. Atovaquone Suspension 1500 mg PO DAILY 3. Enoxaparin Sodium 60 mg SC Q12H 4. Filgrastim-sndz 300 mcg SC Q24H RX *filgrastim [Neupogen] 300 mcg/0.5 mL 1 syringe SC q24 Disp #*5 Syringe Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD Q24H 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Multivitamins 1 TAB PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 12. Levothyroxine Sodium 50 mcg PO DAILY 13. HELD- Montelukast 10 mg PO DAILY This medication was held. Do not restart ___ until your oncologist or PCP determines it is ok to take it again. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Femur fracture Diffuse large B cell lymphoma Pulmonary emboli Secondary: Steroid psychosis/delirium Hypoxemic respiratory failure Warm agglutinin hemolytic anemia Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why was I in the hospital? - You fell at home and were found to have a broken hip - We found out that you had blood clots in your lungs - You were recently diagnosed with lymphoma and needed to begin treatment What was done while I was in the hospital? - You were seen by the orthopedic surgeons who determined that you did not need surgery for your broken hip. - You were started on blood thinners for the blood clots in your lungs. - You received chemotherapy to treat your lymphoma. - During the chemotherapy, you became very confused; this was likely because of the steroids and pain medications you were being given. - You were moved to the ICU for several days because of your confusion and difficulty breathing - In the ICU you received medication to help you urinate, which helped to improve your breathing - Your confusion and breathing improved enough for you to be moved back to the general lymphoma floor. - While on the general floor, your cell counts came back up. - We gave you a second cycle of chemotherapy which you tolerated well. - You worked with physical therapy and became strong enough to go to an acute rehab facility. What should I do when leave the hospital? - You should work with physical therapy at the rehabilitation facility - You should have your blood counts checked about every three days at the rehabilitation facility - You should take all of your medications as prescribed, especially the medications preventing bacterial and viral infections - Please attend your follow-up appointment with your oncologist to discuss your future treatment plan - If you have fevers, chills, feel more confused, have problems breathing, chest pain, or generally feel unwell, please call your oncologist Sincerely, Your ___ Treatment Team Followup Instructions: ___

10049897-DS-6

DS

2176-06-10 00:00:00

2176-06-13 16:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Left trochanteric femoral nail History of Present Illness: ___ healthy male here with left hip pain s/p fall on bicycle. Nonambulatory at the scene. Brought to ___, found to have left femoral neck fracture. Transferred here. Reports history of hip dislocation ___ years ago though he does not remember which side. No other injury. Has not taken any PO today. Past Medical History: OA Social History: ___ Family History: NC Physical Exam: Vitals: O2 sat 88-91% on RA, other vital signs stable Gen: comfortable, NAD LLE: Incision c/d/i, no erythema, induration, drainage SILT in DP/SP/S/S/T distributions ___ WWP Pertinent Results: ___ Left hip films: Intertrochanteric fracture of the left femur. ___ 07:15AM BLOOD Hct-31.0* ___ 05:38AM BLOOD Glucose-143* UreaN-17 Creat-0.8 Na-137 K-4.2 Cl-102 HCO3-28 AnGap-11 ___ 05:38AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8 ___ Chest (AP/Lat): New acute fracture in the left posterior eight rib with an associated small pleural effusion and atelectasis. 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 left intertrochanteric fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for operative fixation with a left trochanteric femoral nail, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after 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 perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. Of note, the patient began to complain of left sided-rib pain while working with ___ on POD#2. A chest x-ray was obtained that showed a left posterior fracture of the 8th rib. It was also noted that the patient's O2 sats were in the high 80's to low 90's. He was intermittently requiring oxgen. On POD#3, the patient continued to have O2 saturations in the low 90's on room air, likely due to poor inspiratory effort from rib fractures. He expressed that he wanted to go home. It discussed with him that the orthopaedic team would prefer that hestay in the hospital for another night for close monitoring and until his O2 sats improve. Mr. ___ fully understood the teams wishes but chose to leave against medical advice. He was informed that he should to return to the emergency room if his respiratory status changes. At the time of discharge the patient was afebrile, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: None Discharge Medications: 1. rolling walker dx left hip fx s/p orif px good 13 months 2. Acetaminophen 650 mg PO Q6H 3. Calcium Carbonate 1250 mg PO TID 4. Docusate Sodium 100 mg PO BID Please take while taking prescription pain medication to prevent/treat constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*0 5. Enoxaparin Sodium 40 mg SC QPM Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe Refills:*0 6. Multivitamins 1 CAP PO DAILY 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*100 Tablet Refills:*0 8. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left intertrochanteric femur 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: 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: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Left lower extremity: weight bearing as tolerated Physical Therapy: Left lower extremity: weight bearing as tolerated Treatments Frequency: Wound Care Wound: Surgical incision Location: Left femur Dressing: Inspect incision and change dressing daily with dry gauze. If non-draining, can leave open to air. Followup Instructions: ___

10050755-DS-12

DS

2132-10-19 00:00:00

2132-10-23 19:38:00

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 arm weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx of PD, HTN, HLD who was sitting at the lunch table when he had the sudden onset of right sided arm weakness (last seen normal 11am). He was eating with a spoon when he suddenly stopped using his right hand. He used his left hand to hold his spoon and his left hand to drink from his cup. He even went as far as to pick up his right hand with his left hand indicating that it was markedly weak. Per his daughter at the bedside, he used to see a neurologist (Dr ___ in ___ but quit seeing him and now gets his ___ medications from his PCP. At baseline, he is able to walk with a two person assist and does not pay bills. He is able to feed himself some of the time, some of the time his family feeds him. He is able to recognize and converse with his family. He has never had a stroke or any acute neurological deficit in the past. Unable to obtain a ROS as the patient is minimally verbal in ___ only. Per his daughter, he has not complained of any pain, confusion, weakness, or numbness recently. Past Medical History: PD HTN HTL chronic hearing loss requiring hearing aids Social History: ___ Family History: Per his daughter, no family history of strokes/seizures. Physical Exam: - Vitals: 98.9 52 133/49 18 100% RA - General: drowsy, awake, ___ speaking only, very hard of hearing - HEENT: NC/AT - Neck: Supple, no carotid bruits appreciated. No nuchal rigidity - Pulmonary: CTABL - Cardiac: RRR, no murmurs - Abdomen: soft, nontender, nondistended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. NEURO EXAM: - Mental Status: decreased verbal output, dysarthria, per his daughter minimal verbal output with confused speech (A&O to name only). Able to follow simple commands with lots of prompting (hold arms up, squeeze hand, smile). Does not respond to more complex commands. - Cranial Nerves: PERRL 5 to 3mm and brisk. Much prompting for EOM. Does bury sclera to the left. Does not bury to the right. Decreased up gaze. Down gaze intact. No obvious nystagmus. Right facial droop with activation. Hearing intact to loud voice in ear only. - Motor: Decreased tone in the right arm. Increased tone in BLE and left arm. Decreased bulk throughout. Right pronation with drift. Able to hold arm antigravity, drifts to gurney in ___. No adventitious movements such as tremor or asterixis noted. Delt Bic Tri FE IP Quad Ham TA ___ L 5 ___ 4 R 4 5- ___ ** unable to test BLE secondary to comprehension difficulties. - Sensory: moves all extremities to light pinch. - DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was extensor in the right toe, flexor on the left. Pertinent Results: ___ 10:40AM BLOOD WBC-4.5 RBC-3.61* Hgb-12.0* Hct-33.6* MCV-93 MCH-33.1* MCHC-35.5* RDW-13.5 Plt ___ ___ 05:29AM BLOOD Neuts-71.4* ___ Monos-7.0 Eos-2.9 Baso-0.3 ___ 10:40AM BLOOD Plt ___ ___ 10:40AM BLOOD Glucose-102* UreaN-20 Creat-1.2 Na-140 K-3.8 Cl-105 HCO3-25 AnGap-14 ___ 10:40AM BLOOD CK(CPK)-78 ___ 05:29AM BLOOD ALT-13 AST-18 AlkPhos-68 TotBili-0.4 ___ 05:29AM BLOOD Lipase-37 ___ 10:40AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 Cholest-157 ___ 09:51AM BLOOD %HbA1c-5.6 eAG-114 ___ 10:40AM BLOOD Triglyc-92 HDL-53 CHOL/HD-3.0 LDLcalc-86 ___ 10:40AM BLOOD TSH-1.3 ___ 05:29AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Head CT ___ No acute intracranial process. Brain MRI ___. Multiple small acute infarcts within the left frontal and left parietal lobes, most of which are cortically based , suggesting embolic etiology. 2. Multiple chronic infarcts. Extensive supratentorial white matter and pontine signal abnormalities, likely sequela of chronic small vessel ischemic disease. 3. Chronic microhemorrhages (likely hypertensive) versus mineralization in bilateral basal ganglia and right thalamus. Possible chronic blood products in the area of the left superior parietal chronic infarct, versus artifact. Carotid ultrasound ___ Less than 40% stenoses at bilateral internal carotid arteries due to mild heterogeneous plaque. Echocardiogram ___ No cardiac source of embolism identified. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction with elevated PCWP. Mild aortic and mitral regurgitation. Pulmonary hypertension. Brief Hospital Course: Mr ___ was admitted for acute onset speech difficulty and right arm weakness. He had an MRI that demonstrated multiple punctate areas of restricted diffusion in the left frontal/parietal region. He had a carotid ultrasound that did not demonstrate significant stenosis. He had an echocardiogram that did not demonstrate evidence of a cardioembolic source. The etiology of the stroke at the time of discharge was unclear but it could be related to an slow flow in the distal vessels or an irregular heart rhythm leading to cardioembolic infarct. (although there were no irregularities noted on telemetry during his admission). He had an echocardiogram that showed some diastolic dysfunction but no other abnormalities to explain a cardiac embolic source. He was evaluated by speech and swallow, and they felt that he was safe to take thickened liquids and purees. He was restarted on his home medications at that time. He was evaluated by physical therapy and occupational therapy. Both teams felt that he could benefit from ___ rehabilitation. However, in extensive discussions with the family, they felt that he would be more agitated in an unfamiliar setting, and they did not want that for him. Therefore, they were trained in specific cares, and he was discharged home with outpatient physical therapy and occupational therapy. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes – () 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)? (x) Yes (LDL = 76) - () No 5. Intensive statin therapy administered? (x) Yes - () No 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 9. Discharged on statin therapy? (x) Yes - () No 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. Venlafaxine XR 75 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Vitamin B Complex 1 CAP PO DAILY 4. Carbidopa-Levodopa (___) 1 TAB PO TID 5. Zonisamide 100 mg PO BID 6. Lisinopril 10 mg PO DAILY 7. Creon 12 1 CAP PO TID W/MEALS 8. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24 hour transdermal daily 9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 11. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Creon 12 1 CAP PO TID W/MEALS 5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 6. Lisinopril 10 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Vitamin B Complex 1 CAP PO DAILY 9. Zonisamide 100 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24 hour transdermal daily 12. Vitamin D 800 UNIT PO DAILY 13. Outpatient Occupational Therapy Dx: acute ischemic stroke. Please evaluate and treat. 14. Outpatient Physical Therapy Dx: acute ischemic stroke. Please evaluate and treat. 15. 3:1 Commode Diagnosis: ischemic stroke (434.91), parkinsons disease (332) Duration: lifetime Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute ischemic stroke 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: Dear Mr ___, You were hospitalized due to symptoms of speech difficulty and right arm weakness resulting from an acute ischemic stroke, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Hypertension We are changing your medications as follows: Starting Aspirin 81mg daily 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: ___

10050755-DS-13

DS

2134-01-29 00:00:00

2134-01-29 22:09:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: altered mental status, right arm weakness Major Surgical or Invasive Procedure: ___ PEG placement by ___ History of Present Illness: The patient is an ___ year-old ___ speaking man with a history of ___ disease, left hemisphere ischemic strokes ___, HTN and HLD who presents to the ED with worsening mental status and right arm weakness. FROM NEUROLOGY NOTE AND DAUGHTER Per the patient's daughter, Mr. ___ has been unwell since for the last two weeks and was seen by his PCP and started on Levaquin for community acquired pneumonia. He became more confused and agitated at home and speaking barely any words (not far from his baseline of a man of few words). His family found it difficult to care from him at home and he was barely able to make transfers with 2 person assist. He was not eating well, but somehow family was able to coax him to take his meds. Yesterday, while cleaning the patient and attempting to bathe him they noticed he was not moving his right arm. His daughter is not exactly sure if this came on suddenly or gradually with the onset of the pneumonia. In the ED, initial vital signs were: 98.3 80 137/47 16 96% RA - Exam was notable for: - Labs were notable for: white cell count of 14.8, lactate of 2.5, creatinine of 1.6 and negative tox screen. - Imaging: CT HEAD: Extensive chronic microvascular ischemic disease and chronic infarcts. There is no intracranial hemorrhage. Loss of gray-white differentiation in the superior left precentral gyrus seen on a single slice (02:30) may artifactual or represent acute ischemia. MRI is more sensitive for detection of an acute ischemic event if there is high clinical suspicion. There is an air-fluid level in the right maxillary sinus CT NECK:The left vertebral artery is dominant. There is moderate calcified and noncalcified plaque in the left carotid bulb and proximal left internal carotid artery. There is no evidence of dissection, occlusion, or flow limiting stenosis involving the internal carotid and vertebral arteries. Extensive cavernous carotid calcifications are present. Tributaries of circle ___ are patent. There is no large aneurysm. CXR:Lower lung consolidations concerning for pneumonia versus aspiration, new from prior. - The patient was given: ___ 19:04 IVF 1000 mL NS 1000 mL ___ ___ 20:48 IV CeftriaXONE 1 gm ___ ___ 21:43 IV Azithromycin 500 mg ___ ___ 21:44 IVF 1000 mL NS ___ Started 75 mL/hr ___ 21:59 PR Aspirin 600 mg An NG tube was placed as the patient was so somnolent and altered. - Consults: Neurology recommended urgent MRI brain Upon arrival to the floor, patient is somnolent but groans when spoken to. Past Medical History: - ___ disease - left hemisphere ischemic strokes - watershed area btw ACA/MCA territory ___ - Detrusor over activity - HTN - HLD - Bilateral hearing loss, wears hearing aids Social History: ___ Family History: Per his daughter, no family history of strokes/seizures. Physical Exam: ADMISSION EXAM: VITALS: 98.1 138 / 43 61 18 96 GENERAL: Somnolent, and wakes up to name, otherwise not responding to any questions HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Bilateral rhonchi at bases ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. NEUROLOGIC: Not co-operative with neuro exam. Left upper extremity with increased tone compared to right. Withdraws to pain in all four extremities. Normal biceps/triceps/knee jerk reflexes DISCHARGE EXAM: Objective: Tmax 99.6 112-140/ 44-57 68 24 100% 1.5L. General: Opens right eye to command, moves extremities with stimulation. Non-verbal, mildly tachypenic, no cyanosis. Increased respiratory muscle use in the neck accessory. HEENT: NC/AT. No scleral icterus, conjunctival pallor Cardiac: RRR, S1, S2. No extra sounds Lungs: diffuse wheezes and crackles b/l Abdomen: Soft. NTND Extremities: Warm, well perfused, no cyanosis. Emaciated. Neurologic: Difficult to assess. Rigid, L > R. Contracted. Withdraws to pain and grossly moves all extremities. Pertinent Results: ADMISSION LABS: ___ 05:10PM BLOOD WBC-14.7*# RBC-3.60* Hgb-11.2* Hct-35.4* MCV-98 MCH-31.1 MCHC-31.6*# RDW-13.2 RDWSD-46.4* Plt ___ ___ 05:10PM BLOOD Neuts-86.4* Lymphs-7.1* Monos-5.2 Eos-0.5* Baso-0.3 Im ___ AbsNeut-12.97* AbsLymp-1.07* AbsMono-0.78 AbsEos-0.07 AbsBaso-0.04 ___ 05:10PM BLOOD ___ PTT-27.3 ___ ___ 05:10PM BLOOD Glucose-127* UreaN-62* Creat-1.6* Na-147* K-3.7 Cl-109* HCO3-26 AnGap-16 ___ 05:10PM BLOOD ALT-7 AST-30 AlkPhos-87 TotBili-0.6 ___ 05:10PM BLOOD Lipase-49 ___ 05:10PM BLOOD Albumin-3.2* ___ 02:51AM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.1 Mg-1.9 ___ 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:30PM BLOOD Lactate-2.5* ___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 09:00PM URINE RBC-60* WBC-17* Bacteri-FEW Yeast-NONE Epi-0 ___ 02:51AM URINE Hours-RANDOM UreaN-1139 Creat-83 Na-82 K-46 Cl-84 ___ 02:51AM URINE Osmolal-806 ___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG PERTINENT LABS: ___ 05:55AM BLOOD calTIBC-114* Hapto-257* Ferritn-840* TRF-88* ___ 05:22AM BLOOD Triglyc-77 ___ 05:28AM BLOOD TSH-1.2 DISCHARGE LABS: MICROBIOLOGY: ___ BLOOD CULTURE X2: NO GROWTH (FINAL) ___ URINE CULTURE: NO GROWTH (FINAL) ___ BLOOD CULTURE X2: NO GROWTH (FINAL) STUDIES: ___ CXR: IMPRESSION: Lower lung consolidations concerning for pneumonia versus aspiration, new from prior. ___ CTA HEAD & NECK: 1. Patent circle of ___. 2. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. 3. New area of hypoattenuation in the left precentral gyrus, which may represent a chronic infarction. Unchanged chronic infarctions in the bilateral occipital, left frontal, and left parietal lobes with probable sequela of severe chronic small vessel ischemic disease. MRI may be obtained for further evaluation. 4. Paranasal sinus disease. 5. Multiple pulmonary nodules, the largest measuring 3 mm in the right lower lobe. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. These guidelines are based upon ___ criteria. ___ BRAIN MRI: 1. Please note the study is substantially degraded by motion. 2. Multiple small acute infarctions in the left MCA and PCA territory. No definite associated hemorrhage, although markedly limited in evaluation given motion artifact. 3. Confluent background of white matter signal abnormality, likely secondary to extensive chronic microvascular ischemic changes. ___ Imaging CHEST (PORTABLE AP) : Cardiomediastinal silhouette is within normal limits. There is again seen an area of consolidation within the right upper lobe which appears more confluent. Additional opacities at the lung bases are unchanged. No pneumothoraces are seen. ___ Imaging CHEST (PORTABLE AP) Heart size and mediastinum are unchanged. There is interval progression of multifocal consolidations in the right lung, substantial as well as unchanged or minimally worse appearance of the left middle lower lung consolidations. The findings are concerning for multifocal infection. >> DISCHARGE LABS: ___ 05:56AM BLOOD WBC-5.9 RBC-2.61* Hgb-8.0* Hct-25.7* MCV-99* MCH-30.7 MCHC-31.1* RDW-15.0 RDWSD-53.3* Plt ___ ___ 06:36AM BLOOD ___ ___ 05:56AM BLOOD Glucose-130* UreaN-28* Creat-0.8 Na-137 K-4.9 Cl-106 HCO3-24 AnGap-12 . >> MICROBIOLOGY ; __________________________________________________________ ___ 4:43 am URINE Source: ___. URINE CULTURE (Pending): __________________________________________________________ ___ 12:20 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 9:31 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:49 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 3:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 9:18 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ ___ ON ___ @ 13:40. GRAM POSITIVE COCCI IN CLUSTERS. Brief Hospital Course: Mr. ___ is an ___ year-old ___ speaking man with a history of ___ disease, left hemisphere ischemic strokes ___, HTN and HLD who presented to the ED with worsening mental status and right arm weakness in the setting of a persistent pneumonia. . >> ACTIVE ISSUES: # Acute Encephalopathy: Patient initially was hospitalized for right sided weakness and worsening mental status. Patient was found to be minimally verbal, and likely thought to have multifactorial etiology for symptoms, including multifocal pneumonia, multifocal CVA seen on brain MRI on ___, and also hypernatremia. Furthermore, patient has underlying ___ disease. Patient required initially mits and these were then discontinued and patient had likely new baseline mental status after treatment for the above. Patient was treated for a second pneumonia, and patient's mental status was minimally verbal, favoring his left side, and intermittent tracking. . # Multifocal Cerbrovascular Event: Patient initially was found to have right sided weakness, and imaging revealed a multifocal CVA in MCA/PCA watershed distribution similar to prior. He continued to receive aspirin, Plavix and atorvastatin with plan for 3 months per neurology stroke. Patient's outpatient neurologist was contacted, and likely has had prior CVAs and likely is responsible for patient's Parkinsons. Patient then . # Pneumonia. Patient initially presented with community acquired pneumonia after failing outpatient levofloxacin treatment. Patient s/p treatment with ceftriaxone and azithromycin for CAP. However, during hospitalization and mental status, patient continued to have aspiration. Patient had an aspiration event leading to an acute hypoxia on ___, and patient then developed a fever in ___. Patient then started on vancomycin and cefepime for completion of true HCAP course. Patient finished IV antibiotics on ___, and then to continue augmentin x 3 days for continued aspiriation coverage. It was discussed with patient's family several times during hospital stay, that likely G-tube is not a prevention for an aspiration type event, and there is a high likelihood for recurrent aspiration in the future. . # Severe Malnutrition: Patient intermittently received peripheral parenteral nutrition x 4 days prior to Dobhoff being placed on ___. Patient had previously had enteral access attempts, and finally PEG tube placed on ___. Patient has been getting tube feeds, and has been followed by nutrition closely. It was discussed repeatedly that aspiration events are not prevented with G-tube placement. Patient was tolerating tube feeds well. . # Anemia: Normocytic, iron studies concerning for anemia of chronic disease. Hemoglobin was trended during hospital stay without obvious signs of bleeding. . # Acute Kidney Injury: patient's creatinine was trended during hospital stay and remained at baseline. . # ___ Disease: Patient is currently on sinemet, this was originally changed to dissolvable carbidopa-levodopa, and Effexor and zonisamide for tremor were discontinued given non enteral access and uncertain benefit. Patient's neurologist was contacted, Dr. ___ discussion regarding potential prognosis given underlying ___ Disease with no worsening status. Patient was restarted on sinemet through G-tube without difficulty. Neurologic exam as above. . #HTN: Lisinopril was held and not restarted, as it was not necessary. . #HLD: Atorvastatin changed to 80 mg qd given new stroke. . TRANSITIONAL ISSUES: # Aspiration Pneumonia: Patient now finishing course of Vancomycin / Cefepime /Flagyl, and transitioned to Augmentin x 3 days for continued treatment until ___. Would consider repeat chest imaging as an outpatient in ___ weeks pending clinical status for resolution # G-tube: Patient's G-tube functioning properly, patient to be contacted by Interventional radiology department regarding further maintenance and changing of tube # Dyspnea: Discussed with family that patient would most likely benefit from low dose morphine for apparent dyspnea, to be further considered as outpatient. # Pulmonary Nodules: Multiple pulmonary nodules, the largest measuring 3 mm in the right lower lobe. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. # Stroke: Patient to be continued on Plavix 75 mg/atorva 80 mg until at least ___ # Aspiration: Patient remains NPO on aspiration precautions. # ___ Disease: Patient to be continued on sinemet as outpatient, with f/u with Dr. ___ # Goals of Care: It was discussed several times likelihood for recovery back to baseline quite low, please continue to readdress as outpatient. Patient remains full code. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 10 mg PO QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Creon 12 1 CAP PO TID W/MEALS 5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 6. Lisinopril 10 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Vitamin B Complex 1 CAP PO DAILY 9. Zonisamide 100 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24 hour transdermal daily 12. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Atorvastatin 80 mg NG QPM 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 5. Clopidogrel 75 mg NG DAILY 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea/wheeze 7. Bisacodyl 10 mg PR QHS:PRN constipation 8. Aspirin 81 mg NG DAILY 9. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Duration: 3 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ischemic Cerebrovascular Accident 2. Multifocal Pneumonia 3. Hypernatremia 4. Acute Kidney Injury SECONDARY DIAGNOSES: ___ Disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted for a change in your mental status and difficulty moving your right arm. You were found to have had another stroke similar to your previous stroke. This is the cause of your right arm weakness. We have added a new medication called clopidogrel and increased the dose of your atorvastatin, in an attempt to reduce your risk of another stroke. You were found to have a pneumonia as well and we treated you with intravenous antibiotics. Your sodium was also high so we gave you intravenous fluids to improve this. You were unable to eat on your own, so we had to give you a feeding tube through which you will continue to receive nutrition. While here, you likely developed a recurrent pneumonia likely from aspiration, and finished antibiotics for this as well. Please continue to take your home medications as prescribed. We wish you the best, Your ___ team Followup Instructions: ___

10051043-DS-4

DS

2192-06-26 00:00:00

2192-06-27 10:54:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left lower face weakness and left hand clumsiness. Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old woman with history of Lyme disease (diagnosed in ___ complicated by recurrent joint pain and headache presenting as OSH transfer for acute onset left lower face weakness and left hand clumsiness. She was in her usual state of health this morning. She works as a ___ and was typing at her computer when she noted that she had clumsiness while typing and could not hit the "a" button. This was around 11AM on ___. Throughout the day she continued to work and noticed only very subtle incoordination of her left hand. This seemed to resolve after hours. After a few hours however, she noticed that she began to slur her words when speaking to her patients. Nurses in her clinic noted that she had some drooping of her face but because of her history of chronic lyme she did not think that her symptoms were necessarily concerning for acute stroke. She also noted feeling slight confused and "not as sharp as usual" throughout the day. It was not until she called her daughter this evening that her daughter convinced her to go into the hospital. She has taken to ___ where NIHSS was 1 significant for only mild left facial droop. She was evaluated by Tele Neuro consult there where facial asymmetry was noted, although could not exclude peripheral vs. central etiology. CT scan showed no acute infarct, chronic left internal capsule infarct. Full dose aspirin, MRI and admission was recommended but ___ had no beds. She has a history of lyme since ___ previously treated with doxycycline. She has recurrent hip pain and headaches and has been on erythromycin and hydroxychloriquine in the past. She has never had a facial droop associated with her lyme in the past. 3 weeks ago was placed on tertacycline 750mg BID for chronic lyme symptoms. No associated fevers/chills/headache/neck pain or stiffness. On neuro ROS, the pt 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: Lyme disease dx ___, on tetracycline Social History: ___ Family History: No family history of early stroke, heart disease. Physical Exam: Vitals: T: 98 HR: 90 BP: 171/97 RR:20 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 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. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was slightly dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 6 to 5mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Left facial droop with asymmetric smile, weakness of left eye closure VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No tremor noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 4+ 4+ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: ___ Tri ___ Pat Ach L 2 2 2 3 2 R 2 2 2 3 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor on FNF, no dysdiadochokinesia noted. No dysmetria on HKS bilaterally. -Gait: Did not assess Discharge exam: facial weakness abated prior to discharge and face was symmetric in both upper and lower face. Subtle weakness remained present in distal muscle groups of all 4 extremities, but no focal weakness was present in the left arm. Gait was steady and within normal limits. Pertinent Results: MRI Brain: TECHNIQUE: MRI of the brain without gad. MRA of the brain using 3D time-of-flight. MRA of the neck using 3D gad technique. HISTORY: New onset facial droop and left hand clumsiness. FINDINGS: There is ___ acute infarction in the right posterior putamen and corona radiata as well as in the left inferior caudate head. There is no evidence for hemorrhagic transformation or significant midline shift. Intracranial flow voids are maintained. There is no hydrocephalus. There are additional scattered small vessel ischemic changes in the white matter which are mild. MRA of the circle of ___ demonstrates no evidence for high-grade vascular stenosis or major vascular occlusion. No aneurysm within limits of the examination. MRA of the neck demonstrates no evidence for high-grade stenosis of the carotid or vertebral arteries. IMPRESSION: Acute infarction in the right putamen, corona radiata and in the left inferior caudate head. On the ADC maps, the area of diffusion abnormality does not appear to be hypointense suggesting that this could be a subacute infarct up to seven days. ECHO: The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. No definite structural cardiac source of embolism identified. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 48) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 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 - (x) N/A Hospital course: The patient was admitted to the stroke service. MRI brain showed 2 subacute ischmeic insults (see above MRI report). The patient was started on aspirin. ECHO was obtained and was normal. The patient's facial weakness and hand weakness improved to baseline prior to discharge. The patient was found to have diffuse, predominantly distal weakness and some diffusely brisk reflexes. She also reported a history of shooting "zings" down her left leg. With these there was some concern for subacute to chronic spinal cord pathology. On the saggital T1 non-contrast image from the MRI there was a hyperintensity seen at the C2 level of the cervical cord. However, in discussion with neuroradiology, this was felt to be artifactual, likely resulting from movement of the soft palate during the study. The patient also reported gradual weight loss over the past year and a feeling of general weakness and fatigue over the same time period. These complaints, as well as further investigation of cord pathology will be condcted on ___ outpatient basis. The patient was discharged to home with planned follow up with Dr. ___. Medications on Admission: tetracycline 750mg BID Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*5 2. Tetracycline 750 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge exam: Left facial droop has resolved. Mild weakness of the distal extremities and diffusely brisk reflexes are suggestive of possible cervical cord process. Discharge Instructions: Dear Ms. ___, You were admitted to the stroke service at ___ for evaluation of your left face and hand weakness. Your MRI showed 2 strokes. Your symptoms improved while you were here. We also found that you have some weakness in both hands and feet, which may indicate a spinal cord problem. These problems can be worked up further when you see Dr. ___ your follow up appointment. We made the following changes to your medications: 1) STARTED ASPIRIN 81mg daily It was a pleasure taking care of you during this hospital stay. Please follow up with Dr. ___ as below. If you experience any of the below danger signs, please present to your nearest emergency room or call ___ and ask for the neurologist on call. Followup Instructions: ___

10051043-DS-5

DS

2192-10-21 00:00:00

2192-10-26 12:02:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hemoptysis and anemia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ with a PMHx of lyme disease, Raynaud's phenomenon, and sp CVA in ___, who presented with URI sx and hemoptysis and was transferred from ___ for management of anemia. Patient notes that cough productive of yellow sputum, faigue and rhinorrhea, which started 10 days ago. Pt also endorses DOE and a sick contact with a co-worker, who was sick with PNA several weeks prior to onset of symptoms. ___ days prior, pt began having hemoptysis (1 tsp blood x ___ times in the AM), as well as decreased appetite, pallor and jaundice. Pt presented to her PCP 1d PTA and was prescribed Keflex. Pt was found to have low HCT and was referred for admission shorly after the visit. At ___ patient noted to have Hct 16, CXR showed diffuse bilateral infiltrates, and she was transferred to ___ ED. In the ___ ED, initial VS: 98.6 90 114/84 24 99% 4L --> temp later increased to 102.2, Labs: WBC 9.5, H/H 5.2/17.1, MCV 89, plt 675, Cr 1.3, TB 0.5, trop < 0.01. EKG: HR 98, sinus rhythm, TWI V2; CXR (___): showed diffuse b/l infiltrates. Chest CT: Diffuse mixed attenuation consolidation most severe in the left upper, left lower, and right lower lobe. Mediastinal and hilar adenopathy. Likely multifocal pneumonia, though diffuse alveolar hemorrhage possible. No definite lung carcinoma identified. If treated for pneumonia would get follow up chest CT after resolution of symptoms in 6 weeks to ensure radiographic clearing. She received 1U PRBC, sputum cx, CTX for CAP. On the floor, pt reports feeling well, without dyspnea or pain. Past Medical History: - Lyme disease (dagnosed in ___, with prior sx including arthralgia, "inflammation behind the eye", Raynauds, rashes, and extremity pain/weakness; treated with erythromycin/tetracycline in the past) - sp CVA ___ Social History: ___ Family History: mother with history of unknown cancer Physical Exam: ADMISSION PHYSICAL EXAM: ==================== Vitals - T: 98.5 BP: 116/66 HR: 91 RR: 20 02 sat: 97%RA GENERAL: NAD, breathing comfortably HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Crackles to mid-lung bl ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ================== Pertinent Results: ADMISSION LAB DATA: =============== ___ 03:40PM BLOOD WBC-9.5 RBC-1.92*# Hgb-5.2*# Hct-17.1*# MCV-89 MCH-27.1 MCHC-30.3* RDW-13.4 Plt ___ ___ 03:40PM BLOOD ___ PTT-26.1 ___ ___ 10:10PM BLOOD Ret Aut-2.4 ___ 03:40PM BLOOD Glucose-93 UreaN-20 Creat-1.3* Na-136 K-4.3 Cl-104 HCO3-22 AnGap-14 ___ 03:40PM BLOOD ALT-10 AST-12 LD(LDH)-143 AlkPhos-90 TotBili-0.5 ___ 07:42AM BLOOD CK(CPK)-12* ___ 03:40PM BLOOD cTropnT-<0.01 ___ 03:40PM BLOOD Albumin-3.0* Iron-9* ___ 03:40PM BLOOD calTIBC-191* VitB12-807 Folate-16.7 Hapto-357* Ferritn-119 TRF-147* ___ 03:49PM BLOOD Lactate-1.0 RELEVANT LAB DATA: ============== ___ 04:07PM BLOOD ANTI-GBM- < 1.0, not detected ___ 11:37PM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY, IGG- < 16, negative ___ 11:37PM BLOOD RNP ANTIBODY- Negative ___ 11:37PM BLOOD RO & LA- Negative ___ 02:28PM BLOOD HCV Ab-NEGATIVE ___ 11:37PM BLOOD C3-87* C4-17 ___ 04:33PM BLOOD ___ * Titer-1:160 , DIFFUSE PATTERN ___ 11:37PM BLOOD RheuFac-34* CRP-217.4* ___ 11:37PM BLOOD dsDNA-NEGATIVE ___ 01:36AM BLOOD CRP-21.1* ___ 03:21AM BLOOD ANCA-POSITIVE * BY INDIRECT IMMUNOFLUORESCENCE P-ANCA PATTERN TITER 1:1280 MPO POSITIVE ___ 11:37PM BLOOD Smooth-NEGATIVE ___ 02:28PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 07:37AM BLOOD TSH-0.51 ___ 05:02AM BLOOD Triglyc-189* ___ 10:37AM BLOOD Lipase-171* ___ 05:02AM BLOOD Lipase-381* ___ 05:14AM BLOOD Lipase-109* ___ 04:33AM BLOOD ALT-20 AST-27 AlkPhos-57 TotBili-1.1 ___ 11:37PM BLOOD ESR-80* ___ 01:36AM BLOOD ESR-5 DISCHARGE LAB DATA: ============== MICROBIOLOGY: ========== ___ blood cultures x 2 -NO GROWTH ___ blood culture - NO GROWTH ___ 5:24 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. MTB Direct Amplification (Final ___: M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. ___ 9:12 pm Influenza A/B by ___ Source: Nasopharyngeal swab. **FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. ___ 3:56 am SPUTUM Source: Expectorated. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 7:41 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 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. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. MTB Direct Amplification (Final ___: M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. 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. ___ 7:41 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **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.. Respiratory Viral Antigen Screen (Final ___: Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by ___ testing. ECG: ==== ___ ECG Sinus rhythm. Cannot exclude anteroseptal wall myocardial infarction of indeterminate age. However, changes may also be consistent with lead positioning. No previous tracing available for comparison. CYTOLOGY: ======== ___ SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE, COMBINED RML AND LEFT LINGULAR BAL Revised A: Special stains: An iron stain displays staining within macrophages, consistent with hemosiderin. No microorganisms are identified on GMS, AFB and gram stains. NEGATIVE FOR MALIGNANT CELLS. Pigment-laden macrophages, bronchial cells, inflammatory cells and red blood cells. (See note.) Note: An iron stain and stains for microorganisms are pending and will be reported in a revised report. No viral cytopathic effects are identified. See also corresponding microbiology lab studies. IMAGING: ======= ___ CT Chest w/ contrast IMPRESSION: 1. Diffuse solid and ground-glass consolidations predominantly involving the left upper and lower lobes and right lower lobe with peribronchovascular distribution. Findings are concerning for multifocal pneumonia with associated reactive adenopathy, though diffuse alveolar hemorrhage is possible in the appropriate clinical setting. Neoplastic process is also not excluded. 2. 11 mm parafissural pulmonary nodule of uncertain etiology. ___ TTE The left atrial volume is normal. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Quantitative (biplane) LVEF = XX %. The estimated cardiac index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests normal diastolic function, and 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 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: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild pulmonary artery hypertension. No valvular pathology or pathologic flow identified. Compared with the prior study (images reviewed) of ___, the estimated PA systolic pressure is slightly higher and mild tricuspid regurgitation is now present. ___ KUB IMPRESSION: No intra-abdominal free air. ___ CT head w/o contrast IMPRESSION: No evidence for acute intracranial abnormalities. Chronic infarctions in bilateral basal ganglia. ___ CT torso w/o contrast IMPRESSION: 1. Severe progression of bilateral lung parenchymal consolidations with severe involvement of the upper lobes and apical segment of the lower lobes is compatible with progression of diffuse alveolar hemorrhage and superimposed pneumonia. Stable lung base involvement, characterized by diffuse peribronchovascular ground glass opacity due to pneumonia. 2. Central lymphadenopathy is stable since ___ and is likely reactive. 3. New bibasilar non-hemorrhagic pleural effusion layering posteriorly with small compression atelectasis of the posterobasal segment of the right lower lobe. 4. Patient has been intubated. The ET tube ends 5.5 cm from carina. 5. There is new ascites and anasarca with minimal peripancreatic fat stranding, compatible mild pancreatitis. ___ RUQ U/S IMPRESSION: 1. Cholelithiasis. Mild focal gallbladder wall edema, however no pericholecystic fluid. No evidence of cholecystitis. 2. Small perihepatic ascites. Right pleural effusion. ___ portable CXR IMPRESSION: AP chest compared to ___ through ___: There is severe widespread pulmonary consolidation probably worsened since ___ following earlier extubation. Right jugular line ends centrally. Pleural effusions small to moderate on the right, unchanged since ___, probably increased since ___. Heart size is normal. Component of mild pulmonary edema would be difficult to detect radiographically. Brief Hospital Course: ___ year old female with reported history of "chronic lyme disease" presented with hemoptysis, pulmonary hemorrhage, renal failure, and Raynauds. She was initially admitted to the ICU given progressive desaturation, with chest x-ray and bronchoscopy revealing active pulmonary hemorrhage. She underwent bronchoscopy with lavage consistent with diffuse alveolar hemorrhage. A lung protective strategy was employed, including increased sedation to limit ventilator dyssynchrony. Although concomitant lung infection was not considered very likely, she was continued upon broad spectrum empiric antibiotics. Bronchoscopy and sputum microbiology studies were unrevealing. Azithromycin was discontinued upon arrival to the ICU, and she completed an extended course of vancomycin and cefepime, with doses adjusted as her renal function changed. Along with treatment for her underlying condition, her ventilator settings were weaned. On ___ after a successful SBT, she was extubated. Initially post-extubation her respiratory status was tenuous due to her underlying disease exacerbated by anxiety and ICU delirium. Her delirium was managed with as needed olanzapine and her air hunger was minimized with very low dose dilaudid. She remained extubated with decreasing oxygen requirement and improving mental status, and was eventually stable enough for the medical floor. Overall studies revealed a positive ___ and RF, hypocomplementemia (C4>C3), positive ANCA. ANCA pattern was P-ANCA, titer 1:1280, MPO positive. Her serologies and organ involvement were most consistent with microscopic polyangiitis. Rheumatology and renal had been following along, and in consultation with them, pulse dose steroids were started on ___ 1 g solumedrol x 3 days. She also received a dose of cyclophosphamide on ___ accompanied by mesna with and 4 hours after infusion. Plasmapheresis was initiated, and she underwent four sessions of plasmapharesis on ___ and ___. The ___ plasma exchange session was complicated by a relatively mild urticarial transfusion reaction. After solumedrol pulse, her steroids were gradually tapered, and she was receiving a total of 72 mg methylprednisolone daily the day of transfer out of the ICU. Given her overall improvement, kidney biopsy for definitive pathologic diagnosis was deferred while in the ICU. Her creatinine peaked at 2.4 on ___, and on that day her total urine output was < 250 mL. After that day, her urine output began to improve as did her creatinine. Creatinine on the day of discharge from the ICU was 1.4. On ___ upon exam Ms. ___ was noted to grimace to palpation in her right upper abdominal quadrant. Labs were significant for a lipase of 381, mildly elevated triglycerides to 187, and normal calcium. Imaging revealed cholelithiasis without cholecystitis, and peripancreatic fluid. The GI pancreas service was consulted. Overall her mild pancreatitis was felt to be multifactorial due to her underlying vasculitis, antibiotics and cyclophosphamide rather than gallstones. Her abdominal symptoms improved and therefore her pancreatitis was without complication. Ms. ___ required multiple transfusions for downtrending hematocrit. She was transfused upon arrival to the ICU on ___ with 1U, and then received 1U each on ___ and ___. After ___ her hematocrit stayed stable and actually improved on subsequent days. On ICU day 2, Ms. ___ developed significant bradycardia as low as into the ___. With heart rates above 40 she was in sinus bradycardia, but in the ___ she was noted to have a junctional escape rhythm. During this bradycardia, she also became hypotensive with MAPs in the ___. Her OG tube was removed to eliminate vagal tone, pressors were added but only helped her heart rate, and eventually her heart rate improved with atropine x 1. Cardiology was consulted. They felt as though her bradycardia and hypotension were likely not related. Both, however, were attributed to her overall critical illness. A TTE was obtained with no significant findings except for pulmonary hypertension, which was attributed to her being on the ventilator. Given the expectation that her bradycardia would improve with her overall clinical picture, there was no indication for transvenous pacing. After extubation, her blood pressure became even more elevated, and her heart rate normalized. Noted to be hypertensive towards the end of her ICU stay. Ms. ___ was started on 5 mg amlodipine daily. She was transferred to the floor on ___ where she was weaned to room air. Although bilateral dry crackles were evident on physical exam, she had no difficulty with respirations. Her creatinine was stable at 1.4 with normal urine output and no edema. She was transitioned to 60 mg PO prednisone and oral cyclophosphamide daily. Her prednisone will be tapered over the next several months under the guidance of nephrology and rheumatology. She was continued on amlodipine. She was seen by physical therapy who recommended continued ___ in rehab setting or home. She was discharged to her friend's house in the ___ area with continued ___. She has follow up appointments set up with both nephrology and rheumatology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___: Microscopic polyangiitis 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 while you were here. You were admitted for bleeding from the lungs. You had to be treated in the ICU for this, where a procedure was done to clear the lungs out. We performed several lab tests to confirm the cause of this bleeding, along with many of your other symptoms. We feel your symptoms are related to a disease called "microscopic polyangiitis." This is an immune disorder that affects the blood vessels. When the blood vessels get inflamed, this can affect your blood supply to different organs. To treat this, we started you on immunosuppressive drugs, including cyclophosphamide and prednisone. You will need to stay on these medicines until your outpatient doctors ___ and rheumatology) decide to change their dose. You will also need to take an antibiotic (bactrim) to prevent infections while you are on these immune medications. Please see below for prescriptions and dosages. Followup Instructions: ___

10051043-DS-9

DS

2197-07-12 00:00:00

2197-07-12 18:25:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___: Diagnostic angiogram ___: Left craniotomy for clipping of left ICA bifurcation aneurysm History of Present Illness: ___ is a ___ female on ASA 81 (last taken ___ being worked up for CNS vasculitis and recent admission for embolic stroke secondary to a-fib who presents today for suspected aneurysmal SAH. Patient awoke with WHOL this morning at 3am. She denies having any neurologic symptoms, visual changes or ___ at this time. She called EMS who took her to ___ where a ___ showed diffuse left-sided SAH. She was transported to the ___ via life flight and Neurosurgery was consulted to evaluate and determine the need for surgical intervention. Past Medical History: Microscopic Polyangiitis Chronic Kidney Disease Paroxysmal Atrial Fibrillation Acute ischemic stroke (multiple) in ___ History of subacute stroke History of multifocal small vessel strokes Diffuse Alveolar Hemorrhage Suspected Lyme disease -Has been seen by a Lyme specialist and has been treated with multiple courses of Erythromycin/Tetracycline over ___ years Social History: ___ Family History: Patient does not believe there is a family history of aneurysms. Mother with unknown cancer. Physical Exam: ON ADMISSION: ============= ___ and ___: [ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity [x]Grade II: Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy. [ ]Grade III: Drowsiness/Confusion, mild focal neurological deficit. [ ]Grade IV: Stupor, moderate-severe hemiparesis. [ ]Grade V: Coma, decerebrate posturing. ___ Grade: [ ]1 No hemorrhage evident [ ]2 Subarachnoid hemorrhage less than 1mm thick [x]3 Subarachnoid hemorrhage more than 1mm thick [ ]4 Subarachnoid hemorrhage of any thickness with IVH or parenchymal extension WFNS SAH Grading Scale: [x]Grade I: GCS 15, no motor deficit [ ]Grade II: GCS ___, no motor deficit [ ]Grade III: GCS ___, with motor deficit [ ]Grade IV: GCS ___, with or without motor deficit [ ]Grade V: GCS ___, with or without motor deficit ___ Coma Scale: [ ]Intubated [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands _15___ Total VS: HR 114; BP 142/72; RR 22; 100% RA Gen: No acute distress - complains of HA. Appears well. HEENT: Pupils: 3-2.5mm bilaterally, EOMs intact. Extremities: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: PERRL 3-2.5mm. Visual fields are full to confrontation. III, IV, VI: EOMI bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch ON DISCHARGE: ============= ___ ___ Temp: 97.5 PO BP: 143/93 L Sitting HR: 79 RR: 19 O2 sat: 98% O2 delivery: ra Exam: Sitting in bed, comfortable. Anxious and awaiting plan for discharge. Opens eyes: [x] Spontaneous [ ] To voice [ ] To noxious Orientation: [x] Person [x] Place [x] Time Follows commands: [ ] Simple [x] Complex [ ] None Pupils: PERRL (3mm to 2mm) EOM: [x] Full [ ] Restricted Face Symmetric: [x] No - Very slight left ptosis, left facial, activates symmetrically Tongue Midline: [x] Yes [ ] No Pronator Drift: [ ] Yes [x] No Speech Fluent: [x] Yes [ ] No Comprehension intact: [x] Yes [ ] No Motor: No drift. Moves all extremities symmetric, full strength throughout. Sensation: Grossly intact to light touch Wound: Clean, dry, intact Sutures removed today- wound well approximated, no signs of infection Pertinent Results: Please see OMR for pertinent lab results and imaging. Brief Hospital Course: #Subarachnoid hemorrhage On ___, Ms. ___ was admitted to the Neuro ICU with diffuse left-sided SAH. She was started on keppra, nimodipine and nicardipine. Diagnostic angiogram was initially negative for aneurysm. She was admitted to the stroke neurology service to evaluate for CNS vasculitis as etiology for hemorrhage. MRI brain w/w contrast was obtained revealing multiple lobar-distributed microhemorrhages suspicious of CAA and an acute left thalamic stroke. She was transferred to ___ on ___. LP was performed ___ and was revealing for elevated OP and elevated RBC's as well as HSV for which she was started of Acyclovir for a total course of 10 days. Repeat CTA on ___ revealed a 2mm aneurysm superior to left carotid terminus. She was transferred back to Neuro ICU and arterial line was placed for close blood pressure control. On ___, she was taken to the OR for elective clipping of left ICA aneurysm. postoperatively, she was noted to have new expressive aphasia. ___ revealed infarct in the left internal capsule and thalamus which were present on prior imaging. Speech improved during her ICU stay. Her mental status continued to improve, she continued her nimodipine for 21 days post SAH. ___ continue to express concerns for cognition and home safety and recommended home with 24h supervision. Social work was consulted. On ___, the patient was transferred to the floor. She completed her Dexamethasone taper. Left craniotomy site sutures were removed on ___ prior to discharge. #Dispo Patient had an argument with her healthcare proxy because she felt the HCProxy was sabotaging her discharge to go home independently. She discontinued communication with the health care proxy and named her daughter HCP. The patient's son and daughter are unable to provide 24h supervision upon discharge home. She has 2 sisters in ___, one is ___ old and unable to provide care while the other she has a turbulent relationship with per her daughter. Psychiatry was consulted for capacity evaluation and a team meeting was held to discuss a safe dispo plan. ___ and social work are in agreement that patient would be safe to go home with ___ services at home and frequent checks from family and friends. Patient's daughter to tentatively return to the ___ on ___ for work business and will stay with her mother. ___ re-evaluated patient on ___ and deemed the patient to have capacity to make her own medical decisions. The patient has agreed to discharge home with maximum services including ___ and social work has assisted the patient to set up elder services upon return home. The patient reports that her friend ___ has agreed that the patient can stay with her tonight after discharge. Patient's daughter has been in touch with case management and is aware of this current plan for discharge home with maximum services. #Hyponatremia On admission, the patient was hyponatremic to 129. She was bolused with normal saline and sodium normalized. She was again hyponatremic to 127 on ___ and started on hypertonic saline, this was eventually weaned and she remained stable on Salt tabs 1G PO TID. Plan to wean salt tabs to off after discharge and the patient will follow-up with PCP upon discharge. #Hyperkalemia The patient was noted to have intermittent hyperkalemia with K up to 5.8 on morning of discharge. Subsequent lab draw in ___ was 5.1. The patient was encouraged to increase PO intake and she will follow-up with her PCP as an outpatient for further monitoring and management. #Fever The patient was febrile on ___ and pancultured. CXR was concerning for infection vs underlying airway disease. HSV PCR was positive and she was started on acyclovir on ___ with end date of ___. Further work up revealed UTI and she was started on MacroBID which was completed on ___. AHA/ASA Core Measures for ICH: 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 given in written form? [x]Yes []No 5. Assessment for rehabilitation and/or rehab services considered? []Yes [x]No -> at baseline functional status. Stroke Measures: 1. Was ___ performed within 6hrs of arrival? [x]Yes []No 2. Was a Procoagulant Reversal agent given? []Yes [x]No [Reason: Stable, small SAH] 3. Was Nimodipine given? [x]Yes []No [Reason:] Medications on Admission: Aspirin 81mg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 2. NiMODipine 60 mg PO Q4H RX *nimodipine 30 mg 2 (Two) capsule(s) by mouth every four (4) hours Disp #*16 Capsule Refills:*0 3. Sodium Chloride 1 gm PO BID RX *sodium chloride 1 gram 1 tablet(s) by mouth BID x2 days then QD x2 days Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid hemorrhage Left ICA bifurcation aneurysm HSV-2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were hospitalized due to symptoms of headache resulting from a subarachnoid hemorrhage. This is a condition caused by a leakage of blood within the brain. While you were here in the hospital, you had an angiogram to look for an aneurysm. Fortunately this showed no evidence of hemorrhage. You also had a lumbar puncture. This showed HSV and you were started on Acyclovir for a total course of 10 days. Please take your medications as prescribed. Please follow up 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 Sincerely, Your ___ Neurology Team Aneurysmal Subarachnoid Hemorrhage • Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. • You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). What You ___ Experience: •Mild to moderate headaches that last several days to a few weeks. •Difficulty with short term memory. •Fatigue is very normal When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site or puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg •Sudden confusion or trouble speaking or understanding •Sudden trouble walking, dizziness, or loss of balance or coordination •Sudden severe headaches with no known reason While you were hospitalized an additional CTA was performed revealing a new 2mm left ICA bifurcation aneurysm for which you underwent a left craniotomy for clipping treatment of your aneurysm. Discharge Instructions for: Elective Aneurysm Clipping Call your neurosurgeon’s office and speak to the Nurse Practitioner if you experience: - Any neurological issues, such as change in vision, speech or movement - Swelling, drainage, or redness of your incision - Any problems with medications, such as nausea vomiting or lethargy - Fever greater than 101.5 degrees Fahrenheit - Headaches not relieved with prescribed medications Activity: - Start to resume all activities as you tolerate – but start slowly and increase at your own pace. -Do not operate any motorized vehicle for at least 10 days after your surgery – your Nurse Practitioner can give you more detail at the time of your suture removal. Your sutures will be removed prior to discharge. Incision Care: - Keep your wound clean and dry. - Do not use shampoo until your sutures are removed. - When you are allowed to shampoo your hair, let the shampoo run off the incision line. Gently pad the incision with a towel to dry. - Do not rub, scrub, scratch, or pick at any scabs on the incision line. - You need your sutures removed 7 to 10 days after surgery Post-Operative Experiences: Physical - Jaw pain on the same side as your surgery; this goes away after about a month - You may experience constipation. Constipation can be prevented by: o Drinking plenty of fluids o Increasing fiber in your diet by eating vegetables, prunes, fiber rich breads and cereals, or fiber supplements o Exercising o Using over-the-counter bowel stimulants or laxatives as needed, stopping usage if you experience loose bowel movements or diarrhea - Fatigue which will slowly resolve over time - Numbness or tingling in the area of the incision; this can take weeks or months to fully resolve - Muffled hearing in the ear near the incision area - Low back pain or shooting pain down the leg which can resolve with increased activity Post-Operative Experiences: Emotional - You may experience depression. Symptoms of depression can include o Feeling “down” or sad o Irritability, frustration, and confusion o Distractibility o Lower Self-Esteem/Relationship Challenges o Insomnia o Loneliness - If you experience these symptoms, you can contact your Primary Care Provider who can make a referral to a Psychologist or Psychiatrist - You can also seek out a local Brain Aneurysm Support Group in your area through the Brain Aneurysm Foundation o More information can be found at ___ Followup Instructions: ___

10051074-DS-19

DS

2180-02-14 00:00:00

2180-02-16 18:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Attending: ___. Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: ___ - cardiac catheterization with normal arteries History of Present Illness: ___ female with h/o afib on Coumadin, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, and NIDDM presenting from outside hospital with chest pain, dyspnea, nausea. Patient reports the pain awoke her from sleep this morning, sharp stabbing pain that radiated to her jaw and left shoulder. She reports associated dyspnea which is slightly worsened her baseline. She also has had multiple sets of vomiting, continues to feel nauseous. She denies fevers or recent illnesses. She denies any abdominal pain. She does report having intermittent periods of chest pain similar to this for the past several months. She also reports noting occasional blood from her ostomy. She is on Coumadin for A. fib. She presented to ___ with chest pain, ekg does not meet STEMI criteria. Global ischemia on ekg, In Afib HR 115 BP 100. Trop <0.01 at OSH. Given 5mg Lopressor on transport with brief decrease in HR to ~100, now back to 110s. Guiac positive from her ostomy was noted, and was not given heparin given therapeutic INR. The patient was then transferred to ___ for further management. Upon arrival here, ECG showed AF @ 119 with slightly improved diffuse ST depressions and STE in aVR. The patient continued to have severe chest pain and was found to be hypotensive to ___. Norepinephrine was started and aspirin 325mg was given. Labs notable for INR 2.8 and TnT 0.05, normal creatinine. During my interview with the patient, she spontaneously converted to sinus rhythm with near total resolution of ischemic ST changes on ECG. Down-titration of norepinephrine was attempted but the patient became again hypotensive to the ___ systolic, so she remained on norepninephrine 0.2mg/kg/min. With stabilization of her hemodynamics on vasopressors, her chest pain improved to ___. She denied any recent illnesses, and has not had sick contacts, productive cough, diarrhea, etc. She notes occasional scant light blood on her ostomy, but denies any frank bloody output or any other bleeding. She has not been on any long trips recently or had recent surgeries, denies other PE risk factors (and is therapeutically Anticoagulated.) On arrival to the CCU the patient was weaned off of levophed and remained in sinus rhythm. The patient had no new acute complaints. REVIEW OF SYSTEMS: Positive per HPI. Current cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies fevers or chills. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes: YES - Hypertension: YES - Dyslipidemia: YES 2. CARDIAC HISTORY - Coronaries: Unknown - Systolic function: Unknown - Rhythm: Paroxysmal Afib with RVR OTHER PAST MEDICAL HISTORY 1. AFib on Coumadin 2. ostomy s/p diverticular resection 3. NIDDM Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Mother and brother with "heart disease". Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: reviewed in metavision GENERAL: Well developed, obese resting in bed. 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 unble to assess due to body habitus. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. significant bibasilar crackles. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: cool but, well perfused. No clubbing, cyanosis, or peripheral edema. No evidence of mottling, however chronic skin changes consistent with diabetes are present PULSES: Distal pulses doplerable and symmetric. DISHCARGE PHYSICAL EXAM: ======================== VS: 98.2, 108-128/55-68, 66-74, 18, 91-94% RA I/O: not saving urine weight 114kg GENERAL: Well developed, obese resting in bed. 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 unble to assess due to body habitus. CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ holosystolic murmur best auscultated at the base of the heart. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Resolution of bibasilar crackles ABDOMEN: obese, non-tender, distended. No hepatomegaly. No splenomegaly. Colostomy with erythematous skin surrounding it. Colostomy bag in place. EXTREMITIES: warm, well perfused. No clubbing, cyanosis, or peripheral edema. No evidence of mottling, however chronic skin changes consistent with diabetes are present PULSES: Distal pulses doplerable and symmetric. Pertinent Results: ADMISSION LABS: =============== ___ 05:34PM GLUCOSE-95 UREA N-19 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 ___ 05:34PM CALCIUM-8.9 PHOSPHATE-5.2* MAGNESIUM-1.5* ___ 01:49PM ___ TEMP-36.4 PO2-37* PCO2-56* PH-7.32* TOTAL CO2-30 BASE XS-0 ___ 01:49PM LACTATE-1.8 ___ 01:49PM O2 SAT-63 ___ 12:13PM GLUCOSE-159* UREA N-20 CREAT-1.2* SODIUM-135 POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21* ___ 12:13PM CK(CPK)-103 ___ 12:13PM CK-MB-8 cTropnT-0.24* proBNP-1459* ___ 12:13PM CALCIUM-8.9 PHOSPHATE-5.5* MAGNESIUM-1.5* ___ 12:13PM TSH-1.8 ___ 12:13PM WBC-13.2* RBC-4.47 HGB-13.8 HCT-42.1 MCV-94 MCH-30.9 MCHC-32.8 RDW-14.3 RDWSD-49.5* ___ 12:13PM PLT COUNT-295 ___ 12:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 12:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 12:13PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE EPI-1 ___ 12:13PM URINE GRANULAR-4* HYALINE-24* ___ 12:13PM URINE AMORPH-FEW ___ 12:13PM URINE MUCOUS-OCC ___ 08:59AM ___ PO2-42* PCO2-63* PH-7.26* TOTAL CO2-30 BASE XS-0 ___ 08:59AM O2 SAT-66 ___ 07:52AM LACTATE-2.8* ___ 07:44AM GLUCOSE-162* UREA N-15 CREAT-1.0 SODIUM-135 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 ___ 07:44AM estGFR-Using this ___ 07:44AM cTropnT-0.05* ___ 07:44AM CK-MB-4 ___ 07:44AM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.5* ___ 07:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-7* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:44AM WBC-13.9* RBC-4.63 HGB-14.3 HCT-43.7 MCV-94 MCH-30.9 MCHC-32.7 RDW-14.4 RDWSD-49.7* ___ 07:44AM NEUTS-72.5* LYMPHS-17.1* MONOS-7.4 EOS-0.7* BASOS-0.4 IM ___ AbsNeut-10.06* AbsLymp-2.37 AbsMono-1.02* AbsEos-0.10 AbsBaso-0.05 ___ 07:44AM PLT COUNT-278 ___ 07:44AM ___ PTT-48.5* ___ MICRO: ====== **FINAL REPORT ___ Blood Culture, Routine (Final ___: WORKUP REQUESTED PER ___ ___. STAPHYLOCOCCUS EPIDERMIDIS. Isolated from only one set in the previous five days. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ON ___, 12:42PM. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. IMAGING and STUDIES ==================== TTE ___ The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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 are mildly thickened (?#). There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, it is reasonable to consider an exercise stress test to confirm symptom status. In addition, a follow-up study is suggested in ___ months. If they are symptomatic (angina, syncope, CHF) and a surgical or TAVI candidate, a mechanical intervention is recommended. BILATERAL LENIS ___ No evidence of DVT in right or left lower extremity veins. CXR ___ IMPRESSION: 1. Cardiomegaly. 2. Engorgement of the pulmonary vasculature, concerning for mild pulmonary edema. 3. No focal consolidations to suggest pneumonia. + ECHO ___ The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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 are mildly thickened (?#). There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Increased PCWP. ___ Cardiac Catheterization: Intra-procedural Complications: Retained small segment of wire subcutaneously Impressions: Normal coronary arteries Moderately severe aortic stenosis - mean AVG 27 mm Hg, ___ 1.2 cm2 Mild elevation of PCW pressure 17 mm Hg Moderate elevation of PA pressure - ___ Normal cardiac index 2.8 L/min/m2 Recommendations Continued medical therapy Prevention of AF Consideration of AVR at later time if further progression Followup of retained short segment of 0.018 wire in L femoral area which is not intravascular - would require surgical retrieval which is unlikely to be necessary DISCHARGE LABS: =============== Brief Hospital Course: ___ female with h/o afib on Coumadin, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, and NIDDM presenting from outside hospital with chest pain, dyspnea, nausea. She was found to be in a fib with RVR, and have and NSTEMI. She was also found to have a staph epidermidis bacteremia. # Acute on chronic diastolic heart failure Patient presented as transfer from ___ with afib with RVR with diffuse downsloping ST depressions and ST elevation in aVR and chest pain. On arrival to ___ ED, EKG with Afib with RVR and rates to 119 with slighty improved ST depressions and STE in aVR. Echo with an EF of 55% and aortic stenosis. Levophed was started given hypotension ___. She spontaneously converted to sinus rthym in the ED with near total resolution of ischemic changes on EKG. Levophed was unable to be weaned in ED and patient remained on Levophed for several days in the CCU. BNP ~1500 with mild pulmonary edema on CXR. TTE with severe aortic stenosis. Do not suspect obstructive (PE) given therapeutic INR and negative LENIS. The patient was initially diuresed with IV Lasix, and transitioned to PO Lasix 40mg daily several days before discharge. Her metoprolol was held initially, and then gradually titrated back to her home dose of Metoprolol XL 100mg. Her lisinopril was discontinued since she did not have evidence of systolic heart failure on echo. #Septic Shock # Staph Epidermidis Bacteremia: On ___, two out of two bottles of blood cultures grew what turned out to be staph epidermidis. Although this is usually a contaminant, the medical team thought that this may have precipitated the afib with RVR. It may be iatrogenic, from the central line that was inserted at the OSH, or from the skin breakdown around her ostomy. She was started on IV vancomycin on ___, and she will need to complete a 14 day course of antibiotics, through ___. # Atrial Fibrillation with RVR: Precipitant likely bacteremia. Patient reports episodes of palpitations intermittently, and spontaneously converted to sinus rhythm. Her Chads-Vasc Sore is 5. An extensive conversation was had about starting apixaban, but the patient did not want to start it at this time. She was discharged on her home warfarin with a Lovenox bridge given a subtherapeutic INR. Her metoprolol was continued for rate control once blood pressures increased. # NTEMI. Likely demand. Coronary arteries on cardiac catheterization without evidence of atherosclerosis. ASA was stopped on ___. Her simvastatin was changed to Atorvastatin 80mg given her high ASCVD risk score. # Moderate Aortic Stenosis Severe aortic stenosis was noted on TTE ___, but the cardiac catheterization on ___ suggested moderate AS. Patient was not symptomatic. Her aortic stenosis should be monitored and she should be considered for further management if she becomes symptomatic. #Acute kidney Injury: Likely ___ to ATN from hypotension. Cr was 0.7 at time of dischare. CHRONIC ISSUES ============== # HLD: Patient was started on atorvastatin 80 mg daily in light of high ASCVD risk score. # HTN: HCTZ and Lisinopril held because of normotension. Maintained on home Metoprolol. Started on PO Lasix 40mg daily. # NIDDM: Metformin was held and the patient was on an insulin sliding scale. # Chronic Back Pain: Continued tramadol. Held naproxen in the setting of possible intervention. TRANSITIONAL ISSUES =================== [] Complication during procedure: guidewire broke, and is in soft tissue of groin. Monitor for signs of infection. [] Patient was discharged to complete a 14 day course of vancomycin 1500mg IV Q12H for coag negative staph bacteremia (last day ___ [] Patient was discharged on enoxaparin bridge to warfarin. The patient will go to her PCP's office to have her INR drawn on ___. Once INR > 2.0, enoxaparin should be stopped. [] Patient was discharged on Lasix 40mg daily due to volume overload. Her weight should be monitored, and her kidney function and electrolytes should be checked at her next appointment. [] Patient's anti lipid therapy was switched from simvastatin 5mg to atorvastatin 80mg. [] Patient was normotensive while in the hospital. Her lisinopril and HCTZ were held at time of discharge, and could be restarted in the outpatient setting if needed. [] Patient was discharged with hydrocortisone cream for ___ irritation. [] Please assist patient with smoking cessation. # CODE: Full # CONTACT/HCP: ___ (Husband) verbally designated HCP: ___ # DRY WEIGHT: Unknown # Discharge weight: 114kg Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Naproxen 500 mg PO Q8H:PRN Pain - Mild 7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 8. Simvastatin 5 mg PO QPM 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 10. Warfarin 8 mg PO DAILY16 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 12. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Enoxaparin Sodium 110 mg SC BID RX *enoxaparin 100 mg/mL 110 mg/mL INJ twice a day Disp #*14 Syringe Refills:*0 3. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Hydrocortisone Cream 1% 1 Appl TP QID ___ irritation RX *hydrocortisone 1 % apply small amount around the ostomy site four times a day Refills:*0 5. Vancomycin 1500 mg IV Q 12H RX *vancomycin 1 gram 1.5 g IV twice a day Disp #*22 Vial Refills:*0 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 7. Levothyroxine Sodium 50 mcg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Naproxen 500 mg PO Q8H:PRN Pain - Mild 11. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q6H:PRN wheezing 12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 13. umeclidinium 62.5 mcg/actuation inhalation DAILY 14. Warfarin 8 mg PO DAILY16 15.Outpatient Lab Work Please draw a ___, and fax results to ___ ATTN: ___ ICD10: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: - Cardiogenic shock - Acute on chronic diastolic heart failure Secondary Diagnoses: - NSTEMI - Moderate Aortic Stenosis - Coagulase Negative Staph bacteremia - Atrial Fibrillation with RVR - Acute kidney injury - Hyperlipidemia - Hypertension - Non-insulin dependent diabetes mellitus - Chronic back 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 to be a part of your care team at ___ ___. Why did you come to the hospital? ================================= - You came to the hospital with chest pain, trouble breathing, and nausea. You were transferred to ___ for further workup for your heart. What did we do for you? ======================= - You were found to have a rapid, irregular heartrate called atrial fibrillation. - We think this atrial fibrillation was triggered by an infection in your blood stream. - We started you on strong antibiotics for an infection in your blood stream (vancomycin). What do you need to do? ======================= - It is important that you follow up with a Cardiologist (appointment information below) - It is important that you continue your vancomycin antibiotic infusions twice per day up through and including ___. - MEDICATION CHANGES: -- STOP taking simvastatin. START taking Atorvastatin 80 mg daily. -- STOP taking lisinopril -- CONTINUE taking warfarin 8mg per day. START Lovenox injections twice per day until your INR is greater than 2. Follow up with your ___ clinic for INR monitoring. It was a pleasure caring for you. We wish you the best! Sincerely, Your ___ Medicine Team Followup Instructions: ___

10051074-DS-21

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2180-08-02 00:00:00

2180-08-02 17:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, extensive tobacco use, COPD, and T2DM, recent TAVR placement ___ complicated by CHB with pacer placement complicated by RV perforation and discharged to rehab on ___ presents with chest pain, dyspnea, N/V that started acutely ___. Her episode of chest pain began the evening of ___, although patient doesn't have clear memory of the exact time or what she was doing. She believes she was lying in bed resting, then had sudden onset, sharp pain with some pressure in epigastrum and radiating to the neck and back. Pain was ___. Had nausea with vomiting x1 and improvement of symptoms. No blood noticed in vomit. The chest pain varies based on her position. Her shortness of breath was better with sitting up than lying down. Patient was admitted ___ for TAVR complicated by complete heart block, pacemaker placement, which was complicated by RV perforation and cardiac tamponade, cardiac arrest with ROSC, and groin hematoma. She had an attempted TAVR on ___, complicated by a groin hematoma, then had TAVR on ___, which was complicated by complete heart block. She had an attempted permanent pacemaker placed on ___, which was complicated by RV perforation and cardiac tamponade, had a drain placed and underwent sternotomy on ___, at which time her RV was repaired and epicardial leads were placed. During her course she also sustained cardiac arrest with ROSC after 1 min of chest compressions. Of note, patient had cath in ___ that showed normal coronary arteries. Also, post-TAVR deployment films ___ showed good flow through RCA and left main arteries at the end of the procedure. Recent device interrogation ___ showed normal pacemaker function. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF (EF > 55%) - Paroxysmal AFib - NSTEMI ___ 3. OTHER PAST MEDICAL HISTORY Ostomy s/p diverticular resection COPD Hypothyroidism Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM ========================= VS: T 97.8 PO BP 114/50 R Lying HR 81 RR 18 O2 95 RA GENERAL: Well developed, well nourished obese female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist mucous membranes NECK: Supple. CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic murmur, no rubs or gallops. No thrills or lifts. CHEST: Midline sternotomy scar, non-erythematous, without drainage. Some scab formation. Diffusely tender to palpation over the chest, pt unclear whether this reproduces pain from previous night. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended, morbidly obese. Ostomy bag in mid-lower abdomen. EXTREMITIES: Cool to touch. No clubbing, cyanosis. 1+ pitting edema bilateral lower ext. SKIN: No significant skin lesions or rashes. DISCHARGE SUMMARY ================== VITALS: 98.6 PO 103 / 66 L Sitting 72 18 100 1L GENERAL: morbidly obese, no acute distress, complaining of some diffuse chest pain HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist mucous membranes NECK: Supple. CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic murmur, no rubs or gallops. No thrills or lifts. CHEST: Midline sternotomy scar, non-erythematous, c/d/i. Some scab formation. Diffusely tender to palpation over the chest. LUNGS: CTABL, no wheezes or crackles ABDOMEN: Soft, non-tender, non-distended, morbidly obese. Ostomy bag in mid-lower abdomen. EXTREMITIES:No clubbing, cyanosis, edema SKIN: No significant skin lesions or rashes. Pertinent Results: ADMISSION LABS =================== ___ 05:50AM BLOOD WBC-8.7 RBC-3.02* Hgb-9.2* Hct-30.0* MCV-99* MCH-30.5 MCHC-30.7* RDW-19.1* RDWSD-69.0* Plt ___ ___ 05:50AM BLOOD Neuts-62.1 ___ Monos-13.0 Eos-2.4 Baso-0.2 Im ___ AbsNeut-5.41# AbsLymp-1.82 AbsMono-1.13* AbsEos-0.21 AbsBaso-0.02 ___ 09:15PM BLOOD ___ ___ 05:50AM BLOOD Plt ___ ___ 09:15PM BLOOD Glucose-174* UreaN-21* Creat-1.6* Na-139 K-3.8 HCO3-25 AnGap-14 ___ 05:50AM BLOOD Glucose-119* UreaN-19 Creat-1.6* Na-139 K-4.7 Cl-98 HCO3-24 AnGap-17* ___ 05:50AM BLOOD ALT-22 AST-47* AlkPhos-157* TotBili-0.9 ___ 05:50AM BLOOD Lipase-82* ___ 11:12AM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD cTropnT-<0.01 ___ 05:50AM BLOOD proBNP-1340* ___ 09:15PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8 ___ 05:50AM BLOOD Albumin-3.4* Calcium-9.0 Phos-4.1 Mg-1.8 ___ 09:15PM BLOOD TSH-3.8 ___ 05:50AM BLOOD HoldBLu-HOLD ___ 09:15PM BLOOD ___ 09:26PM BLOOD Lactate-1.6 ___ 06:00AM BLOOD Lactate-2.3* ECHO ___ ============== The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size is normal with borderline normal free wall function. There is abnormal septal motion suggestive of pericardial constriction (clip 38). The diameters of aorta at the sinus, ascending and arch levels are normal. An Evolut aortic valve bioprosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The effective orifice area/m2 is moderately depressed (0.7; nl >0.9 cm2/m2) No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (clip 48). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. The echo findings are suggestive but not diagnostic of pericardial constriction. A right pleural effusion is present. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No pericardial effusion, but abnormal septal motion suggestive of pericardial constriction. Normal functioning Evolute TAVR with normal gradient and no aortic regurgitation. Compared with the prior study (images reviewed) of ___, the pericardial effusion has resolved and abnormal septal motion is now present suggesting possible pericardial constriction. CXR ___ ============ IMPRESSION: No acute process. Small left pleural effusion. DISCHARGE LABS ================== ___ 05:50AM BLOOD ___ PTT-26.0 ___ ___ 05:50AM BLOOD Glucose-121* UreaN-19 Creat-1.5* Na-138 K-3.8 Cl-98 HCO3-26 AnGap-14 ___ 12:00AM BLOOD UreaN-20 Creat-1.5* Na-138 K-4.0 ___ 05:50AM BLOOD ___ PTT-26.0 ___ ___ 12:00AM BLOOD CK(CPK)-35 ___ 12:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:50AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 ___ 12:00AM BLOOD Phos-3.7 Mg-1.8 ___ 05:50AM BLOOD Brief Hospital Course: Ms. ___ is a ___ year old woman with past medical history of aortic stenosis, paroxysmal AFib on Coumadin and amiodarone, severe diverticular disease s/p partial colectomy with end ostomy, COPD, recent TAVR placement ___ complicated by CHB with pacer placement complicated by RV perforation s/p sternotomy with RV repair, discharged to rehab on ___, who presented with chest pain found to most likely be of musculoskeletal etiology. Problems addressed during this hospital admission are as follows: ACTIVE ISSUES: ==================================== #Chest Pain: Sudden onset on ___, sharp, epigastric, radiating to the neck and back, relieved with vomiting x1. On second day of admission, described as dull ache in anterior chest surrounding sternotomy scar. Initially concerning for ACS v dissection v pericarditis v cardiac effusion/restriction v PE v GI (gastroparesis, pancreatitis, GERD). Vital signs stable and workups all negative: EKG nl (LBBB), trops negative, chest x-ray nl, lipase 82, lactate 2.3-->1.6, CBC nl, BMP nl. Blood pressures were equal in both arms. Echo revealed no effusion, some pericardial constriction, most likely related to sternotomy. Most likely musculoskeletal due to relief of pain with oxycodone, reproducible chest tenderness on physical exam. Managed with pain control (oxycodone, Tylenol, lidocaine patch). #Nausea/Vomiting: No episodes of vomiting during admission, tolerated regular diet. Received metoclopramide x1 on admission. #Severe AS s/p TAVR ___ #Complete Heart Block s/p PPM ___ complicated by RV perforation: Last hospitalization (___), patient had TAVR complicated by complete heart block. PPM placed, complicated by RV perforation, cardiac tamponade, cardiac arrest w/ ROSC, s/p sternotomy with RV repair and epicardial lead placement. Repeat echo on this admission revealed good gradients. Continued ASA. #Paroxysmal AFib. Admitted with subtherapeutic INR (___), as warfarin held at rehab due to hematoma, discharge paperwork from pervious admission stated warfarin should have been continued. Restarted home warfarin. CHRONIC/STABLE ISSUES: ==================================== #Heart Failure w/ preserved Ejection Fraction: EF >55% on ___ echo. Thought to be secondary to severe AS. Admission weight: 103.3 kg, discharge weight 103.3 kg. Remained euvolemic, Cr stable. Continued home lasix, spironolactone. #GERD: Switched from ranitidine to omeprazole to better manage GERD. Discharged with ranitidine, continued calcium carbonate. #Normocytic Anemia: Stable, remained at baseline (___). Continued ferrous sulfate. #T2DM: Standing lantus and HISS. #HLD: Continued atorvastatin. #Hypothyroidism. Continued levothyroxine. TRANSITIONAL ISSUES: -Please be sure patient continues to take home warfarin, was discharged on warfarin during last admission (___), however was held at rehab due to a hematoma despite discharge recommendations stating to continue warfarin, admitted with subtherapeutic INR ___ (goal INR ___. -Please check INR on ___, and adjust warfarin dosing as needed. -Can consider switching from ranitidine to PPI for GERD management. #CODE STATUS: Full (presumed) #CONTACT: ___ (husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 20 mEq PO DAILY 2. Epoetin ___ ___ units SC QWEEK 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 40 mg PO BID 5. Spironolactone 25 mg PO BID 6. Calcium Carbonate 1000 mg PO QID:PRN GERD 7. umeclidinium 62.5 mcg/actuation inhalation DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 12. Milk of Magnesia 30 mL PO DAILY constipation 13. Amiodarone 200 mg PO DAILY 14. Cyanocobalamin 100 mcg PO DAILY 15. Ranitidine 150 mg PO DAILY 16. Miconazole 2% Cream 1 Appl TP BID rash 17. Miconazole Powder 2% 1 Appl TP BID rash 18. Levothyroxine Sodium 50 mcg PO DAILY 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 20. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath 21. GuaiFENesin 10 mL PO Q4H:PRN cough 22. Bisacodyl 10 mg PR QHS:PRN constipation 23. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 24. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin Discharge Medications: 1. Nicotine Patch 14 mg TD DAILY 2. Warfarin 6 mg PO DAILY16 3. Glargine 10 Units Breakfast Insulin SC Sliding Scale using aspart Insulin 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 6. Amiodarone 200 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Bisacodyl 10 mg PR QHS:PRN constipation 10. Calcium Carbonate 1000 mg PO QID:PRN GERD 11. Cyanocobalamin 100 mcg PO DAILY 12. Epoetin ___ ___ units SC QWEEK 13. Ferrous Sulfate 325 mg PO BID 14. Furosemide 40 mg PO BID 15. GuaiFENesin 10 mL PO Q4H:PRN cough 16. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath 17. Levothyroxine Sodium 50 mcg PO DAILY 18. Lidocaine 5% Patch 1 PTCH TD QAM 19. Miconazole 2% Cream 1 Appl TP BID rash 20. Miconazole Powder 2% 1 Appl TP BID rash 21. Milk of Magnesia 30 mL PO DAILY constipation 22. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*9 Tablet Refills:*0 23. Potassium Chloride 20 mEq PO DAILY Hold for K > 24. Ranitidine 150 mg PO DAILY 25. Spironolactone 25 mg PO BID 26. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Chest Pain SECONDARY DIAGNOSES ===================== aortic stenosis s/p TAVR Paroxysmal Atrial fibrillation chronic diastolic heart failure GERD HLD T2DM COPD Diverticulitis s/p partial colectomy 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 to care for you at the ___ ___. You came to the hospital because you had chest pain. We performed blood tests, EKGs, which measure the electrical activity of the heart, and a heart ultrasound to evaluate your chest pain. The results of the tests we performed were all normal. We believe the chest pain is related to the joints and muscles surrounding your heart, especially because you recently had a surgical procedure in your chest. Your symptoms improved with pain medications which you will be able to take after you leave the hospital. Please be sure to follow up with your doctors as listed below and to take all of your prescribed medications. We wish you all the best! -Your ___ care team Followup Instructions: ___

10051555-DS-3

DS

2170-03-01 00:00:00

2170-03-01 20:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / lisinopril / atenolol / Erythromycin Base / clindamycin / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin / Benadryl / Effient Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with history of CAD, s/p cardiac cath with stents placed at an OSH one week ago via right femoral axis. She has been on aspirin and plavix for anticoagulation. She states that she began to have right lower quadrant abdominal pain one day after the procedure, and that it worsened over the course of the week. Over the same period she began to have increased urinary frequency, and went to her PCP to be evaluated for a UTI. Her PCP started ___, but was concerned about her RLQ pain and sent her to the ED for further evaluation. Her Hct at that time was 33, down from 43 prior to her cath, and a CTA demonstrated a retroperitoneal hematoma. She was transferred to ___ for further evaluation. At time of consult in the ED, she states that her abdominal pain has improved over the past two days. She denies back or leg pain, weakness, light-headedness, or difficulty walking. Her blood pressure and heart rate are stable. Past Medical History: PMH: CAD, HTN, HLD PSH: cardiac cath with stents placed Social History: ___ Family History: No Significant Inheritable Disorder Physical Exam: Discharge Physical Exam VITALS: T 98.0, HR 68, BP 128/55, RR 14 99%RA GEN: alert and oriented x3, NAD HEENT: palpable carotid pulse CV: RRR, no audible murmurs PULM: CTA bilaterally, no extra work of breathing ABD: soft, TTP RLQ, no rebound/gaurding. Small area of ecchymosisover right groin, soft, no palpable hematoma EXT: WWP, all distal pulses palpable Pertinent Results: ___ 10:20AM BLOOD Hct-34.1* ___ 08:24AM BLOOD WBC-10.2 RBC-3.61* Hgb-11.3* Hct-33.4* MCV-93 MCH-31.3 MCHC-33.8 RDW-12.1 Plt ___ ___ 01:11AM BLOOD Hct-30.5* ___ 05:30PM BLOOD Hct-32.8* ___ 10:40AM BLOOD Hct-30.8* ___ 07:24AM BLOOD WBC-7.0 RBC-3.39* Hgb-10.8* Hct-31.5* MCV-93 MCH-31.9 MCHC-34.3 RDW-11.9 Plt ___ ___ 09:10PM BLOOD WBC-8.8 RBC-3.88* Hgb-12.2 Hct-36.0 MCV-93 MCH-31.4 MCHC-33.8 RDW-12.3 Plt ___ ___ 08:24AM BLOOD ___ PTT-30.4 ___ ___ 08:24AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-141 K-4.2 Cl-104 HCO3-27 AnGap-14 ___ 09:10PM BLOOD Glucose-108* UreaN-15 Creat-0.7 Na-142 K-3.2* Cl-107 HCO3-25 AnGap-13 ___ 09:30PM BLOOD Lactate-1.9 ___ CTA abdomen/pelvis AWAITING FINAL INTERPRETATION Brief Hospital Course: Mrs. ___ is a ___ year old female with retroperitoneal hematoma after cardiac cath. She was transferred from OSH and admitted on ___. She abdominal pain was stable over the course of her admission as was her hemodynamic status. Serial hematocrits were obtained throughout her admission which were stable. Her admission Hct was 36.0 and her discharge Hct was 34.1 There were no signs of ongoing bleeding or extravasation. On hospital day 1 her diet was advanced and all of her home medications were started. She had an uneventful hospital stay and on ___ a repeat CTA abdomen/pelvis was obtained which revealed a stable-to-slightly decreased hematoma. At the time of discharge on ___, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She was instructed to call the office to set up a follow-up appointment with Dr. ___. Medications on Admission: 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Metoprolol Tartrate 25 mg PO BID 5. Valsartan 20 mg PO DAILY 6. Simvastatin 10 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Metoprolol Tartrate 25 mg PO BID 5. Valsartan 20 mg PO DAILY 6. Simvastatin 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: retroperitoneal hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted on ___ for management of your right lower quadrant retroperitoneal hematoma. You were observed with serial blood tests to check your blood levels which remained stable throughout your admission. You had a repeat CTA abd/pelvis on ___ prior to your discharge which showed a stable hematoma. You will have a follow-up appointment with Dr. ___. Please call Dr. ___ office on ___ to schedule, the number is ___. We will also notify the office of your discharge and follow-up appointment needs. Otherwise, you should continue all of your home medications and notify your PCP if anything changes in your health. Followup Instructions: ___

10051850-DS-2

DS

2163-12-14 00:00:00

2163-12-14 15:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right hip pain/fracture Major Surgical or Invasive Procedure: None History of Present Illness: ___ pleasant Femail with pmhx of anemia, schizophrenia, dementia, who was transferred from an outside hospital for a fall with R hip pain. Unable to elicit history ___ patient mental status. CT head/C-spine negative. Past Medical History: None on File Social History: ___ Family History: None on File Physical Exam: AVSS NAD RLE No open wounds observed to move legs, wiggles toes/moves feet; limited by pain Sensation exam deferred ___ mental status wwp distally. 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 hip fracture and was admitted to the orthopedic surgery service. After long discussion with the surgical team, family, palliative care team, nursing staff, and hospice care team. The decision was made to forego surgery at this point and pursue hospice care for comfort. If any questions or concerns arise regarding the hip fracture, may contact Dr. ___ in the ___ Trauma Clinic ___ to schedule appointment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Metoprolol Tartrate 25 mg PO BID 9. Atorvastatin 40 mg PO QPM 10. TraZODone 12.5 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Fentanyl Patch 12 mcg/h TD Q72H RX *fentanyl 12 mcg/hour Apply to affected area q72 Hrs Disp #*100 Patch Refills:*0 5. Glycopyrrolate 0.1-0.2 mg IV Q6H:PRN Dry Mouth 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN Pain - Mild RX *morphine concentrate 20 mg/mL 4 mg by mouth ___ q1H Disp #*100 Syringe Refills:*0 8. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN Agitation 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: R hip fracture (previous hardware in femoral shaft) Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC INPATIENT ADMISSION: - You were in the hospital after fracturing your hip. It is normal to feel tired or "washed out" after this injury. ACTIVITY AND WEIGHT BEARING: per patient comfort MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue medications prescribed under palliative care/hospice team - 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. Physical Therapy: NWB - Activity per patient comfort Treatment Frequency: Per Hospice service Followup Instructions: ___

10051872-DS-13

DS

2174-08-09 00:00:00

2174-08-10 16:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of T1D on Humalog insulin pump (followed by Dr. ___ at ___, HTN, hypothyroid, and recent stroke 2 weeks ago without residual deficits who is admitted for DKA. He reports that his blood sugar has been under good control today (low 200s) until this morning when he noted it to be 220 prior to breakfast. He then went out to eat and when he returned noted his glucose to be in the 500s. He set his pump to deliver additional insulin boluses and reports that he received approximately 1500 units between 3pm and 9pm when he presented to the ___. He typically receives a basal infusion plus boluses of ___ for meals. He reports 3 episodes of NBNB vomiting, no fevers, chills, abdominal pain, diarrhea, dysuria, or cough. No known sick contacts. He was initially diagnosed with T1D in ___ and received an insulin pump ___ years ago. His BG was initially very difficult to control and he reports three prior episodes of DKA, last being in ___ at which time he was thought to have a pump malfunction and it was replaced. At ___, he was found to have a BG in the 500s, Bicarb 11, and anion gap 29 c/w DKA, with WBC of 17. CXR concerning for a possible pneumonia and he was initiated on vanc/zosyn. He was started on an insulin drip, given 2 L of fluids and transferred here since no ICU beds available at ___. The patient felt well on arrival to our ___. Denied any pain and breathing comfortably. Clear lungs and normal heart sounds. Soft and non-tender abdomen. Mild tachycardia (90s-100s) with stable BPs 120-130s/40-50s, SaO2 94-96% RA. He was continued on an insulin drip. ___ L NS administered. Additional ___ L with K running at 250 per hour. Antibiotics continued with Vanc and Zosyn. Labs: WBC 17 -> 20.5, Bicarb 11 -> 8, Glucose 519 -> 425 -> 372, Anion gap 29 - > 25, K 4.7. ROS: Positives as per HPI; otherwise negative. Past Medical History: T1DM Hypothyroid Hypertension Prior CVA Social History: ___ Family History: Not obtained Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: HR 78, BP 134/59, O2 99% RA, BG 465 GEN: Well appearing HEENT: No JVD CV: RRR RESP: CTAB GI: Soft, non-tender, non-distended MSK: No abnormalities SKIN: WWP NEURO: Mentating appropriately, neurologic exam grossly intact DISCHARGE PHYSICAL EXAM: ======================= 24 HR Data (last updated ___ @ 807) Temp: 97.6 (Tm 98.7), BP: 161/88 (139-181/63-92), HR: 64 (55-68), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA GEN: Alert, NAD, appears comfortable CV: RRR; no m/r/g PULM: breathing comfortably, clear to auscultation bilaterally, no wheezes, ronchi or crackles NEURO: AAOx3, grossly intact, moving all 4 extremities spontaneously and with purpose Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 01:20AM BLOOD WBC-20.5* RBC-4.74 Hgb-14.7 Hct-46.4 MCV-98 MCH-31.0 MCHC-31.7* RDW-13.8 RDWSD-49.8* Plt ___ ___ 05:01AM BLOOD ___ PTT-26.5 ___ ___ 01:20AM BLOOD Glucose-425* UreaN-30* Creat-1.4* Na-144 K-4.7 Cl-111* HCO3-8* AnGap-25* ___ 01:20AM BLOOD Phos-4.4 Mg-2.0 ___ 03:25AM BLOOD Beta-OH-4.1* ___ 01:26AM BLOOD Glucose-419* Lactate-2.9* Na-138 K-4.1 Cl-115* calHCO3-9* ___ 03:25AM BLOOD ___ pO2-48* pCO2-20* pH-7.22* calTCO2-9* Base XS--17 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== =========================== REPORTS AND IMAGING STUDIES =========================== ___ IMPRESSION: Low lung volumes. No good evidence for cardiopulmonary abnormality. Although no acute or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma, or other osseous soft tissue abnormality involving the chest wall is clinically warranted, the location of any referable focal findings should be described in the imaging request, clearly marked, and imaged with either bone detail radiographs or Chest CT scanning. ============ MICROBIOLOGY ============ ___ Blood Culture #1 = ___ Blood Culture #2 = ============================ DISCHARGE LABS ============================== ___ 04:43AM BLOOD WBC-9.6 RBC-4.72 Hgb-14.5 Hct-43.0 MCV-91 MCH-30.7 MCHC-33.7 RDW-13.4 RDWSD-45.1 Plt ___ ___ 04:43AM BLOOD Plt ___ ___ 04:43AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-144 K-4.0 Cl-108 HCO3-26 AnGap-10 ___ 04:43AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old man with a history of T1D on Humalog insulin pump (followed by Dr. ___ at ___, HTN, hypothyroid, and recent stroke 2 weeks ago without residual deficits who is admitted for DKA. #Diabetic Ketoacidosis Mr. ___ presented in DKA with anion gap of 25, serum glucose of 425, elevated beta hydroxybuterate and a metabolic acidosis. He was initiated on an insulin infusion, normal saline boluses, and potassium and phosphate repletion. His gap rapidly closed and his beta hydroxy-buterate trended to zero. His acidosis also rapidly resolved. His insulin infusion was eventually weaned down per protocol and when it reached 4u/hour we initiated insulin subcutaneously with a initial basal dose of 28u glargine, standing humalog of 3u per meal and a sliding scale. He was able to eat at this time and he was then transferred to the floor. The etiology of his DKA was not immediately clear. He reports multiple prior episodes. CXR did not reveal pneumonia and a UA at an OSH did not show evidence of infection. His leukocytosis was thought to be reactive. There was concern that his insulin pump may have malfunctioned, though there was no clear evidence this was the case. ___ endocrinology was consulted. FLOOR COURSE: # DKA now resolved: # Type I DM Patient was continued on SC insulin at the time of transfer to the floor. Due to some issue with his insulin order, the patient did not receive his QHS glargine on the evening of ___. Subsequently had high BG readings the next AM w/ sugars in the 400s. He received 28u of lantus and IVF w/ improvement in his sugars. He had his insulin adjusted by ___ and ___ be discharged with a regimen of #######. He will follow up with his endocrinologist, Dr. ___. #Hx recent CVA #Mild aphasia: Patient and his wife were concerned about him exhibiting word-finding difficulties (cardinal symptom noted during stroke a couple weeks ago) and some fine motor difficulties (he was unable to write in his usual cursive and instead tried to write in print, unable to draw his wife a picture and per her is usually a great artist) at the time of his admission to the MICU. This was thought to be most likely recrudescence in the setting of his DKA as it improved w/ treatment of that condition. Patient notably with a recent CVA (2 weeks ago) during which ___ neuro noted reported "L subcortical location and distribution of the stroke is most consistent with a small vessel occlusive mechanism." Carotid U/S noting "Bilateral carotid bulb and proximal ICA soft atherosclerotic plaque, left >right." Carotid disease thought to be possibly the culprit though no residual disease which would be amenable to surgical intervention. TTE fairly unremarkable and w/o e/o intracardiac thrombi. Sent home w/ holter monitor (no results communicated to patient yet). He reports history of intermittent "fast heart rate" but is not sure if it is a-fib and no documented history of this. Per ___ notes appears to be some unspecified SVT, w/ AVNRT noted on tele on the AM of ___. He was monitored for the rest of the admission and with no concern for new deficits which might suggest a CVA. He will be referred to neuro at the time of discharge. #SVT #Likely AVNRT: Patient w/ self-limited episodes of SVT which appeared to be AVNRT on the AM of ___. He was hemodynamically stable and asymptomatic. He reports having palpitations in the past and having "fast heart rates" followed by Dr. ___. Notably not on any nodal blockade as an outpatient. He was started on a low dose of metoprolol, but was limited by bradycardia so he was not discharged on this. # Hypertension: SBP in the 200s overnight on ___ but reassuringly asymptomatic. He continued to have elevated BPs during this admission and so had his antihypertensive regimen titrated. He was on a regimen including an increased dose of lisinopril at the time of discharge. # Leukocytosis: Admitted w/ a WBC of 20K. Thought to be reactive in the setting of DKA. WBC downtrended over the course of the admission, and the patient had no localizing signs/symptoms of infection. CHRONIC ISSUES =============== # Hyperlipidemia: Continued home atorvastatin # Hypothyroid: Continued home levothyroxine TRANSITIONAL ISSUES: ================== []Patient discharged on basal/bolus insulin regimen. He should follow up with his endocrinologist, Dr. ___. []Discharged on Lisinopril 40 for hypertension. Follow up BP for titration of his antihypertensives []Patient referred to neuro for follow up after his recent CVA Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. tadalafil 2.5 mg oral DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Glargine 28 Units Bedtime Humalog 7 Units Breakfast Humalog 7 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) AS DIR 28 Units before BED; Disp #*1 Syringe Refills:*0 RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 5 Units QID per sliding scale 7 Units before LNCH; Units QID per sliding scale 7 Units before DINR; Units QID per sliding scale Disp #*1 Syringe Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY nasal congestion 3. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Levothyroxine Sodium 150 mcg PO DAILY 8. tadalafil 2.5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: DKA SVT Hypertensive urgency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were confused and feeling unwell at home and were found to be in a dangerous condition called diabetic ketoacidosis. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were admitted to the ICU where you were given insulin, fluid, and electrolytes. Your condition improved quite quickly. - You were evaluated by the doctors from ___. Your insulin regimen was adjusted, and you will go out on injectable insulin instead of your insulin pump. - You had elevated blood pressures and had your blood pressure medications increased. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10052077-DS-15

DS

2143-02-03 00:00:00

2143-02-04 21:14:00

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, Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ F with history of chronic abdominal presents wtih 10 days of worsening LLQ pain, now radiating to the back. Pt reports the pain is ___, sharp in character, and focused to the left of her umbilicus. She was admitted for this pain on ___ and the middle ___ at ___, treated for constipation and discharged on both occassions. Her bowel movement frequency improved, but pain did not subside. It has been more generalized in the past, but is now primarily in the LLQ. After her most recent d/c, she was sent out on metamucil, lactulose, and senna. After discharge, she developed fevers to 100.5F with chills over the past 3 days, although currently has no fevers or chills. She says she now has intermittent liquid and hard stools. Also, she has experiened ___ episodes of bilious vomiting over the past 3 days with associated nausea. Last episode of vomiting was yesterday. No blood, mucous in stools. Abdominal pain is relieved by tylenol, not improved or worsened with bowel movements. Regarding her recent w/u of her abdominal pain, she has seen numerous providers and MR enterography, colonoscopy, and egd have not identified an etiology. Additionally, it has been unresponsive to gabapentin, cymbalta, sucralfate, and omeprazole. . She also reports 6 episodes of syncope over the past 4 days, most recently occurred yesterday. Occurrs with standing or bending over, preceded by dizziness. No bowel/bladder incotenence, palpiations, tongue biting, or postictal period. She has attempted to maintain adequate PO but admits that with vomiting and diarrhea, she may not have kept up. Spoke with PCP, reports history of narcotics addiction and rehab wtih chronic abdominal pain. Per patient, no current narcotic use. . She was seen in her urgent care with BP 87/64 and P ___. She was given IV fluids and told to d/c desipramine, start miralax, and hold clonidine. . In the ED, initial vitals 6 98.8 96 98/68 16 99% RA Exam notable for significant LLQ tenderness, rebound pain, but otherwise soft belly, also tenderness throughout back including the CVA. Labs notable for Lip: 49 ALT: 17 AP: 62 Tbili: 0.1 Alb: 4.6 AST: 17. Lactate:1.2 WBC 8.2 PMN:61.0%, U/A was negative, UCG was negative. The pt underwent a CT abdomen whichh showed equivocal wall thickening in the descending colon. She received Dilaudid, 1mg, Ketorlac 30mg Ondansetron 4mg and 1L D51/2NS, Cipro 400mg and Flagyl 500mg. While in the ED, her peripheral IV became infiltrated with IV contrast and she complained of left arm numbness and swelling, seen by plastics who recommended volar splint and elevation. Vitals prior to transfer: Temp: 98 °F (36.7 °C), Pulse: 75, RR: 18, BP: 104/57, O2Sat: 98%, O2Flow: RA, Pain: 1. . Currently, she still complains of abdominal pain adn mild nausea. States that she feels quite a bit better after fluids in the ED. . ROS were otherwise negative in detail. Past Medical History: Chronic abdominal/pelvic pain since ___ fibrocystic breast disease depression anxiety TAH ___ c/b pelvic abscesses c-section ___ Chole ___ Social History: ___ Family History: Father deceased from colon cancer ___ ___ Sister cholecystectomy at ___ ___ Brother with UC Physical Exam: Admission: VS afebrile 106/70 95 18 98% RA Orthostatic 92/55; 55 sitting--> 106/70; ___ standing GENERAL - well-appearing woman in some discomforg HEENT - NC/AT, EOMI grossly in tact, sclerae anicteric, semidry mm, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, no masses or HSM, TTP (mild rebound) in LLQ without guarding, or other peritoneal signs EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs). Left arm in volar splint with swelling of the upper arm noted. SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ Discharge: VS afebrile, normotensive, not tachy Orthostasis resolved GENERAL - well-appearing woman HEENT - MMM, EOMI, PERRL NECK - supple, no JVD LUNGS - CTAB, no w/r/r HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, no masses or HSM, mild TTP in LLQ without peritoneal signs EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), no edema NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ Pertinent Results: Admission: ___ 07:55AM BLOOD WBC-8.2 RBC-4.57 Hgb-13.9 Hct-42.7 MCV-93 MCH-30.4 MCHC-32.6 RDW-13.4 Plt ___ ___ 07:55AM BLOOD ___ PTT-27.1 ___ ___ 07:10AM BLOOD ESR-4 ___ 07:55AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-139 K-4.5 Cl-103 HCO3-28 AnGap-13 ___ 07:55AM BLOOD ALT-17 AST-17 AlkPhos-62 TotBili-0.1 ___ 07:55AM BLOOD Albumin-4.6 Calcium-9.8 Phos-3.7 Mg-2.1 ___ 08:05AM BLOOD Lactate-1.2 . Discharge: ___ 07:10AM BLOOD WBC-8.4 RBC-4.19* Hgb-12.9 Hct-39.6 MCV-94 MCH-30.8 MCHC-32.6 RDW-13.2 Plt ___ ___ 07:10AM BLOOD UreaN-5* Creat-0.7 Na-140 K-4.0 Cl-107 HCO3-24 AnGap-13 . Studies: CT A/P ___ 1. Underdistended descending colon with equivocal wall thickening. This raises the possibility for colitis, but may be an artifact of underdistension and intramural debris; however colonoscopy could be considered for further work-up if there is clinical concern regarding the possibility of mild colitis. 2. Symptomatic extravasation of intravenous contrast (left arm). Brief Hospital Course: Ms ___ is a ___ yo female with a PMH notable for chronic abdominal pain who presents today with 10 days of LLQ pain associate with intermittent nausea/vomitting with subsequent development of syncope Acute #Abdominal Pain - Pt has a long history of abdominal pain and several recent admissions at outside hospitals for constipation. Per the patient, this represents acute on chronic abdominal pain associated now with occasional diarrhea, nausea, vomiting, and syncopal episodes over the past 3 days. CT scan in ED demonstrated equivocal wall thickening with an underdistended colon, concerning for colitis. Pt received cipro and flagyl in ED. However, she had no fever or white count on admission, and antibiotics were not continued. We did not suspect constipation given bowel underdistention and aggressive bowel regimen started at outside hospitals. Additionally IBD was less likely given negative w/u thus far (colonoscopy, EGD, MR enterography in outpatient settings) and normal ESR. IBS or functional abdominal pain remain possible causes of her pain. Would also consider viral gastroenteritis in setting of nausea, vomiting, and diarrhea. Pain was treated with tylenol and toradol and improved by discharge. Her home gabapentin, sucralfate, and omeprazole were continued. Patient was advised to use naproxen for pain management at home. She will follow-up with Dr. ___ in ___ as an outpatient # Syncope - Differential included seizure, cardiogenic syncope, and orthostasis. On admission, she was found to be orthostatic and history was not consistent with seizure. She was monitored on telemetry and no events were observed. Positive orthostatics with recent history of vomiting/diarrhea made orthostasis the most likely cause of syncope. She was aggressively rehydrated with IV fluids. Orthostatics were negative and discharge, and the patients symptoms had improved. She was encouraged to continue hydrating at home. # Nausea/vomiting/loose stools - Pt had three days of nausea, vomiting, and loose stools prior to admission. She had some nausea during her stay, but no vomiting or loose stools. Her nausea was controlled with zofran. In setting of worsened abdominal pain, viral gastroenteritis was suspected. # IV contrast infiltration of arm - CT A/P was complicated by contrast infiltration into the left arm. Patient was seen by plastics who placed arm in volar splint and elevated arm x 2 days. Swelling in arm resolved and pt had full range of motion without pain, numbness, or tingling by day 2. Splint was removed on discharge. Chronic #Anxiety - Continued clonazepam while in house. #Depression - Continued desipramine while in house Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Omeprazole 20 mg PO DAILY 2. Psyllium 1 PKT PO BID:PRN constapation 3. Senna 2 TAB PO HS 4. Desipramine 25 mg PO QHS 5. Ibuprofen 600 mg PO Q8H:PRN pain 6. CloniDINE 0.1 mg PO TID 7. Vivelle-Dot *NF* (estradiol) 0.05 mg/24 hr Transdermal 2x weekly 8. Methocarbamol 1000 mg PO QID 9. Clonazepam 1 mg PO BID 10. Ondansetron 4 mg PO DAILY 11. Gabapentin 400 mg PO TID 12. Acetaminophen 500 mg PO Q6H:PRN pain 13. Sucralfate 1 gm PO BID Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Clonazepam 1 mg PO BID 3. Desipramine 25 mg PO QHS 4. Gabapentin 400 mg PO TID 5. Omeprazole 20 mg PO DAILY 6. Ondansetron 4 mg PO DAILY 7. Sucralfate 1 gm PO BID 8. Vivelle-Dot *NF* (estradiol) 0.05 mg/24 hr Transdermal 2x weekly 9. Methocarbamol 1000 mg PO QID 10. Psyllium 1 PKT PO BID:PRN constapation 11. Senna 2 TAB PO HS 12. Naproxen 250 mg PO Q12H Duration: 2 Weeks Take with food Discharge Disposition: Home Discharge Diagnosis: Primary: Syncope Secondary: Abdominal Pain, Anxiety, IV contrast infiltration of arm 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 while you were admitted here at ___. You were hospitalized because of several episodes of fainting as well as abdominal pain. As you know, your abdominal pain is chronic in nature. The worsened pain could have been due to a virus that caused some inflammation of your colon. This would also explain your nausea, vomitting, and diarrhea, all of which have improved now. We believe your syncope was related to your vomiting and diarrhea. Therefore we treated you with tylenol, IV pain meds, and IV antinausea meds, as well as IV hydration. Your pain improved over the 2 days and your dizziness has, as well. Please continue to hydrate very well. You may take naproxen (aleve) and tylenol for your pain if it persists. Please followup with your PCP and Dr. ___ ___ GI. Followup Instructions: ___

10052193-DS-20

DS

2178-10-18 00:00:00

2178-10-18 16:08:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: morphine Attending: ___ Chief Complaint: Fall with R orbital fracture Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o female presents with right orbital fracture on CT from OSH and right knee pain after a fall this morning. The fall occurred at 2am while she was walking downstairs in her home. She fell forward on the last step and recalls hitting her knee and the right side of her face on the floor. The fall was not witnessed. She lives with her daughter's family, and they found her down immediately after the incident. She remembers the event and there are no reports of LOC by family members. She was taken to an OSH where CT imaging showed evidence of a right orbital fracture. Was referred to ___ to assess need for surgical intervention. She has no reported falls in the past. She has right knee pain ___, some pain on her right flank, and a headache. She denies nausea/vomiting. Past Medical History: Past Medical History: Diabetes HTN Arthritis Past Surgical History: Left knee surgery Cholecystectomy Cataract surgery Social History: ___ Family History: Non-contributory Physical Exam: Discharge Physical Exam: Gen: AAOx3, NAD, lying comfortably in bed HEENT: MMM, no scleral icterus ***** Resp: nl effort, CTABL, no wheezes/rales/rhonchi CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops Abd: +BS, soft, ND, appropriately tender to palpation Ext: WWP, no edema, 2+ DP Physical examination upon discharge: ___ Pertinent Results: ___ 12:34AM GLUCOSE-198* UREA N-19 CREAT-1.3* SODIUM-137 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19 ___ 12:34AM estGFR-Using this ___ 12:34AM WBC-10.7* RBC-3.70* HGB-9.8* HCT-32.4* MCV-88 MCH-26.5 MCHC-30.2* RDW-15.4 RDWSD-49.0* ___ 12:34AM NEUTS-79.2* LYMPHS-11.8* MONOS-6.5 EOS-1.1 BASOS-0.5 IM ___ AbsNeut-8.48* AbsLymp-1.26 AbsMono-0.70 AbsEos-0.12 AbsBaso-0.05 ___ 12:34AM PLT COUNT-224 ___ 12:34AM ___ PTT-31.7 ___ ___ 09:28PM URINE HOURS-RANDOM ___ 09:28PM URINE HOURS-RANDOM ___ 09:28PM URINE UHOLD-HOLD ___ 09:28PM URINE GR HOLD-HOLD ___ 09:28PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 09:28PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 Imaging: Head CT at OSH showed right orbital fracture. CT of high lower extremity w/o contrast: 1. Moderate-to-large high-density joint effusion suggests the possibility of hemarthrosis. 2. No fracture identified. 3. Moderate-to-severe tricompartmental degenerative changes. CT Torso: NO traumatic injuries Assessment/Plan: ___ y/o female with right orbital fracture and right knee pain/swelling s/p fall w/o LOC while walking down the stairs this morning. No concern for neurological injury based on history and physical exam and thus no need for operative management. Right knee is tender with mild swelling, but there is no evidence of fracture on imaging. Plan to discharge home with c Brief Hospital Course: Ms. ___ is a ___ old woman who had fallen down stairs, landing on her right side. She was transferred to ___ on ___ from ___ for further management of a right orbital fracture and R knee swelling and pain. Ophthalmology was consulted and recommended sinus precautions for 1 week, including no nose blowing, no drinking out of straw, no smoking. They also recommended follow up with her regular ophthalmologist in 1 week for dilated fundus exam. She should also seek ophthalmic evaluation sooner as outpatient if she experiences new onset flashes/floaters, diplopia, decrease in vision or other significant ophthalmic concerns. A right lower extremity CT was obtained on ___, which showed knee joint effusion with possible hemarthrosis, no fracture, and severe tricompartmental degenerative changes. Orthopedic surgery was consulted and recommended ACE wrap to right knee for support, weight bearing as tolerated, follow up with PCP and follow up in ___ clinic as needed. On ___, the patient was reported to have a decreased urine output and was given additional intravenous fluids. She had kidney studies done and was reported to be in ___. Her creatinine peaked at 2.8. Her kidney function tests were measured and at the time of discharge her creatinine was 1.2 with a bun of 26. The patient's vital signs remained stable and she was afebrile. She was tolerating a regular diet. She did have some bacteria in her urine but was asymptomatic. In preparation for discharge, she was evaluated by physical therapy who made recommendations for discharge to a rehabilitation facility where the patient could regain her strength and mobility. The patient was discharged on HD #5 in stable condition. Appointments for follow-up were made with the Plastic surgery service and with her primary care provider. Medications on Admission: Atenolol 25 mg PO DAILY Hypertension GlipiZIDE 5 mg PO BID MetFORMIN (Glucophage) 1000 mg PO BID NIFEdipine CR 30 mg PO DAILY Hypertension Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Heparin 5000 UNIT SC BID ___ d/c when patient ambulatory 3. Simethicone 40-80 mg PO QID:PRN bloating 4. TraMADol 25 mg PO Q6H:PRN pain 5. Atenolol 25 mg PO DAILY Hypertension 6. GlipiZIDE 5 mg PO BID 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. NIFEdipine CR 30 mg PO DAILY Hypertension 9. Omeprazole 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right orbital floor fracture Right knee 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 Ms. ___, You were admitted to ___ for evaluation and treatment of your injuries after a fall. Please follow the instructions below to continue your recovery: •Apply ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag. Cover it with a towel and place it on your face for 15 to 20 minutes every hour as directed. •Keep your head elevated: Keep you head above the level of your heart as often as you can. This will help decrease swelling and pain. Prop your head on pillows or blankets to keep it elevated comfortably. •Avoid putting pressure on your face: -Do not sleep on the injured side of your face. Pressure on the area of your injury may cause further damage. -Sneeze with your mouth open to decrease pressure on your broken facial bones. Too much pressure from a sneeze may cause your broken bones to move and cause more damage. -Try not to blow your nose because it may cause more damage if you have a fracture near your eye. The pressure from blowing your nose may pinch the nerve of your eye and cause permanent damage. Contact your primary healthcare provider ___: •You have double vision or you suddenly have problems with your eyesight. •You have questions or concerns about your condition or care. Return to the emergency department if: •You have clear or pinkish fluid draining from your nose or mouth. •You have numbness in your face. •You have worsening pain in your eye or face. •You suddenly have trouble chewing or swallowing. •You suddenly feel lightheaded and short of breath. •You have chest pain when you take a deep breath or cough. You may cough up blood. •Your arm or leg feels warmer, more tender, or more painful. It may look swollen and red. Regarding your knee injury: •Rest your knee so it can heal. Limit activities that increase your pain. •Ice can help reduce swelling. Wrap ice in a towel and put it on your knee for as long and as often as directed. •Compression with a brace or bandage can help reduce swelling. Use a brace or bandage only as directed. •Elevation helps decrease pain and swelling. Elevate your knee while you are sitting or lying down. Prop your leg on pillows to keep your knee above the level of your heart. Followup Instructions: ___

10052340-DS-2

DS

2145-04-06 00:00:00

2145-04-06 17:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Penicillins Attending: ___. Chief Complaint: New Atrial Fibrillation with Rapid Ventricular Response Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old lady with a history of anemia requiring blood transfusions in the past, hypertension, arthritis, and non-obstructive CAD who presented via EMS for weakness, found to have tachycardia and concern for STEMI in the ambulance. Ms. ___ is accompanied by her son and grandson. Today, she was shopping with her grandson when she became short of breath, and initially went to rest in the car for a few minutes while he continued shopping. They went home and then she developed acutely a "funny feeling all over" and right-sided chest discomfort. She has difficulty describing this further. She did have shortness of breath at the time, as well as abdominal discomfort and nausea. She denied lightheadedness, presyncope, syncope, dizziness or radiation. She took a SL nitroglycerin and after her son noticed that she was very pale he called EMS at 2:50. On arrival, they found her to be normotensive but tachycardic to the 200s. She was given 100mg IV amiodarone with improvement in HR. Rhythm strip was concerning for STEMI in III and aVF and code STEMI activated. In the ambulance on the way to BI, she returned to feeling completely normal. On arrival to the ED, she stated she was feeling well, denied nausea and vomiting. She denies any history of arrhythmia or MI. She has never had an experience similar to that of today before. In the ED... - Initial vitals: T 98, HR 90, BP 139/87, RR 18, O2 97%RA - EKG: LLB, no sgarbossa criteria; New afib with rvr - Labs/studies notable for: CBC 6.9>-110.5/32.7-<216 BUN 23, Cr 1.3 (baseline) Trop < 0.01 VBG 7.32 | 48 Lactate 2.5 Serum tox notable for acetaminophen level of 14; o/w negative BNP 1647 (no baseline) Coags wnl CXR with mild pulmonary edema, possible retrocardiac opacification. - Patient was given: ASA 324 On arrival to the floor, she confirmed the above history and feels well without symptoms. Her last bowel movement was this morning. She denies any recent changes in medications, any recent illnesses, any recent travel. REVIEW OF SYSTEMS: Positives in HPI. Otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY - Constipation - Osteoarthritis - Hypothyroidism Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: ___ 1830 Temp: 97.9 PO BP: 117/68 HR: 99 RR: 18 O2 sat: 96% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple, thyroid midline and symmetric. No JVD at 30 degrees. CARDIAC: PMI located in ___ intercostal space, midclavicular line. NR, RR. Normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm. No ___ edema. SKIN: No rashes. PULSES: ___ pulses 1+ bilaterally NEURO: Alert and Oriented x3. Some difficulties with counting backwards from 10. DISCHARGE PHYSICAL EXAM: ========================== 98.2 PO 152/75 57 20 95 Ra FSBG: 95 GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, No JVD at 90 degrees. CARDIAC: irregular rhythm, but regular rate. No murmurs/rubs/gallops. LUNGS: Resp unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NT, mildly distended. No HSM or tenderness. EXTREMITIES: Warm. No ___ edema. Varicose veins b/l lower extremities. SKIN: No rashes. PULSES: ___ pulses 1+ bilaterally NEURO: Alert and Oriented x3. Pertinent Results: ADMISSION LABS: ================== ___ 03:52PM WBC-6.9 RBC-3.49* HGB-10.5* HCT-32.7* MCV-94 MCH-30.1 MCHC-32.1 RDW-13.8 RDWSD-46.9* ___ 03:52PM NEUTS-65.1 ___ MONOS-10.4 EOS-2.3 BASOS-0.6 IM ___ AbsNeut-4.46 AbsLymp-1.45 AbsMono-0.71 AbsEos-0.16 AbsBaso-0.04 ___ 06:50PM BLOOD cTropnT-0.32* ___ 07:28AM BLOOD CK-MB-16* cTropnT-0.48* ___ 10:59PM BLOOD cTropnT-0.76* ___ 03:30PM BLOOD cTropnT-<0.01 ___ 03:37PM GLUCOSE-104 LACTATE-2.5* NA+-141 K+-4.5 CL--104 ___ 03:37PM PO2-28* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--2 COMMENTS-GREEN TOP ___ 03:37PM freeCa-1.16 ___ 03:30PM cTropnT-<0.01 ___ 03:30PM CK-MB-3 proBNP-1647* ___ 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-14 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03:30PM ___ PTT-28.7 ___ ___ 03:30PM ___ DISCHARGE LABS: ==================== ___ 07:50AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.7* Hct-33.4* MCV-93 MCH-29.8 MCHC-32.0 RDW-14.0 RDWSD-47.5* Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD ___ PTT-28.3 ___ ___ 07:50AM BLOOD Glucose-91 UreaN-25* Creat-1.3* Na-139 K-4.4 Cl-103 HCO3-25 AnGap-11 ___ 07:50AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 PERTINENT OTHER STUDIES: =========================== ___ Cardiovascular TTE Report CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy with a moderately increased/dilated cavity. There is mild global left ventricular hypokinesis. There is beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The visually estimated left ventricular ejection fraction is 40-45%. There is no resting left ventricular outflow tract gradient. No thrombus or mass is seen in the left ventricle. 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. An aortic coarctation cannot be fully excluded. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is a valvular jet of moderate [2+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate symmetric left ventricular hypertrophy with moderate cavity dilation and mild global systolic dysfunction. Moderate mitral regurgitation. Mild tricuspid regurgitation. Brief Hospital Course: Ms. ___ is a ___ y/o F with a history of anemia requiring blood transfusions in the past, hypertension, arthritis, hypothyroidism, and non-obstructive CAD who presented via EMS for weakness, found to have atrial fibrillation with RVR, asymptomatic on arrival to ___. # CORONARIES: Unknown # PUMP: EF 40-45% # RHYTHM: Irregularly irregular ACUTE ISSUES ============ # Paroxysmal Atrial Fibrillation with RVR # Non sustained ventricular tachycardia versus Afib with Aberrancy Presented with weakness, dyspnea with HR 200s with initiation of amiodarone gtt by EMS while en route to ___. No history of known atrial fibrillation. Her hospital course was c/b WCT with rates up to 180s concerning for atrial fibrillation with aberrancy vs. ventricular tachycardia. She was monitored on telemetry which was notable for frequent episodes of Non sustained VT as well as intermittent conversion to sinus rhythm. She was initiated on metoprolol PO with ultimate uptitration to 37.5mg every 6 hours. Her blood pressure and heart rates tolerated this well. She was started on a heparin gtt for CHADS-VASc of 5 without significant bleeding history and transitioned to apixaban 2.5 mg BID prior to discharge (secondary to fluctuating renal function per pharmacy). TTE was performed without evidence of focal wall motion abnormalities. # Troponemia Presented with initial concern for STEMI by EMS due to STE in III, aVF. On arrival she was noted to be asymptomatic with LBBB with negative sgarbossa and these elevations were felt to be more likely consistent with early repolarization or demand in setting of tachyarrhythmia. Initial trop negative x 1, however then peaked at 0.76 in the absence of symptoms. She reportedly had a cardiac catheterization at ___ ___ years ago with evidence of non-obstructive CAD per family report. Records were requested from ___ daily, but did not arrive. Her troponemia was felt to most likely be due to demand ischemia in the setting of rapid atrial fibrillation, and in discussion with patient and her son, cardiac catheterization would not be consistent with her goals of care at this time. She was started on aspirin 81 mg daily, and will continue on statin, metoprolol, and imdur. # Heart failure with reduced ejection fraction On arrival, patient was dyspneic while in a-fib with RVR, with elevated BNP, pulmonary edema on CXR. She appeared euvolemic on exam. TTE was obtained with evidence of mild GLOBAL left ventricular hypokinesis, EF 40-45%. TSH nl. Was given intermittent iv diuresis. Discharged on 20mg furosemide PO daily, metoprolol, imdur (home med), statin (home med) CHRONIC ISSUES ============== # Hypothyroidism TSH wnl at 0.63 at last appointment. Continued home synthroid. # CKD Cr 1.32 and eGFR 39 at last PCP ___. Cr remained 1.2-1.4 during admission. # Normocytic Anemia Hb 11.8 with MCV 92.4 at last PCP ___. RDW not elevated. Hgb ranged between ___ during admission without evidence of active bleeding. # Osteoarthritis - Continue Tylenol prn # Hypertension - Continued imdur # HLD - Continued pravastatin TRANSITIONAL ISSUES =================== #discharge weight: 99.57 kg (219.51 lb) #d/c BUN/Cr: ___ [] will need close monitoring of weights while initiating Lasix and chem 7 chem check. Will need to check labs ___ [] Started Aspirin 81mg EC daily [] has f/u with ___ cardiology [] Consider cardiac stress test as outpatient [] consider holter monitor/ziopatch to determine NSVT vs Aberrant afib and overall burden of episodes # CODE: Ok to resuscitate, DNI. - to be discussed with each admission as appropriate. Made aware of conflict between # CONTACT: Son/HCP ___ (___) ___ time 40 min Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Psyllium Powder 1 PKT PO DAILY 4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 5. Vitamin D 1000 UNIT PO DAILY 6. LOPERamide 2 mg PO 8X/DAILY 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 3. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*1 5. LOPERamide 2 mg PO QID:PRN constipation 6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. Psyllium Powder 1 PKT PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13.Outpatient Lab Work Dx: Systolic Heart Failure; ICD 10: I50.2 Labs: chem 10 For/By: ___ Attention: ___, MD Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Atrial fibrillation Troponemia Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you at ___. Why was I here? - You came to the hospital because you were feeling weak - You were found to have an abnormal heart rhythm called atrial fibrillation with fast heart rates What was done while I was here? - You were started on a medication called metoprolol to help with your heart rates - You were also started on a medication called apixaban which is a blood thinner - You had an ultrasound of your heart which showed it wasn't pumping as well as it could be, but the medications you were already on and the new medications we started for you help with this. What should I do when I get home? - Please take all of your medications as prescribed and attend all of your follow up appointments, as listed below. Please review this list carefully and you MUST bring this list and this documentation with you to your upcoming appointments that we have made for you with Dr. ___ here at ___ Cardiology. - You should weigh yourself first thing every morning at the same time. You may need to purchase a scale. You should call your primary care doctor if your weight goes up greater than three pounds between any two days or slowly goes up five pounds over a week or two. They may have to change your new medication, "furosemide" also known as "Lasix." We wish you the best, Your ___ Care Team Followup Instructions: ___

10052530-DS-12

DS

2186-01-27 00:00:00

2186-01-27 11:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Laparoscopy Appendectomy ___ History of Present Illness: Patient presents with 12 hours of acute abdominal pain. Symptoms began suddenly upon waking this AM. Pain was initially at periumbillical area but now radiated to his RLQ. Reports one episode of emesis and anorexia. Denies fever, chills, diarrhea, and urinary symptoms. Has not tried analgesics for symptoms. Upon evaluation. No acute distress. VSS. Abdomen soft, non-distended. He has localized tenderness with rebound at RLQ. Otherwise his abdomen is soft. Pain is reproducible with RLE extension. Also has psoas sign. No rovsing. Work up notable for leukocytosis to ___ with left shift. Imaging demonstrating inflamed retrocecal appendix without signs of perforation. Past Medical History: none Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 98.9, 60, 122/68, 16, 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Tenderness with localized rebound at RLQ. Otherwise is soft, nondistended, nontender. + psoas sign Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 97.8 PO 116 / 68 54 18 97 Ra GEN: Awake, alert, pleasant and interactive. CV: RRR PULM: Clear bilaterally. ABD: Soft, mildly tender incisionally as anticipated, mildly distended. EXT: Warm and dry. 2+ ___ pulses. NEURO: A&Ox3. Follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 12:37PM BLOOD Neuts-91.3* Lymphs-4.3* Monos-3.2* Eos-0.2* Baso-0.5 Im ___ AbsNeut-13.96* AbsLymp-0.66* AbsMono-0.49 AbsEos-0.03* AbsBaso-0.07 ___ 12:37PM BLOOD WBC-15.3* RBC-4.99 Hgb-15.0 Hct-43.0 MCV-86 MCH-30.1 MCHC-34.9 RDW-12.5 RDWSD-38.6 Plt ___ ___ 12:37PM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-141 K-4.5 Cl-100 HCO3-24 AnGap-17 ___ 03:03AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 ___ 6:___BD & PELVIS WITH CONTRAST Clip # ___ IMPRESSION: Acute appendicitis without evidence of gross perforation. Brief Hospital Course: Mr. ___ is a ___ yo M who was admitted to the Acute care surgery Service on ___ with abdominal pain and found to have acute appendicitis on CT scan. Informed consent was obtained and the patient underwent laparoscopic appendectomy on ___. Please see operative report for details. After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquid diet, on IV fluids, and IV dilaudid for pain control. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. 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. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills:*0 4. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: Appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with abdominal pain and found to have an infection in your appendix. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___

10052875-DS-13

DS

2139-09-08 00:00:00

2139-09-08 21:09:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: hay fever / oxycodone Attending: ___. Chief Complaint: fall, fever Major Surgical or Invasive Procedure: Flex sig ___ History of Present Illness: ___ history of HTN, recently diagnosed anal fistulas who initially presented to an OSH after falling at the golf course in the setting of fevers to 102.7 and a month of LLQ abdominal pain. The patient also reports associated intermittent diarrhea, non-bloody. Denies po intolerance or dysuria. Denies prior episodes of similar pain. At the OSH, she underwent CT imaging initially read as concerning for microperforated colitis or diverticulitis, prompting her transfer here. Repeat CT imaging was obtained here due to inability to transfer the imaging from the OSH. Of note, the patient was seen by Dr. ___ in clinic on ___ due to her PCP's concern for perianal disease. She was noted to have a perianal fistula on exam and underwent an MRI pelvis on ___ showing multiple complex anal fistulas; no further work-up or intervention has been performed. Her last colonoscopy was in ___ without concern for IBD and no evidence of diverticulosis; 4 sessile polyps were removed with hyperplastic pathology. Past Medical History: PMH: complex fistula-in-ano HTN PSH: vein stripping (b/l)- ___ excision R breast papillomatosis- ___ Social History: ___ Family History: Denies FH of IBD. Father with colon cancer at age ___. Mother with colon cancer in ___. Physical Exam: ADMISSION EXAM: ========== Vitals-98.00 81 122/71 22 95RA General- no acute distress HEENT- face flushed, PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB Abdomen- soft, moderately tender to palpation in the suprapubic region and LLQ with involuntary guarding, nondistended. No rebound. Rectal exam without palpable mass or gross blood, posterior midline fistula tract noted with scant purulent drainage. Ext- WWP, no edema DISCHARGE EXAM: ========== VS: ___ 1126 Temp: 98.5 PO BP: 116/71 L Lying HR: 86 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. No carotid bruit CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No GU catheter in place MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: abrasion in R temporal area and R shoulder PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ============= ___ 09:38PM BLOOD WBC-9.9 RBC-3.36* Hgb-7.6* Hct-26.7* MCV-80* MCH-22.6* MCHC-28.5* RDW-16.4* RDWSD-46.8* Plt ___ ___ 09:38PM BLOOD Neuts-79.9* Lymphs-9.4* Monos-9.7 Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.92* AbsLymp-0.93* AbsMono-0.96* AbsEos-0.01* AbsBaso-0.02 ___ 09:38PM BLOOD ___ PTT-26.4 ___ ___ 09:38PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-138 K-4.1 Cl-99 HCO3-25 AnGap-14 ___ 09:38PM BLOOD ALT-12 AST-17 AlkPhos-63 TotBili-0.2 ___ 09:38PM BLOOD Lipase-13 ___ 09:38PM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.9 Mg-2.0 ___ 09:38PM BLOOD CRP-89.8* ___ 09:44PM BLOOD Lactate-0.8 IMPORTANT INTERIM RESULTS: ============= ___ 05:13AM BLOOD calTIBC-170* Ferritn-726* TRF-131* ___ 05:00AM BLOOD Triglyc-168* ___ 05:13AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG MICRO: ============= ___ 8:07 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ Blood Culture x1 - NEGATIVE ___ C Diff PCR - NEGATIVE ___ O/P - NEGATIVE ___ O/P - NEGATIVE ___ MRSA SCREEN - NEGATIVE IMAGING: ============= ___ CT ABD/PEL W/ CO 1. Extensive inflammatory change and adjacent phlegmon involving the sigmoid colon greater than the rectum. These findings are consistent with a severe proctocolitis, and Crohn's disease is favored given the presence of a perianal fistula and appearance of penetrating disease. An infectious etiology could also be considered. The appearance and distribution are less compatible with ischemia. 2. No fluid collection. No evidence of perforation. No intrapelvic fistula. 3. Known perianal fistula is better seen on the recent MRI performed ___. ___ CT ABD/PEL W/ CO 1. Redemonstration of extensive inflammatory changes associated with surrounding phlegmon in the sigmoid colon and to a lesser extent the rectum consistent with severe proctocolitis. No evidence of small bowel involvement. 2. Please refer to recent rectal MR for more details on the known perianal fistula, which was incompletely evaluated today. 3. At least 3 hypodense nodules in the pancreas likely dilated side branch ducts, the largest measuring 2.0 cm. See recommendations below. RECOMMENDATION(S): For pancreatic cysts measuring more than 1.5cm, patients should be referred to the pancreas cyst clinic for consultation. These referrals can be made by emailing ___ or by calling ___. For cysts measuring up to 1.5 cm: (a) These guidelines apply only to incidental findings, and not to patients who are symptomatic, have abnormal blood tests, or have history of pancreas neoplasm resection. (b) Clinical decisions should be made on a case-by-case basis taking into account patient's comorbidities, family history, willingness to undergo treatment, and risk tolerance. Local ___ follow-up guidelines adopted from: ___ ___ TTE Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Trace aortic regurgitation. Borderline mildly dilated ascending aorta. DISCHARGE LABS: ============= ___ 05:03AM BLOOD WBC-7.3 RBC-3.25* Hgb-7.4* Hct-26.0* MCV-80* MCH-22.8* MCHC-28.5* RDW-17.5* RDWSD-49.4* Plt ___ ___ 05:03AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-141 K-4.2 Cl-105 HCO3-24 AnGap-12 ___ 05:03AM BLOOD CRP-13.1* Brief Hospital Course: Ms. ___ presented to ___ on ___, arriving from an OSH, after having a fall (syncope) at a golf course, fevers of 102.7F, 1 month LLQ abd pain, with nonbloody diarrhea intermittently. She was transferred from the OSH to surgical service after being found on CT to have a possible microperforated colitis/diverticulitis. SURGERY HOSPITAL COURSE: She was seen colorectal surgeon Dr. ___ had an MRI in ___ showing multiple complex anal fistulas. Upon admission, pt was admitted to the colorectal surgery service treated with Zosyn, made NPO w IVFs, received serial abdominal exams, had her CRP trended, stool studies (Cdiff, O&P - r/o infectious colitis), with a GI and medicine consult. CV: Medicine was consulted for a syncope work up and had EKGs, TTE, as well as telemetry performed. EKGs - showed NSR with PACs TTE - IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Trace aortic regurgitation. Borderline mildly dilated ascending aorta. Telemetry - no arrhythmias reported. Syncope work up was not pursued further inpatient with a stress test recommended outpatient. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. She had good pulmonary toileting, as early ambulation were encouraged throughout hospitalization. GI: Pt initially received a repeat CT abd/pelvis with contrast because of inability to obtain OSH records. CT abd/pelvis w contrast showed - IMPRESSION: 1. Redemonstration of extensive inflammatory changes associated with surrounding phlegmon in the sigmoid colon and to a lesser extent the rectum consistent with severe proctocolitis. No evidence of small bowel involvement. 2. Please refer to recent rectal MR for more details on the known perianal fistula, which was incompletely evaluated today. 3. At least 3 hypodense nodules in the pancreas likely dilated side branch ducts, the largest measuring 2.0 cm. See recommendations below. She was started on Zosyn and then changed to ceftriaxone/metronidazole -> swapped during admission to ___/metronidazole, to be continued outpatient until repeat CT scan in 2 weeks (which abx can be d/c'ed if improvements on imaging). Pt was made NPO w IVF and had a PICC placed with Nutrition recommending initiation of TPN. GI was consulted and recommended infectious colitis work up (O&P, c.diff), hepatitis serologies, a quant gold, clear liquid diet attempt, abx, planned scope, CRP trending. GI also recommended a repeat CT in 2 weeks to ensure improvement with long term management including a full colonoscopy (luminal and TI eval w dx biopsies - prior to antiTNF initiation). She received a flexible sigmoidoscopy during her stay which showed: Erosions, friability and severe inflammation of the rectum and sigmoid though with preferential involvement of the rectum. Biopsies taken. In combination with anal fistulae, as discussed before, this most likely represents new diagnosis of Crohn's disease. GU: UA and urine cultures were negative. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: Pt was tested for C.diff, HBV serologies, TB quantiferon gold (pre-biologic rx initiation testing), blood and urine cxs, MRSA. MRSA, HBV, blood and urine cx's, cdiff were negative. She was started on Zosyn and then changed to ceftriaxone/metronidazole -> swapped during admission to cipro/metronidazole, to be continued outpatient until repeat CT scan in 2 weeks (which abx can be d/c'ed if improvements on imaging). Heme: The patient received subcutaneous heparin and ___ dyne boots during this stay. She was encouraged to get up and ambulate as early as possible. MEDICINE HOSPITAL COURSE: Patient was transferred to medical team on ___ given ongoing need for inpatient monitoring on antibiotics for treatment of intra-abdominal infection. Antibiotics continued with ciprofloxacin and flagyl. On ___, CRP down to 13 and patient feeling significantly better. After discussion with GI team, patient stable for discharge. Plan to continue these antibiotics on discharge, with final course to be determined by GI after follow-up arranged in Dr. ___. GI will arrange repeat imaging at that time. In regards to syncope, patient did not seem to actually syncopize, rather fell over and hit her head on the ground with minor abrasions. EKG with nonspecific T wave changes and TTE with mild hypokinesis in distribution of single vessel. Very low suspicion for acute coronary event. Patient will follow up with PCP for outpatient stress test. TRANSITIONAL ISSUES: [] Outpatient stress test scheduled by PCP to evaluate changes on TTE [] GI follow-up will be arranged by their clinic and patient will be contacted [] QUANT-GOLD pending on discharge (drew on ___ but issue with tubes, so re-drawn on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. raloxifene 60 mg oral DAILY 2. Rosuvastatin Calcium 20 mg PO QPM 3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Take until your GI follow-up, final course to be determined by repeat imaging. RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO TID Take until your GI follow-up, final course to be determined by repeat imaging. RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*63 Tablet Refills:*0 3. raloxifene 60 mg oral DAILY 4. Rosuvastatin Calcium 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Inflammatory bowel disease/Crohn's Disease Fistula with abscess Fall 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 for fever, fall, and found to have GI fistula with infection. You were started on antibiotics and seen by GI, who performed a flexible sigmoidoscopy which showed inflammation in your colon consistent with likely new diagnosis of Crohn's Disease. You will continue antibiotics, and will need to follow-up closely with GI after discharge to determine the further course of action and have discussions about treating the Crohn's. It was a pleasure taking care of you! Sincerely, your ___ Team Followup Instructions: ___

10052992-DS-11

DS

2124-09-05 00:00:00

2124-09-09 12:32:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: Colonoscopy ___ Percutaneous cholecystostomy tube placement ___ History of Present Illness: ___ yo M, ___ dialect) speaking, w/ hx of HBV/HCV cirrhosis (c/b portal HTN, no varices; c/b HCC s/p resection ___, HTN presenting with BRBPR. He was admitted last week ___ an incidental finding of acute cholecystitis found on an MRI that was performed to assess for HCC recurrence. He was treated non-operatively with abx (unasyn -> cipro/flagyl); discharged ___ to complete 14 day course. He now re-presents with 2 days of bright red blood per rectum. History is obtained from the patient's son via an interpreter. The patient's son reports that he has been newly passing bright red blood mixed with stool. He estimates the quantity at ___ tbsp per episode. He has not had any melena, and further denies abdominal or rectal pain. His son was concerned because this reminded him of a prior episode in which his father had bloody emesis; however, he denies that his father has had any emesis since discharge. ROS further negative for fever/chills, nausea, diarrhea. ED COURSE: - VS 97.9; HR 63-68; BP 97/67-122/71; RR 18; 99% on RA - Initial exam: well-appearing, minimal epigastric tenderness, guiac positive stool in vault On admission to the floor he is well-appearing, in no distress, and has not yet had a bowel movement. Past Medical History: HBV, HCV, h/o hepatitis E infection HCC (presumed) s/p resection in ___ Cirrhosis c/b UGIB ___ (EGD: portal hypertensive gastropathy, no varices) HTN HLD GERD Hearing loss Resection of HCC (segment V/VI) in ___ ___ Social History: ___ Family History: No liver disease, problems with bleeding or anesthesia. Physical Exam: ADMISSION PHYSICAL EXAM: = = ================================================================ VS - 97.3; 119/71; 63; 18; 96% on RA (beta blocked) Gen - very pleasant elderly M in no distress; lying comfortably in bed with his home blankets; ___ speaking; hard of hearing HEENT - anicteric, PERRL, MMM, upper dentures; erythema in the posterior oropharynx Cor - regular, no MRG Pulm - comfortable on room air; clear throughout Abd - soft, normoactive bowel sounds, non-tender throughout Rectal - deferred, guiac positive in ED, known hemorrhoids Extrem - warm, no edema Neuro - no asterixis DISCHARGE PHYSICAL EXAM: = = = ================================================================ Vitals - T 97.7 120/78 51 18 99%RA, PTBD output 100 cc overnight General - Lying in bed in NAD, speaking with interpreter in ___ HEENT - Conjunctiva clear/sclera anicteric, EOMI, MMM. Heart - S1/S2 no m/r/g. Pulm - CTAB, normal respiratory effort ___ - Soft, no tenderness in RUQ, negative ___ sign, nondistended, normoactive bowel sounds, no peritoneal signs or palpable organomegaly, PTBD in place, draining thick sanguineous fluid Extr - warm, no edema Neuro - A/Ox3, awake/appropriate, no asterixis Skin - non-jaundiced, no spider angiomata or distension of abdominal wall vessels Pertinent Results: ADMISSION LABS: = ================================================================ ___ 06:24PM BLOOD WBC-10.0 RBC-4.39* Hgb-15.0 Hct-43.0 MCV-98 MCH-34.1* MCHC-34.8 RDW-13.6 Plt ___ ___ 06:24PM BLOOD Neuts-73.8* ___ Monos-6.3 Eos-1.4 Baso-0.3 ___ 06:24PM BLOOD ___ PTT-41.7* ___ ___ 06:24PM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-134 K-4.1 Cl-101 HCO3-24 AnGap-13 ___ 06:24PM BLOOD ALT-40 AST-61* AlkPhos-115 TotBili-0.7 ___ 06:24PM BLOOD Albumin-3.4* ___ 06:40AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.7 Mg-2.1 ___ 06:26PM BLOOD Lactate-2.1* INTERVAL STUDIES & IMAGING: = ================================================================ ___ ECG Sinus rhythm. Respiratory variation in QRS morphology. Compared to the previous tracing of ___ the rate is slower. Computed QRS duration is slightly narrower. Q waves are no longer seen in leads III and aVF arguing against prior myocardial infarction. Previously described non-specific repolarization abnormalities have improved with taller T wave amplitudes throughout. ___ COLONOSCOPY Findings: Protruding Lesions A circumferential mildly bleeding 5 cm mass was found in the sigmoid colon at around 25cm. The scope could not traverse the lesion and the examination was interrupted. Cold forceps biopsies were performed for histology at the sigmoid mass. Impression: Mass in the sigmoid colon (biopsy) Otherwise normal colonoscopy to sigmoid colon Recommendations: - Differential diagnosis includes neoplastic, ischemic, or inflammatory process which explains patient's hematochezia. Most likely and concerning diagnosis is malignancy. - Recommend CT torso and CEA for staging - Pathology results will be rushed and patient informed as soon as they become available - Follow-up with inpatient Liver team ___ CT ABDOMEN + PELVIS 1. Interval development of a lobulated fluid collection inferior to the inflamed gallbladder consistent with perforated cholecystitis, with gallstones layering within the collection. 2. Approximately 2.5-3 cm partly circumferential mass in the sigmoid colon consistent with the reported malignancy. Lymph nodes in the adjacent mesocolon do not meet CT criteria for pathologic enlargement and mesenteric stranding is nonspecific. No definite evidence of metastatic disease in the abdomen or pelvis. 3. Re- demonstration of 1.5 cm lesion in hepatic segment 7, better depicted on previous MRI, but with probable observation of washout on today's study. This remains suspicious for ___ although today's examination does not meet criteria to assess OPTN features. 4. 7 mm nodularity of the right adrenal gland, which might represent a tiny adenoma, is stable. Nonenhancing possible chronic hematoma inferior to the right adrenal gland is also stable. 5. Stranding along the inferior mesenteric artery distribution. Given thickwalled appearance of the inferior mesenteric artery, superimposed vasculitis is not excluded. ___ CT CHEST 1. Moderate to severe centrilobular and paraseptal emphysema. No metastatic lesions within the lungs. MICROBIOLOGY = ================================================================ ___ 12:00 pm FLUID,OTHER Site: GALLBLADDER **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. DISCHARGE LABS: = ================================================================ ___ 06:45AM BLOOD WBC-7.1 RBC-4.06* Hgb-13.7* Hct-40.9 MCV-101* MCH-33.6* MCHC-33.4 RDW-13.7 Plt ___ ___ 06:45AM BLOOD Glucose-95 UreaN-9 Creat-1.1 Na-136 K-4.0 Cl-103 HCO3-27 AnGap-10 ___ 06:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ yo M, ___ speaking, with history of HBV/HCV cirrhosis (c/b grade 1 esophageal varices, and ___ s/p resection ___, now presenting with painless BRBPR. Active issues. # Ruptured gallbladder: The patient presented for a recent hospitalization (___) where he was found to have cholecystitis. He was managed medically with a 14 day course of ciprofloxacin and metronidazole. While in house for this current admission (CC: ___, he underwent colonscopy, where he was discovered to have a sigmoid mass. He underwent CT imaging of the torso for staging, given his new sigmoid adenocarcinoma, and was incidentally found to have a perforated gallbladder (see IMAGING reports above). He complained of ___ pain in the RUQ and remained hemodynamically stable, with a rather benign abdominal exam, and afebrile. He is s/p PTBD on ___, with tube in place, draining well. The patient will retain the PTBD for decompression and plan for an interval cholecystectomy with Dr. ___. Continue ciprofloxacin 500mg BID, Flagyl 500mg q8h until seen by Dr. ___ as outpatient. # Sigmoid colon mass: on colonoscopy yesterday, a partially obstructing, circumferential mass was identified in the sigmoid colon. Hemoglobin is stable and within normal limits (14.3 mg/dL). Staging torso scan showed no evidence of pulmonary or intra-abdominal metastases. Pathology report of the mass biopsy is consistent with adenocarcinoma. At this point, the patient is still having bowel movements and has a non-distended abdomen; therefore he does not appear to be clinically obstructed. The patient is OK to have a regular diet, but was educated about warning signs of obstruction. It is planned that is to have an interval laparoscopic resection of the mass and interval management of the perforated gallbladder as well. # HBV/HCV cirrhosis: history of decompensated cirrhosis in the setting of upper GI bleed. Currently, MELD 9, ___ class A cirrhosis. No thrombocytopenia, mild elevation of INR to 1.3. Continued home tenofovir for HBV and propranolol for variceal hemorrhage prophylaxis. # Dizziness: the patient reported dizziness, that was improved when sitting. He did not endorse any signs/symptoms of vertigo. His orthostatic vital signs were negative. He denied headache, difficulty hearing, otorrhea or instability. He had no focal neurologic findings. His dizziness/lightheadedness was attributed to fluid status, infection and concomittant use of antibiotics. Inactive issues. # LGIB: Resolved. He remained hemodynamically stable and found on admission to have H/H ___ mg/dL range), which is above his baseline without coagulopathy. He did not require any transfusion of blood products or fluid resuscitation while in house. The etiology of the LGIB was determined to be the sigmoid adenocarcinoma. # HCC: He has history of ___ s/p excision in ___ in ___, now with suspicious 1.8cm lesion seen on repeat liver MRI; this will need to be followed in the outpatient ___ clinic. - Outpatient hepatology follow up # HTN: Currently normotensive, so holding home antihypertensives other than propanolol. Given reports of dizziness, propranolol was held, withotu change in his dizziness. His orthostatic vital signs were negative and he appeared well hydrated. # Portal Hypertensive Gastropathy: discovered on EGD in early ___. Currently managed on propranolol. Plan for 3 month interval EGD to follow up. Outpatient hepatology follow up in ___ for EGD and evaluation of PHG. ****TRANSITIONAL ISSUES:***** - He will continue on cipro 500mg BID, flagyl 500mg q8h (D1 ABX ___ - originally planned for 14 day course, however continued given GB rupture & PTBD placement - He will need outpatient management for laparoscopic cholecystectomy after completion of his antibiotic course - He will need outpatient management for laparoscopic resection of his sigmoid cancer - He has history of ___ s/p excision, now with suspicious 1.8cm lesion seen on repeat liver MRI; this will need to be followed in the outpatient ___ clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Docusate Sodium 100 mg PO BID 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 6. Acetaminophen 500 mg PO Q6H:PRN pain or fever 7. Gemfibrozil 600 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Potassium Chloride 10 mEq PO DAILY 11. Propranolol 20 mg PO BID 12. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain or fever 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 5. Pantoprazole 40 mg PO Q24H 6. Propranolol 20 mg PO BID 7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 8. Amlodipine 10 mg PO DAILY 9. Gemfibrozil 600 mg PO DAILY 10. Losartan Potassium 100 mg PO DAILY 11. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: lower GI bleed secondary to mass in the colon Secondary diagnoses: cholecystitis, HBV + HCV cirrhosis, HCC s/p partial resection, HTN, portal hypertensive gastropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure being part of your care at ___. You were admitted to the hospital due to blood in your stools. You underwent a colonoscopy which showed a mass in your colon. You were also continued on antibiotics for cholecystitis (inflammation of the gallbladder). After discharge, please follow up with your outpatient providers as described below, including your liver doctor, and the surgeons for your gallbladder and colon mass. It was a pleasure caring for you! We wish you a speedy recovery. - Your team at ___ Followup Instructions: ___

10052992-DS-18

DS

2128-10-25 00:00:00

2128-10-25 15:28:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bright red blood in stools Major Surgical or Invasive Procedure: None. History of Present Illness: PCP: ___. ___ -- ___ (___) CC: ___ bleeding HISTORY OF PRESENT ILLNESS: =========================== Mr. ___ is a ___ with history of HTN, HLD, CRC s/p sigmoidectomy/FOLFOX (___) and HCV + HBV c/b cirrhosis and HCC s/p resection/adjuvant chemo c/b recurrence and lung mets (___) who presents with BRBPR in setting of anticoagulation for recent PE. History taken from son and chart. Mr. ___ was discharged from ___ ___ for hospitalization where he was found to have metastatic HCC to the lung as well as new PE. He was discharged on 3 days of Lovenox, with instructions to switch to apixaban on ___. Son reports that patient only just filled the apixaban script prior to presenting to the ED on ___ and has not been taking any anticoagulation since his Lovenox ran out on ___. By report, the patient has been experiencing rectal urgency and tenesmus for the last ~20 days. 3 days PTA, he began noticing blood in the toilet bowl. Since then, he has been having ___ very small bowel movements per day, all with bright red blood. He denies pain with defecation, lightheadedness or presyncope, and his appetite is minimal at baseline. He endorses 2 episodes of non-bloody emesis- toward the end of his second episode he had streaks of emesis but no frank blood. He denies generalized itchiness and his son reports he does not look more jaundiced than usual. He reports ~10 days of mild hemoptysis that he attributed to his lung met, but he has not had any hemoptysis since the rectal bleeding began. Yesterday morning (in the ED) he began experiencing ___ right frontal headaches that are non-positional and do not change withneck flexion, as well as mild lower abdominal/suprapubic pain. He had a paracentesis ___ with removal 3.4L, negative for SBP - PMNs 60. Since then his son reports that his abdominal swelling has slowly re-accumulated but is not as tense or distended as it was prior to the paracentesis. He does not get regular paracenteses. In the ED, vitals were: T 96.7 HR 76 BP 113/77 RR 18 O2 Sat 98% RA Exam: No acute distress RRR, no m/r/g Lungs CTAB Distended abdomen w/ ascites, nontender No spider angiomas/nail changes No asterixis Labs: CBC: WBC 3.4, Hb 11.6 from nadir of 10.8, Plt 89 BMP: Na 137, K 4.9, Cl 110, HCO3 19, BUN 14, Cr 1.0, Ca 8.2, Mg 2.4, Ph 1.9 LFT: ALT 176, AST 685, AP 238, Tbili 7.7. Alb 2.5 Lactate 2.4 UA with 2+ urobilinogen, otherwie unremarkable UCx pending Studies: Colonoscopy ___: internal hemorrhoids, no active bleeding. Also showed small angiodysplasia and submucosal mass RUQUS ___ 1. Cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy. These masses are better evaluated on the previously performed CT abdomen pelvis. 2. Nonocclusive thrombus in the main portal vein with reversal flow. Main portal vein velocity is 12.2 cm/s. 3. Reversal of normal directional flow in the right portal vein. There is appropriate directional flow in the left portal vein. 4. Moderate volume ascites in all 4 abdominal quadrants. 5. Splenomegaly. He was given: For GIB: 2L LR, CTX 1g IV (ppx) For BP: home amlodipine He also got fleet enema in preparation for his colonoscopy. On arrival to the floor, patient reports that he has ___ headache which is improved compared to the ED. He also reports a little abdominal discomfort and fullness. He feels cold which is his baseline. He does not have any dizziness or lightheadedness. He does not have any blurred vision, palpitations, or shortness of breath. He denies any fever, chills or sweats. No abdominal pain. His last bowel movement was ___ in the evening. He has not had anything to drink for most of the day. Past Medical History: HCV HBV Cirrhosis HCC s/p resection (___) and RFA (___) c/b recurrence and lung mets (___) Colon CA stage 3B KRAS+ s/p sigmoid colectomy and adjuvant chemo (___) Acute cholecystitis s/p CCY ___ HTN Dyslipidemia GERD Hearing loss Social History: ___ Family History: No pertinent family history Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 98.2, HR 75, BP 120/79, RR 18, SpO2 97% RA GENERAL: Alert and interactive. In no acute distress. ___. HEENT: PERRL, EOMI. MMM. Sclera and soft palate are icteric. Bilateral hearing aids in place. Wearing glasses. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, no organomegaly. Abdomen is visibly distended with shifting dullness to percussion. No tenderness to deep palpation in ___ quadrants or suprapubic EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Diffusely jaundiced with some palmar erythema, no spider angiomata. Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3 but confused about longterm history. Defers to son. Moving all 4 limbs spontaneously. CN2-12 intact.Normal sensation. No asterixis DISCHARGE PHYSCIAL EXAM ======================== 24 HR Data (last updated ___ @ 024) Temp: 98.2 (Tm 98.2), BP: 109/62 (102-115/62-75), HR: 78 (78-82), RR: 18 (___), O2 sat: 95% (95-98), O2 delivery: RA GENERAL: NAD, ___. Son at bedside. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: On RA. CTAB. ABDOMEN: well-healed scar in RUQ from prior procedure. Firm particularly in RUQ, mildly distended, no ttp. EXTREMITIES: Trace ___. SKIN: Diffusely jaundiced in lower extremities. NEUROLOGIC: Awake, not oriented to time (per son, this is baseline). No focal neurologic deficits. Normal gait. Pertinent Results: ADMISSION LABS: ___ 06:15PM BLOOD WBC-4.6 RBC-4.17* Hgb-13.1* Hct-39.0* MCV-94 MCH-31.4 MCHC-33.6 RDW-30.5* RDWSD-102.2* Plt ___ ___ 06:15PM BLOOD Neuts-59.8 Lymphs-17.2* Monos-14.9* Eos-3.4 Baso-1.5* Im ___ AbsNeut-2.77 AbsLymp-0.80* AbsMono-0.69 AbsEos-0.16 AbsBaso-0.___ 06:15PM BLOOD ___ PTT-38.1* ___ ___ 06:15PM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-137 K-4.9 Cl-105 HCO3-21* AnGap-11 ___ 06:15PM BLOOD ALT-176* AST-685* AlkPhos-238* TotBili-7.7* ___ 07:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.8 ___ 06:27AM BLOOD calTIBC-122* Ferritn-397 TRF-94* ___ 06:27AM BLOOD IgM HAV-NEG ___ 07:45AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT ___ 08:06AM BLOOD pO2-70* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Comment-GREEN TOP ___ 06:24PM BLOOD Lactate-2.8* ___ 12:13AM BLOOD Lactate-3.3* ___ 03:04AM BLOOD Lactate-3.0* ___ 03:25PM BLOOD Lactate-2.4* ___ 08:06AM BLOOD Lactate-2.0 DISCHARGE LABS: ___ 07:35AM BLOOD WBC-5.1 RBC-3.01* Hgb-9.8* Hct-29.2* MCV-97 MCH-32.6* MCHC-33.6 RDW-32.1* RDWSD-110.6* Plt Ct-65* ___ 07:35AM BLOOD Glucose-108* UreaN-17 Creat-1.1 Na-141 K-4.1 Cl-112* HCO3-21* AnGap-8* MICRO: ___ 3:16 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 3:16 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): No growth to date. REPORTS: ___ PERITONEAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS ___ LIVER U/S: 1. Cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy. These masses are better evaluated on the previously performed CT abdomen pelvis. 2. Nonocclusive thrombus in the main portal vein with reversal flow. Main portal vein velocity is 12.2 cm/s. 3. Reversal of normal directional flow in the right portal vein. There is appropriate directional flow in the left portal vein. 4. Moderate volume ascites in all 4 abdominal quadrants. 5. Splenomegaly. ___ COLONOSCOPY: POLYPS IN COLON, ANGIOECTASIAS IN COLON, INTERNAL HEMMORHOIDS, PREVIOUS SURGERY IN COLON. Brief Hospital Course: Mr. ___ is a ___ y.o. male patient with HBC, HCV cirrhosis c/b HCC with newly diagnosed lung mets (___), s/p resection ___, RFA to segment VIII lesions, RFA to recurrent lesion ___, adenocarcinoma of colon (s/p sigmoid colectomy and FOLFOX ___, and non-occlusive L portal vein thrombus who was recently admitted for acute RLL subsegmental PE from ___ and re-admitted on ___ for BRBPR likely ___ internal hemorrhoids. Given metastatic HCC, new lesion c/f recurrence of colon adenocarcinoma, all c/b acute PE, Palliative Care was consulted and family decision was made to make pt DNR/DNI with plan to transition to home with hospice. ACUTE ISSUES: ============= # Rectal bleeding # Normocytic anemia # History of colon cancer s/p sigmoid resection in ___ in ___ + FOLFOX: Stage IIIB, T3N1cM0 ___ # New 2cm lesion in neo-sigmoid colon ___ CT abd) Patient presenting with BRBPR likely ___ internal hemorrhoids though possibly also rectal varices given cirrhosis. ___ colonoscopy notable for internal hemorrhoids, non-bleeding angioectasias in colon. Of note patient also restarted apixaban for cancer-associated PE, but did not take this due to inability to fill the medication. He was initially started on hep gtt and apixaban for recent diagnosis of PE, but this was discontinued on ___ given ongoing BRBPR. He continued to have ongoing BRBPR, but reported this decreased compared to admission. He was hemodynamically stable and did not require any transfusions during his hospitalization. #Recent dx PE We discussed the risks of not angicoagulating, to which pt's son agreed to stopping anticoagulation given ongoing BRBPR. # Decompensated cirrhosis c/b coagulopathy # ___ s/p liver resection in ___ ___ # History of HBC and HCV Patient has a long h/o cirrhosis ___ viral hepatitis (HCV and HBV) and c/b HCC. Has historically been well-compensated but presents now in decompensation i/s/o hyperbilirubinemia, elevated LFTs and tumor markers, and coagulopathy. He has a h/o ascites with last outpatient paracentesis on ___, with removal of 3.4L; studies negative for SBP. Repeat para on ___ removed ~2L fluid while inpatient and studies neg for SBP. He was started on PO Lasix 20mg qd + PO spironolactone 50mg qd (___) for abd distension discomfort. #GOC After discussion w/ Pall Care on ___, decision was made to make pt DNR/DNI and plan for home with hospice. He continues to have repeated episodes of BRBPR, though appears to have improved after stopping apixaban for PE. They prefer to have a hospice agency that works with ___ pts. DNR/DNI as of ___. MOLST in chart. #Hemoptysis Presented with blood-tinged sputum during this admission, reportedly had this in the past as well. Likely ___ re-starting AC, though improving. Predisposed to bleeding given pt has cirrhosis, coagulopathy. Per pt, this resolved. # Elevated lactate: 2.8 on arrival increased to 3.0 and then back down to 2.4 with some fluids. UA with trace blood and protein, 11 WBC but no signs of infection. Lactate was wnl on ___. =============== CHRONIC ISSUES: =============== # HCV # HBV # Transaminitis Has a nonocclusive thrombus on RUQUS. Continued tenofovir for now given possible flare of hepatitis if stopped. # Cancer associated pain Received Tylenol up to 2g daily and oxy 5mg prn for pain. # HTN d/c'ed home amlodipine, losartan due to soft pressures (SBP ~100s). # GERD Continued home omeprazole for discomfort from acid reflux. #CODE: DNR/DNI (as of ___ - MOLST in chart). #CONTACT: ___ Relationship: son Phone number: ___ TRANSITIONAL ISSUES =================== []FYI: Pt is DNR/DNI, MOLST form in chart (signed ___. []Holding home lenvatinib (Onc) for the time being. Can consider restarting if within goals of care/offers symptomatic support. []Continued Viread (tenofovir) due to concern for possible hepatitis flare if stopped. Can discontinue if not within GOC. []Consider using dark towels/wipes. Suspect he will have ongoing bleeding from rectum. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Lenvima (lenvatinib) 12 mg oral DAILY 4. Omeprazole 20 mg PO DAILY 5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 6. Propranolol 20 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Losartan Potassium 100 mg PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN acid reflux 2. Furosemide 20 mg PO DAILY 3. Lactulose 15 mL PO DAILY:PRN Constipation - Second Line 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. Senna 8.6 mg PO DAILY 7. Spironolactone 50 mg PO DAILY cirrhosis c/b ascites 8. Docusate Sodium 100 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 11. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 12. HELD- Lenvima (lenvatinib) 12 mg oral DAILY This medication was held. Do not restart Lenvima until you discuss with Dr ___ ___ Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hematochezia Internal hemmorhoids Acute on chronic anemia Colon cancer Recent diagnosis pulmonary embolism Decompensated cirrhosis Coagulopathy Hepatocellular carcinoma Hemoptysis Elevated lactate Transaminitis Secondary Diagnoses: Hypertension Acid reflux History of Hep B, Hep C Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital for blood in your stools. WHAT HAPPENED TO ME IN THE HOSPITAL? - We did a colonoscopy (taking a look inside your gut to figure out where the bleeding was coming from). The bleeding is due to hemorrhoids (dilated veins in your rectum). Your bleeding improved, but you still had some bleeding when you left. -We had our Palliative Care doctors ___. They helped arrange home with hospice services. Hospice is type of care you receive to make people comfortable as they near the end of their lives. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Please call hospice if you have any questions or concerns We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10053000-DS-6

DS

2160-11-25 00:00:00

2160-11-25 15:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / Tetracycline Attending: ___. Chief Complaint: acute diverticulitis Major Surgical or Invasive Procedure: none History of Present Illness: ___ man with history of ANCA positive vasculitis on chronic prednisone,who presents to the ED after 3 days of abdominal pain. Patient reports that he has been having periumbilical bandlike pain since 3 days ago that worsened 1 day ago after a large meal. He continues to pass gas his last bowel movement was yesterday and that was normal, and he does not endorse nausea vomiting. Patient reports that his last episode of diverticulitis was in ___ and his last colonoscopy was done to ___ years ago and was negative. He is admitted to the ED for evaluation of his acute diverticulitis that was found on CT that shows 1.6 cm phlegmonous change in the ascending colon. No drainable collection. He is otherwise feeling well. Past Medical History: HYPERTENSION Hypercholesterolemia ANCA-associated vasculitis Wegener's granulomatosis (granulomatosis with polyangiitis) I do not think he will likely need the medicine BPH (benign prostatic hyperplasia) The patient is having really like seeing the patient because he was cutting the Mosaic Klinefelter syndrome Social History: ___ Family History: No family history of IBD, grandfather with colon cancer at age of ___ Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, mildly tender to palpation on the right lower quadrant, no rebound or guarding, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 02:40PM GLUCOSE-107* UREA N-18 CREAT-0.9 SODIUM-141 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-28 ANION GAP-17 ___ 02:40PM estGFR-Using this ___ 02:40PM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-81 TOT BILI-0.9 ___ 02:40PM LIPASE-42 ___ 02:40PM ALBUMIN-4.4 ___ 02:40PM NEUTS-84.2* LYMPHS-5.8* MONOS-8.4 EOS-0.9* BASOS-0.2 IM ___ AbsNeut-14.52* AbsLymp-1.01* AbsMono-1.45* AbsEos-0.16 AbsBaso-0.04 ___ 02:40PM PLT COUNT-238 ___ 02:40PM PLT COUNT-238 ___ 02:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Brief Hospital Course: ___ w h/o ANCA+ vasculitis on chronic steroid p/w acute diverticulitis. The patient was placed on IV abx and pain meds. The patients pain improved on HD2. ON HD3, Mr. ___ was transitioned to PO Abx and pain peds. He was given a regular diet. Mr. ___ was discharged from the hospital on HD3 in stable condition. He was tolearing a regular diet, voiding, but still mildly tender on abdominal exam. He was asked to follow up in ___ clinic and placed on a total of 10 days of cipro/flagyl. Medications on Admission: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10 Capsule Refills:*0 3. amLODIPine 2.5 mg PO DAILY 4. Lisinopril 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*16 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10 Capsule Refills:*0 5. amLODIPine 2.5 mg PO DAILY 6. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner 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. Followup Instructions: ___

10053139-DS-11

DS

2179-05-09 00:00:00

2179-05-09 13:43:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: penicillin Attending: ___ Chief Complaint: jaundice Major Surgical or Invasive Procedure: ERCP w sphincterotomy and stent placement ___ History of Present Illness: Ms. ___ is a ___ female with past medical history of type 2 diabetes, diabetic neuropathy, and hypercholesterolemia who presents with painless jaundice. Patient states that 3 weeks ago she had an acute diarrheal illness with frequent frothy stools lasting for approximately 7 days. Symptoms resolved and patient has been feeling relatively well however ___ days ago has noticed yellowing of her eyes and skin. On questioning has remarked that her urine has been quite dark over the last several weeks as well. Otherwise denies fevers, chills, headache, sore throat, cough, lymph node swelling, chest pain, palpitations, dyspnea, nausea, vomiting, abdominal pain, blood in her stools, dysuria, unusual joint pains or muscle aches, focal weakness. Endorses bilateral lower extremity neuropathy that has been chronic. Estimates that she may have lost approximately 5 pounds in the last week. Past Medical History: # T2DM # Diabetic neuropathy # Hyperlipidemia Social History: ___ Family History: No family history of cancer of liver disease. Physical Exam: ADMISSION EXAM VITALS: ___ Temp: 98.0 PO BP: 129/60 R Sitting HR: 70 RR: 16 O2 sat: 95% O2 delivery: RA GENERAL: Alert and in no apparent distress, markedly jaundiced EYES: Scleral icterus ENT: OP clear with MMMs JVP: Not elevated CV: S1 S2 RRR without audible M/R/G RESP: Lungs clear to auscultation bilaterally without rales or wheeze. GI: Abdomen soft, mildly distended, non-tender to palpation. Bowel sounds present. Palpable liver edge. GU: No suprapubic fullness or tenderness to palpation EXTREM: No edema SKIN: Jaundiced. NEURO: Alert, detailed and fluent historian. No pronator drift. No asterixis. PSYCH: pleasant, appropriate affect ========= DISCHARGE EXAM AVSS pleasant, NAD NCAT, scar over forehead well-healed, mild dysarthria per baseline RRR CTAB sntnd wwp, neg edema jaundice, icteric, subglossal icterus A&O grossly, MAEE, gait wnl, CN II-XII intact except mild scarring effect causing decreased L facial asymmetry on smiling Pertinent Results: ADMISSION RESULTS ___ 02:04PM BLOOD WBC-8.3 RBC-3.30* Hgb-10.1* Hct-30.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-19.9* RDWSD-66.6* Plt ___ ___ 02:04PM BLOOD Neuts-66.8 ___ Monos-7.7 Eos-1.2 Baso-0.2 Im ___ AbsNeut-5.53 AbsLymp-1.91 AbsMono-0.64 AbsEos-0.10 AbsBaso-0.02 ___ 08:50AM BLOOD ___ PTT-32.7 ___ ___ 02:04PM BLOOD Glucose-238* UreaN-14 Creat-0.4 Na-136 K-3.6 Cl-103 HCO3-22 AnGap-11 ___ 02:04PM BLOOD ALT-221* AST-146* AlkPhos-1315* TotBili-13.5* ___ 02:04PM BLOOD Albumin-3.4* ___ 02:04PM BLOOD ___ pO2-59* pCO2-40 pH-7.41 calTCO2-26 Base XS-0 ========== PERTINENT INTERVAL RESULTS ___ BCx NGTD x2 ___ Conclusion: Intrahepatic, extrahepatic Biliary dilatation with distended Courvo___ appearance of gallbladder. Gallbladder contains sludge, no definite stones. Common duct 12.4 mm. 2. No pancreas duct dilatation seen. Pancreas head obscured by gas. Further evaluation of the pancreas with CT recommended. 3. Otherwise Normal ultrasound survey of upper abdomen and retroperitoneum. ERCP: 1.5cm indeterminate stricture at distal CBD, successful ERCP with brushing and biliary stent placement across CBD stricture; biliary duct deeply cannulated with sphincterotome, cannulation moderately difficult, ___ 7cm straight plastic biliary stent placed successfully CTA PANCREAS PROTOCOL: Final Report EXAMINATION: CTA PANCREAS (ABDOMEN AND PELVIS) INDICATION: ___ year old woman with painless jaundice, head of pancreas obscured on ___ at ___// r/o pancreatic cancer TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.3 s, 47.2 cm; CTDIvol = 18.8 mGy (Body) DLP = 874.5 mGy-cm. Total DLP (Body) = 875 mGy-cm. COMPARISON: None. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. A biliary stent is in place. There is mild intrahepatic biliary ductal dilatation, and few foci of air within the biliary tree. The common bile duct is dilated, measuring up to 1.3 cm, with abrupt cutoff in the pancreatic head (05:40). Gall bladder is distended. The wall is not thickened. Hyperdense content suggests presence of stones or sludge within the gall bladder lumen. PANCREAS: The pancreatic body and tail are atrophic. The main pancreatic duct is dilated, measuring up to 8 mm, with abrupt cutoff within the pancreatic head (05:36). A side branch in the uncinate process is dilated to 5 mm (05:42). There is a 6 mm hypodensity in the pancreatic head, just anterior to the stent (03:45). No discrete masses visible, but these finding suggest presence of an occult pancreatic masses causing biliary and pancreatic ductal obstruction. There is no peripancreatic stranding. There is no vascular involvement. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There are bilateral renal cysts, measuring up to 1.5 cm in the interpolar region of the right kidney and 2.2 cm in the interpolar region of the left kidney, as well as additional bilateral subcentimeter hypodensities too small to characterize by CT. There are also peripheral striations to the nephrogram of each kidney suggesting either acute or chronic parenchymal disease versus fairly uniform bilateral appearance of scarring. There is no renal stenosis. There is no evidence of stones or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. There are few prominent lymph nodes, for example, a hepatic artery lymph node measuring 8 mm (03:30) and a porta hepatis lymph node measuring 8 mm (___:43). PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Calcifications are noted within the uterus, likely representing degenerated fibroids. BONES: There is a mild anterior compression deformity of L2. There are moderate multilevel degenerative changes. No suspicious bone lesions are found. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild intrahepatic biliary dilatation, and dilation of the CBD, with abrupt, within the pancreatic head, with biliary stent in place, as well as dilation of the main pancreatic duct and of a pancreatic side branch in the uncinate process, also with abrupt cutoffs in the pancreatic head. Findings are highly suggestive of an otherwise occult pancreatic head mass. There is no evidence of local invasion or metastatic disease. 2. Mild anterior compression deformity of L2 is likely chronic. ======== DISCHARGE RESULTS ___ 05:40AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.2* Hct-31.3* MCV-93 MCH-30.4 MCHC-32.6 RDW-19.8* RDWSD-67.6* Plt ___ ___ 05:40AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-140 K-3.9 Cl-102 HCO3-24 AnGap-14 ___ 05:40AM BLOOD ALT-204* AST-138* LD(LDH)-152 AlkPhos-1105* TotBili-8.3* ___ 07:21AM BLOOD %HbA1c-6.3* eAG-134* ___ 05:40AM BLOOD CA ___ -PND Brief Hospital Course: ___ w DM, neuropathy p/w painless jaundice and weight loss c/f malignant stricture. ACUTE/ACTIVE PROBLEMS: # Painless jaundice, with ultrasound evidence of intra- and extra-hepatic biliary dilatation, CBD 12.4mm. No signs/symptoms of active cholangitis at this time. Underwent ERCP on ___ with sphincterotomy and stent placement. CTA pancreas obtained with findings concerning for occult pancreatic malignancy. Brushings pending at time of discharge. Pt will be contacted by ___ team with results and if results c/f malignancy, ERCP will arrange outpatient oncology follow up. If brushings are negative (only 60% sensitive in pancreatic malignancy) will need endoscopic ultrasound. Bilirubins improved with above mgmt. with improvement in clinical jaundice. CHRONIC/STABLE PROBLEMS: # T2DM: held home metformin while inpt, continued home humalin (70/30) at 16u qam, 10 qpm per home regimen. A1c 6.8, so decreased home 70/30 insulin to 10u BID. # Diabetic neuropathy: continued home duloxetine, pregabalin # Hyperlipidemia: continued home simvastatin >30 minutes spent on patient care and coordination on day of discharge. TRANSITIONAL ISSUES - biliary brushing cytology results pending at time of discharge; to be followed up by ___ team; if positive, patient will be referred by ___ team to ___ oncology; if negative, patient will require EUS; please ensure this process occurs - please monitor LFTs as outpatient within next week and monitor for resolution of jaundice; if does not resolve, may require further procedures e.g. PTBD versus repeat ERCP - stent placed by ___, removal will be arranged by their service; please ensure patient has follow up scheduled - given A1c 6.8 and age/co-morbidities, decreased insulin to 10U BID from 16 qam /10 qpm - ___ pending at time of discharge; please follow up final result - blood cultures at ___ and ___ pending at time of discharge but do not expect these to be positive; please follow up final results Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO DAILY 2. Simvastatin 40 mg PO QPM 3. DULoxetine 60 mg PO DAILY 4. Pregabalin 50 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 8. NovoLIN 70/30 U-100 Insulin (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous BID Discharge Medications: 1. NovoLIN ___ FlexPen U-100 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous BID Please now take 10 units twice a day. 2. Aspirin 81 mg PO DAILY 3. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg) oral DAILY 4. DULoxetine 60 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO DAILY 6. Pregabalin 50 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: jaundice biliary stricture pancreatic mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ was a pleasure caring for you. You were admitted for yellowing of your eyes and skin ("jaundice"). We believe this was caused by a mass in your pancreas leading to a blockage in your bile ducts. We are concerned this mass is a cancer, but we are awaiting test results. You will be contacted with the results of the brushings and will make a plan with the ERCP doctors for follow up, including when to replace your stent as an outpatient. Please contact your PCP and have your labs checked again in the next week to ensure the jaundice is continuing to resolve. We also decreased your insulin because your sugars were a little more tightly controlled than necessary. We wish you the best in your recovery! Followup Instructions: ___

10053207-DS-9

DS

2199-12-22 00:00:00

2199-12-22 13:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Haldol Attending: ___. Chief Complaint: Abdominal Pain, Diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o F with history of bipolar disorder, prior TKA with subsequent C.diff infection in ___ in setting of prolonged antibiotic course, and subsequent recurrent infection ___ presents with cough, diarrhea, and vomiting. Patient states she's had abd pain for "some time" but can't clarify. Also endorses intermittent diarrhea but is unable to provide additional details. She lives at a nursing home where she states everyone has been coming down with a similar virus. Recent flu swab negative on ___ and there is report she was seeen recently at ___. E___ ED for similar symptoms. per nursing home, pt is incontinent of urine at baseline. Received Rocephin IM yesterday. ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: Triage 13:18 0 96.8 127 122/69 18 96% - EKG: Sinus tach @126, LAD, NI, nonspecific ST-T changes, STP - labs showed: Lactate:1.4. UA positive for nitrites, >182 WBC. chem: (hemolyzed) 134/5.1; 105/17; 61/2.9 <96 (b/l creatinine several years ago 1.2). Mg 1.4. ALT: 51 AP: 89 Tbili: 0.2 Alb: 3.0 AST: 63. Lip 26. CBC: 6.9 > 9.3/29.5 <341. PMNs 45%, 2 bands. - imaging: CXR: R base lung opacity, dilated loops of bowel - KUB: Markedly distended colon, similar to prior scan from ___. Deferred CT abd at this time - Rectal temp: 100.6. Guiac+ - interventions: Pt received 3L NS, 1gm vanc, 750mg IV levaquin, and 1g CTX Pt admitted to medicine for UTI, PNA, ___, drop in Hct. v/s prior to transfer: sleeping 99.6 129 136/80 26 95% RA On arrival to the MICU, she is comfortable with normal stable vitals with the exception of HR in the 130 range. She reports abdominal pain, no recent nausea/vomiting, and has several large watery bowel movements. Denies hematochezia or melena. Past Medical History: 1. Bipolar disorder. 2. Nonhealing cellulitis ___. 3. Spinal stenosis. 4. Osteoarthritis. 5. History of delirium. 6. Left ___ complicated by PJI of unknown etiology, s/p IV vancomycin and oral suppressive doxycycline x 6 months which finished on ___. 7. Right ___. 8. Cholecystectomy. 9. C. diff colitis in ___, treated with flagyl, followed by recurrent C. diff infection ___ s/p course of flagyl Social History: ___ Family History: NC Physical Exam: ADMISSION EXAM: General- well-appearing obese woman in no distress fully oriented. HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- diffuse crackles, distant breath sounds CV- tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen- tender to palpation diffusely GU- foley in place Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal no asterixis/tremor Pertinent Results: ADMISSION LABS: ___ 01:55PM BLOOD WBC-6.9 RBC-3.28* Hgb-9.3* Hct-29.5* MCV-90 MCH-28.3 MCHC-31.4 RDW-16.2* Plt ___ ___ 01:55PM BLOOD Neuts-45* Bands-2 ___ Monos-31* Eos-0 Baso-0 ___ Metas-3* Myelos-0 ___ 03:28AM BLOOD ___ PTT-35.9 ___ ___ 01:55PM BLOOD Glucose-96 UreaN-61* Creat-2.9*# Na-134 K-5.1 Cl-105 HCO3-17* AnGap-17 ___ 01:55PM BLOOD ALT-51* AST-63* AlkPhos-89 TotBili-0.2 ___ 01:55PM BLOOD Lipase-26 ___ 03:28AM BLOOD CK-MB-5 ___ 01:55PM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.8 Mg-1.4* ___ 02:07PM BLOOD Lactate-1.4 OTHER RELEVANT LABS: ___ 03:28AM BLOOD CK-MB-5 ___ 03:28AM BLOOD TSH-0.79 ___ 04:12AM BLOOD tTG-IgA-PND ___ 02:20PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 02:20PM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 02:20PM URINE RBC-36* WBC->182* Bacteri-MANY Yeast-NONE Epi-4 ___ 02:21PM URINE Hours-RANDOM UreaN-327 Creat-21 Na-77 K-7 Cl-75 ___ 02:20PM URINE Hours-RANDOM Creat-47 Na-30 K-23 Cl-32 HCO3-LESS THAN ___ 02:21PM URINE Osmolal-298 ___ 02:20PM URINE Osmolal-273 MICRO LABS: ___ BLOOD CX: PENDNG ___ URINE CX: NEGATIVE ___ URINE LEGIONELLA: NEGATIVE ___ C. DIFF: NEGATIVE IMAGING: ___ Chest (Pa & Lat) IMPRESSION: Right basilar opacity likely due to at least some atelectasis, noting that infection is also possible. Distended loops of bowel visualized in the upper abdomen for which clinical correlation suggested regarding need for additional imaging. ___ KUB Diffuse gaseous distention of the colon. Appearances are similar compared to the prior radiographs from ___. Findings ___ be suggestive of chronic pseudoobstruction, but if there is continued concern, CT is recommended. No small bowel obstruction. ___ CT Abd/pelvis w/o contrast IMPRESSION: 1. Perinephric stranding, left worse than right, is non-specific, but pyelonephritis cannot be excluded. Additionally, the left proximal ureter is mildly prominent with urothelial thickening, a finding that can also be seen with infection. 2. Consolidation in the posterior aspect of the right lower lobe ___ be secondary to atelectasis but infectious or inflammatory processes cannot be excluded. 3. Diffuse mild colonic dilatation without wall thickening or evidence of obstruction ___ be secondary to chronic pseudo-obstruction, particularly as prior abdominal radiographs have shown a diffusely distended colon. Fluid in the colon is compatible with a history of diarrhea. 4. Left adrenal nodule which does not meet strict criteria for an adenoma, but in the absence of prior malignancy is likely benign. Consider follow up adrenal CT or MRI in 12 months. EKG: sinus tachycardia, left axis deviation, evidence of left anterior fascicular block, no concerning ST-segment or T-wave ___: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF=75%). The estimated cardiac index is normal (>=2.5L/min/m2). 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 is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. 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 no pericardial effusion. IMPRESSION: Suboptimal image quality. Small biventricular cavity size with borderline hyperdynamic systolic function. Small collapsable IVC. Brief Hospital Course: ___ with PMH significant bipolar disorder, recurrent cdiff in the setting of antibiotic use who presents with 1 week of nausea, vomiting, and diarrhea found to have a UA suggestive of infection. She was initially admitted to the ICU for tachycardia - this was felt to be in the setting of her underlying UTI, although her heart rate is elevated at baseline. She was also noted to have significant diarrhea which resolved, felt to be secondary to a viral gastroenteritis. She was transferred to the floor after receiving fluids and after she was noted to be hemodynamically stable. On the floor, a midline was placed for continued administration of IV ceftriaxone to treat her UTI. She will need to continue this up through ___. She was constipated and was treated with kayexalate especially in the setting of a potassium near 5.5. She also had mild ___ in the setting of her fluid losses which improved during the course of her hospitalization. She was discharged to rehab following stabilization of her hemodynamics, resolution of her diarrhea, ___, and constipation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraMADOL (Ultram) 50 mg PO BID 2. Ascorbic Acid ___ mg PO BID 3. ClonazePAM 1 mg PO QHS 4. Colchicine 0.6 mg PO BID 5. Allopurinol ___ mg PO DAILY 6. Florastor (saccharomyces boulardii) 250 mg oral BID 7. Divalproex (DELayed Release) 500 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Famotidine 20 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Gabapentin 100 mg PO TID 12. Multivitamins 1 TAB PO DAILY 13. RISperidone 1 mg PO HS 14. Senna 17.2 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Ascorbic Acid ___ mg PO BID 3. ClonazePAM 1 mg PO QHS 4. Divalproex (DELayed Release) 500 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Famotidine 20 mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Multivitamins 1 TAB PO DAILY 10. RISperidone 1 mg PO HS 11. Senna 17.2 mg PO DAILY 12. TraMADOL (Ultram) 50 mg PO BID 13. CeftriaXONE 1 gm IV Q24H 14. Colchicine 0.6 mg PO BID 15. Florastor (saccharomyces boulardii) 250 mg oral BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: acute pyelonephritis chronic intestinal pseudo-obstruction ___, likely ATN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital with a kidney infection. This improved slowly after starting antibiotics and receiving IV fluids. You will need to complete antibiotics over a 10 day course - the last day of antibiotics will be on ___. You also had some kidney damage however you recovered during the hospitalization. Followup Instructions: ___

10053782-DS-14

DS

2156-06-10 00:00:00

2156-06-11 16:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness, nausea and slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ F with recent diagnosis of ___ disease (but has not taken Sinemet) who presents with left cerebellar IPH. The patient has had a progressive decline in function over the past year, becoming less and less mobile. She was recently diagnosed with ___ disease by an outside neurologist, but has not taken any sinemet due to her concerns about side effects. As a result she has become immobile to the point that she only gets up, using a walker, to go to and from the bathroom, but does not otherwise move much. Last ___ (1 week ago) the patient had the sudden onset of dizziness, nausea and slurred speech. Her blood pressure was noted to be 220/100 at that time. She presented to ___ with these complaints and also complained of some abdominal pain at that time. She had a CT scan of her abdomen which reportedly showed a pancreatic mass which could not be fully characterized and labs were unrevealing (per the daughter-in-law). She was briefly admitted to the hospital, but discharged the next day, apparently without neurologic or physical therapy evaluation. Since that time she has been even more immobile than her previous baseline, unable to get to and from the bathroom on her own and essentially has been laying flat for the past ___ days. She has continued to report dizziness. Her speech continued to sound slurred (there have been no problems with language content), but did improve some yesterday. The patient's family has become more and more concerned and called the PCP today who recommended presentation to the ___ ED. Upon presentation to ___ she was found to have a left cerebellar hemorrhage on ___. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal 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: Hypothyroidism ___ disease (new diagnosis) Patient's daughter-in-law denies h/o of HTN, HLD, DM Social History: ___ Family History: Mother and ___ aunt with ___ disease Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== 98.0 86 159/82 18 94% GEN: Awake, cooperative, NAD. HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx NECK: Supple RESP: CTAB CV: RRR ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: Pressure ulcer on left calf covered with bandage clean, dry and intact NEURO EXAM: MS: Alert, oriented to person, place and time. Patient is ___ speaking and daughter-in-law translates. She reports that language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Speech is reportedly somewhat dysarthric. Able to follow both midline and appendicular commands. No evidence of apraxia or neglect. CN: II: PERRLA 3 to 2mm and brisk. VFF to confrontation. 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 is increased in the RUE>LUE, cogwheeling noted at the wrists bilaterally. Mild downward drift of both arms without pronation. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ 5 5 * * * * * * R ___ ___ ___ ___ 5 5 *unable to assess left leg due to severe pain from pressure ulcer Sensory: No deficits to light touch, pinprick throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Brisk withdrawal of toes bilaterally Coordination: No tremor observed. Dysdiadochokinesia noted on left FNF. ============================ DISCHARGE PHYSICAL EXAM ============================ General examination unchanged apart from normalization of blood pressure. NEURO EXAM: Mental status and cranial nerve examination unchanged apart from improvement in dysarthria. Motor: Normal bulk and tone, mild cogwheeling noted at the wrists bilaterally. No drift. No adventitious movements. No asterixis. Strength is grossly 4+ in the bilateral upper extremities and right lower extremity, partially due to effort. Strength is 3 in left lower extremity due to burning sensation limiting movement. Sensory: No deficits to light touch, pinprick throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Toes extensor bilaterally Coordination: No tremor observed. Dysdiadochokinesia and dysynergia noted on left > right finger-nose-finger. Gait: Deferred Pertinent Results: ======= LABS ======= ___ 02:10AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:10AM BLOOD %HbA1c-5.3 eAG-105 ___:10AM BLOOD Triglyc-71 HDL-40 CHOL/HD-3.6 LDLcalc-90 ___ 02:10AM BLOOD TSH-19* ___ 07:10AM BLOOD Free T4-1.3 ========== IMAGING ========== NCHCT (___): Acute left cerebellar intraparenchymal hemorrhage with surrounding edema. Small amount of hemorrhage layering within the lateral ventricles. Mild effacement of the fourth ventricle without hydrocephalus. Underlying mass is not excluded on this study and can be further evaluated with an MRI. Echo (___): The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mildly dilated ascending aorta. No definite structural cardiac source of embolism identified. MRI HEAD WITH AND WITHOUT CONTRAST (___): 1. Left cerebellar hemispheric hemorrhage with mild mass effect on the fourth ventricle, but no evidence of hydrocephalus or herniation, 2. No definite underlying mass or evidence of cerebral venous thrombosis. 3. No large flow voids in the region of the hemorrhage to indicate a large underlying vascular malformation. Re-evaluation can be performed after resolution of blood products, which may require ___ weeks. However, given the scattered foci of susceptibility representing micro-bleeds, in quite typical locations, hypertensive hemorrhage is the likely etiology of both current and previous hemorrhage. CTA HEAD WITH AND WITHOUT CONTRAST (___): 1. Stable left cerebellar intraparenchymal hematoma with layering intraventricular hemorrhage within the posterior horns of the lateral ventricles. 2. No evidence of new intracranial hemorrhage or mass effect. 3. No evidence of hemodynamically significant stenosis or aneurysm within the arterial vasculature of the head. CT ABDOMEN AND PELVIS (___): 1. No evidence of focal pancreatic lesion. 2. Diverticulosis without diverticulitis. MRI L, T, C-SPINE WITHOUT CONTRAST (___): 1. Degenerative disc and joint disease of the lumbar spine superimposed on congenital spinal canal stenosis. The worst level of spondylosis is at L4-5 where there is impingement of the bilateral L5 nerve roots, right greater than left. 2. No disc herniation of the thoracic spine. 3. Small disc herniations at C3-4 and C6-7 but without cord contact. 4. Left cerebellar hemorrhage, not significantly changed from recent MRI on ___. Brief Hospital Course: ___ is a ___ year old woman with a past medical history of hypothyroidism and recent diagnosis of ___ disease who presented to the ___ ED ___ with worsening dizziness, nausea and slurred speech over 1 week. ___ showed a left cerebellar intraparenchymal hemorrhage. Neurosurgery was consulted who deferred to medical management. Ms. ___ was consquently admitted to the neurology stroke service for further management. Etiology of the intraparenchymal hemorrhage was investigated during Ms. ___ hospitalization. As her blood pressure was found to be 220/100 at outside hospital at initial presentation 1 week prior to admission (see HPI for details), hypertension was believed to be the likely contributing factor. Upon admission to ___, blood pressure was only found to be elevated to 159/82 but did fluctuate during hospitalization. She was started on lisinopril with blood pressure control (SBP < 140) at time of discharge. To rule out other factors, Ms. ___ also underwent an echo, CT abdomen and pelvis, CTA head and MRI head. Echo did not show any ASD, PFO, or clot. CT abdomen and pelvis did not show any malignancy; there was no pancreatic lesion visualized. The CTA head did not show any AVM or aneurysm. MRI head did not show definite underlying mass, cerebral venous thrombosis or large underlying vascular malformation. Ms. ___ was scheduled for a repeat MRI at time of discharge to confirm these findings following the resolution of the blood products. She also had a LDL of 90 and hemoglobin A1C of 5.3%. Telemetry did not show any arrhythmias. For her history of newly diagnosed ___ disease, she was started on Sinemet during hospitalization. She was started on 0.5 tab TID and this was increased to 1 tab TID at time of discharge. This medication was gradually helping to decrease tone and improve bradykinesia at time of discharge. Ms. ___ also described persistent, chronic left lower extremity burning pain which sounded like sciatica. As she had an episode of bowel incontinence, she underwent an MRI of the L-, C- and T-spine. This MRI showed lumbar spondylosis and congenital spinal canal stenosis with no concern for cord compression. She was started on gabapentin for pain at time of discharge; this medication can be increased gradually to a goal of 200 mg TID over weeks. Ms. ___ was continued on her home levothyroxine while in the hospital. TSH was checked and found to be elevated to 19 with a normal free T4 of 1.3. She will need these values re-checked as an outpatient. On day of discharge, Ms. ___ was feeling improved and eager to leave the hospital. Her presenting symptoms had resolved and she worked with physical therapy. ===================== TRANSITIONS OF CARE ===================== -TSH was elevated to 19 and free T4 was normal at 1.3. Will need repeat thyroid function tests in 6 wks. -Has repeat MRI scheduled for ___. This will further evaluate for mass or AVM following resolution of blood products. -She was started on gabapentin 100mg BID. Please increase gradually by 100mg every 5 days to a goal of 200mg TID. -She was started on lisinopril 10mg daily for blood pressure control. -She was started on Sinemet 1 tab TID for new diagnosis of ___, please further adjust as an outpatient. ==================================================== AHA/ASA Core Measures for Intracerebral Hemorrhage 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. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 4. 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) 5. Assessment for rehabilitation or rehab services considered? (X) Yes - () No [if no, reason not assessed: ____ ] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Carbidopa-Levodopa (___) 1 TAB PO TID 3. Gabapentin 100 mg PO BID 4. Lisinopril 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Left cerebellar intraparenchymal hemorrhage Secondary diagnoses: Hypertension ___ disease Spondylosis of lumbar spine Small disc herniations cervical spine 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. ___, You were hospitalized due to symptoms of dizziness, nausea and slurred speech resulting from a brain bleed, a condition in which a blood vessel providing oxygen and nutrients to the brain bleeds. 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. Brain bleeds can have many different causes, so we assessed you for medical conditions that might raise your risk of having this again. In order to prevent future brain bleeds, we plan to modify those risk factors. Your risk factors are: High blood pressure We are changing your medications as follows: Starting lisinopril for blood pressure control 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. We wish you all the best! Followup Instructions: ___

10053810-DS-10

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2164-09-16 15:28:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: dapagliflozin Attending: ___. Chief Complaint: Abnormal head CT, nausea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ year old active woman with diabetes type 2, hypertension, atrial fibrillation on eliquis, mild cognitive decline (presumed), who presents as hospital-to-hospital transfer for evaluation of abnormal finding on head CT. History obtained by patient and patient's daughter and niece at bedside. Per patient (who digresses quite a bit on conversation), she was feeling well up until about 4 days ago when she became nauseous and started to vomit. She thought she had a stomach bug because she just was not feeling well at all and didn't even good enough to get up out of bed to dust the TV. The patient cannot say if her symptoms suddenly came on. She does endorse some double vision when she does not wear her glasses that "comes and goes" and "gets better" after she puts her glasses on. Additional details regarding nausea and vomiting limited as patient continues to digress in conversations. Her daughter notes that she last saw her mother 5 days ago for ___. She had picked her mother up to celebrate Thanksgiving with the family down at the ___. During that week, while she was watching her mother throughout the day she noticed that her mother's word-finding difficulty was worse and that her appetite was significantly decreased. She also noted that her mother's gait was worse, wobbling to both the left and the right despite use of a cane. The daughter does note that this decline has been ongoing for the past several months, however despite this decline the patient is completely independent at home and continues to work 15 hrs a week at Stop and Shop and continues to drive at night. When asked to elaborate on the decline over the last few months, the daughter notes a slow decline in the patient's word-finding difficulty, disorientation to day and month sometimes. She also notes a ___ weight loss over the past ___ months. ROS challenging as patient continues to digress without clarity of specific details regarding timing/intensity of symptoms noted. She does endorse transient double vision that resolves with wearing glasses, nausea that has subsided, and denies vertigo. She had a frontal throbbing headache but that has since resolved. She thinks her gait is steady with her cane. Her daughter notes that several weeks ago the patient broke out in a rash in her thighs that resolved with a 14d course of doxycycline. Regarding cancer history/risk factors, the patient is a former smoker but quit ___ years ago. She has never carried a diagnosis of cancer. At OSH, she was noted to be hypochloremic (97) and hypomagnesemic (1.4), which was corrected with electrolyte repletion. Past Medical History: diverticulitis s/p surgery diabetes atrial fibrillation hypertension hyperlipidemia bilateral cataract repair bilateral hip repair ___ years ago) Social History: ___ Family History: Sister with skin cancer and then glioblastoma diagnosed at the age of ___ Brother with throat cancer and then died of brain tumor ___ years later Physical Exam: Vitals: T97.6, HR80-110, BP119/70, RR17, 98RA glucose 222 General: Awake, cooperative, appears younger than stated age HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: irregular rate, warm and well-perfused Abdomen: Soft, non-distended. Extremities: trace bipedal edema Skin: inner thighs with maculopapular rash that appears to be resolving (confirmed with daughter that looks better than in prior days) Neurologic: -Mental Status: Alert, oriented to name, location (hospital in ___ but not ___, ___ but not date. Able to relate general history but with significant digressions in story, taking time to describe how she felt too tired to dust the TV then noting that it didn't matter because "they are coming to see her and not the TV" and then telling me how kind they are to visit her and proceeding to elaborate on her family support network. ___ forward is rapid. ___ backwards is slower and the patient only reaches ___ and then digresses. She is able to follow two-step commands. Has ocassional paraphasic errors, referring to "novels" regarding the book she likes to read as "novelities." Repetition intact. Normal prosody. Able to name both high frequency objects but some errors with low-frequency objects. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: post cataract surgery bilateral, PERRL 2>1 and sluggish, EOMI no nystagmus, no ptosis, face appears symmetric hearing diminished to conversation tongue deviates to right, uvula deviates to right right pupil, dysmetria on left finger. -Motor: Decreased bulk, normal tone. No pronator drift. No adventitious movements, such as tremor or asterixis noted. **Full confrontational strength testing limited largely by best effort but to best of ability, patient gives symmetric resistance throughout. [___] L 5 5 5 5 5 5 4 4 4 4 5 5 R 5 5 5 5 5 5 4 4 4 4 5 5 -Sensory: Diminished sensation to pinprick in stocking-glove pattern. Light touch, temperature, vibratory sense intact. -Reflexes: Plantar response was flexor bilaterally. -Coordination: Dysmetria on left FNF, left HKS. Diminished amplitude with fast movements on left hand. -Gait: Deferred secondary to fatigue (patient refused) and absence of cane at bedside. No leaning to one side with sitting on bed with eyes closed. ==================================== DISCHARGE Vitals: Tm/c: 99.1 BP: 107/49 HR: 60 RR: 22 SaO2: 99 General: Awake, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: skin warm, well-perfused. Extremities: Symmetric, no edema. Neurologic: -Mental Status: Awake, alert, and oriented to person and time, but thinks she is at a hospital in ___. Attentive, able to name ___ forward and backward without difficulty. Language is fluent with intact comprehension and slightly impaired repetition ("no ifs ands and buts"). There were no paraphasic errors. Naming intact to high and low frequency objects. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing impaired bilaterally to conversation. Palate elevates symmetrically. Tongue protrudes in midline. No dysarthria. -Motor: Decreased bulk. No adventitious movements, such as tremor, noted. Remainder of exam deferred. -Sensory: Deferred. -DTRs: ___. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Patient able to walk evenly with assistance on either side. No wide-based gait or unsteadiness inconsistent with muscle bulk noted. Pertinent Results: ___ 07:29PM BLOOD WBC-4.6 RBC-3.71* Hgb-12.6 Hct-37.0 MCV-100* MCH-34.0* MCHC-34.1 RDW-13.6 RDWSD-49.5* Plt ___ ___ 05:08AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.8 Hct-35.9 MCV-104* MCH-34.0* MCHC-32.9 RDW-14.4 RDWSD-54.4* Plt ___ ___ 07:29PM BLOOD ___ PTT-27.5 ___ ___ 12:40PM BLOOD ___ PTT-26.5 ___ ___ 05:08AM BLOOD ___ PTT-27.1 ___ ___ 07:29PM BLOOD Glucose-230* UreaN-20 Creat-0.7 Na-133* K-4.1 Cl-99 HCO3-22 AnGap-12 ___ 12:40PM BLOOD Glucose-240* UreaN-21* Creat-0.7 Na-137 K-4.7 Cl-101 HCO3-26 AnGap-10 ___ 06:40AM BLOOD Glucose-299* UreaN-30* Creat-0.7 Na-137 K-4.9 Cl-103 HCO3-25 AnGap-9* ___ 05:08AM BLOOD Glucose-257* UreaN-34* Creat-1.0 Na-139 K-4.9 Cl-104 HCO3-28 AnGap-7* ___ 12:40PM BLOOD ALT-8 AST-11 LD(LDH)-160 CK(CPK)-15* AlkPhos-67 TotBili-0.6 ___ 12:40PM BLOOD GGT-15 ___ 07:29PM BLOOD Lipase-20 ___ 07:29PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12:40PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 07:29PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.9 Mg-1.7 ___ 12:40PM BLOOD Albumin-3.3* Cholest-102 ___ 05:08AM BLOOD Phos-2.6* Mg-1.6 ___ 12:40PM BLOOD %HbA1c-9.4* eAG-223* ___ 12:40PM BLOOD Triglyc-79 HDL-53 CHOL/HD-1.9 LDLcalc-33 ___ 07:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 07:40PM BLOOD Lactate-1.5 CTA HEAD ___ FINDINGS: CT HEAD WITHOUT CONTRAST: A 3 x 3.7 cm intra-axial hypodense focus is seen in the left cerebellar hemisphere exerting mass effect on the adjacent fourth ventricle without evidence of associated hydrocephalus. Subtle hyperdensity within the left cerebellar hemisphere lesion suggests possible underlying microhemorrhage. The ventricles and sulci are prominent, consistent global cerebral volume loss. Patchy periventricular hypodensities are most consistent with chronic microvascular ischemic disease. The left mastoid air cells are underpneumatized with a small effusion. The visualized portion of the paranasal sinuses,right mastoid air cells,andbilateral middle ear cavities are clear. The visualized portion of the orbits demonstrates sequela of prior bilateral cataract surgery. CTA HEAD: Infundibular origin of the right posterior cerebral artery. Otherwise, the vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Atherosclerotic changes of the carotid bifurcations are seen without narrowing of the internal carotid arteries, by NASCET criteria. Mild atherosclerotic disease narrows the origin of the left common carotid and vertebral arteries. The vertebral arteries appear otherwise unremarkable with no evidence of stenosis or occlusion. The bilateral subclavian arteries are unremarkable allowing for mild atherosclerotic disease. OTHER: The visualized portion of the lungs demonstrates an 8 mm nodule in the right upper lobe, is seen on the prior chest x-ray. A smaller 2 mm right upper lobe nodule also noted. A multinodular goiter is seen, with largest nodule measuring approximately 2.0 cm on the left.. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. 3 x 3.7 cm intra-axial hypodense focus in the left cerebellar hemisphere likely represents a late acute to subacute infarct. No large hemorrhage identified. Possible microhemorrhages within the region of infarct. 2. Allowing for atherosclerotic disease, essentially unremarkable CTA of the head and neck. No evidence of occlusion. No stenosis of the cervical internal carotid arteries by NASCET criteria. 3. 8 mm nodule in the right upper lobe. A smaller 2 mm right upper lobe nodule also noted. 4. Multinodular goiter. Largest discrete nodule appears to be approximately 2 cm in the left lobe. 5. Small left mastoid effusion. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule measuring 6 to 8 mm, a CT follow-up in 6 to 12 months is recommended in a low-risk patient, optionally followed by a CT in ___ months. In a high-risk patient, a CT follow-up in 6 to 12 months, and a CT in ___ months is recommended. See the ___ ___ Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Thyroid nodule. Ultrasound follow up recommended. ___ College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm in patients age ___ or ___, or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. MRI BRAIN ___ IMPRESSION: 1. 4 x 5 x 2.3 cm left cerebellar hemisphere focus of diffusion and gradient echo susceptibility artifact, felt to be most compatible with late acute infarct in hemorrhagic transformation. Associated linear foci of enhancement, predominantly located within the cerebellar folia is felt to be secondary to luxury perfusion rather than nodular enhancement of underlying mass lesion. 2. Associated edema pattern results in mass effect and mild effacement of the fourth ventricle. No definite evidence of hydrocephalus. The size of the ventricles are unchanged from outside hospital examination of ___. 3. Recommend repeat MRI head with without contrast in approximately 1 month to document stability or resolution of linear enhancement to exclude underlying lesion. 4. Additional findings as described above. TTE ___ CONCLUSION: The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. No thrombus or mass is seen in the left ventricle. Quantitative 3D volumetric left ventricular ejection fraction is 63 %. There is a mild (peak 10 mmHg) resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). There is echocardiographic evidence for diastolic dysfunction (grade indeterminate). 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. There is a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. There is mild to moderate [___] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness, cavity size, and regional/global systolic function. Increased PCWP. Diastolic dysfunction. Mild to moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. MR PERFUSION ___ FINDINGS: Again seen is cerebellar abnormality on T1 postcontrast images, stable since yesterday. ASL Perfusion: There is decreased perfusion in the left inferior cerebellar hemisphere corresponding to the left cerebellar hemisphere infarct identified on brain MRI 1 day prior.. MR Spectroscopy: Relatively preserved spectroscopy pattern, no evidence of tumor spectra. IMPRESSION: Findings consistent with left cerebellar infarct. Brief Hospital Course: Ms. ___ is a ___ year old right-handed female with a h/o afib on eliquis, TIIDM, and HTN who presents with ___ days of nausea, unsteady gait, and word finding difficulty and was transferred to ___ from OSH after abnormal findings on NCHCT. #Left intrapernchymal cerebellar lesion The patient complains of nausea and gait disturbance lasting ___ days, and the patient's daughter began to notice word finding difficulty and gait disturbance during this same period. The patient's daughter also reported that the patient has been declining cognitively and lost approximately 15 pounds over the past several months. The patient's family history is notable for two incidences of brain cancer, with one confirmed GBM. The patient's physical exam did not provide any localizing or alarming findings, demonstrating minor ataxia that has improved since admission, and the patient is now able to ambulate with assistance. Initial NCHCT showed a hypodense focus in the left cerebellar hemisphere, and CTA did not show any evidence of an occlusion in the head or neck. MRI w/ and w/o contrast showed a left cerebellar hemisphere lesion with restricted diffusion and gradient echo susceptibility. F/u MR perfusion scanning demonstrated hypoperfusion in that region and did not show any evidence of tumor spectra. This lesion most likely represents a subacute venous infarct with surrounding edema and hemorrhagic transformation given the hypoperfusion on MR spectroscopy and preserved spectroscopy pattern. Mass unlikely, Abscess/infection is unlikely given lack of elevated WBC or fever/constitutional symptoms. Stroke risk factor labs show HbA1c 9.4, LDL 33. -Repeat MRI 2 weeks after discharge to monitor concerning changes in lesion (e.g. continued bleed, change in morphology that could suggest mass) -Hold Eliquis for 2 weeks, continue ASA #Cognitive decline -Patient has inattention, difficulty with recall. Will need more thorough mental status/memory/cognition work-up and rehab after discharge. #Afib: -Eliquis held, aspirin continued. This should be re-started AFTER a repeat MRI brain is done in about 2-weeks if the hemorrhage is stable/improved. Her atenolol was decreased from 50mg to 12.5mg daily due to bradycardia. #Diabetes: -The patient was initially started on steroids (decadron) when this lesion was thought to be a mass. Her sugars prior to even starting the steroids however were also elevated and her A1C was elevated at 9.4. -A ___ diabetes consult was placed as her glucose levels were still elevated on a sliding scale insulin regiment and she was discharged on insulin #Gait unsteadiness: -Due to cerebellar stroke, ___ recommended rehab Transitional Issues: -Follow blood sugars very carefully -Repeat MRI in 2 weeks before starting Eliquis -Follow-up with Neurology -Incidental pulmonary and thyroid nodules found on CT, follow-up with PCP for further ___ imaging ========================== 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 =33 ) - () 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 [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [x ] 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 - (x) No - If no, why not (I.e. bleeding risk, etc.) () N/A - bleeding risk due to hemorrhagic conversion of ischemic infarct Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Atenolol 50 mg PO DAILY 3. Donepezil 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. WelChol (colesevelam) 6.25 gram oral BREAKFAST Discharge Medications: 1. Glargine 12 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using REG Insulin 2. Atenolol 12.5 mg PO DAILY 3. Donepezil 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. WelChol (___) 6.25 gram oral BREAKFAST 6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do not restart Apixaban until after your doctor says it is okay Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute cerebellar infarct with hemorrhagic conversion Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you were having difficulty walking, nausea, and some confusion resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. You went to an outside hospital where a cat scan of your brain was done which showed a worrisome lesion. You then were transferred to ___ in ___ where we ran two more tests including two MRI brain scans. We initially thought that the lesion in your brain could have been a mass but on further testing the finding is more consistent with a stroke. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: ATRIAL FIBRILLATION DIABETES HYPERLIPIDEMIA HYPERTENSION We are worried that you were not taking your medications because your sugar was also high in your blood, therefore we have started you on INSULIN. Your heart rate was low and your blood pressure was good while you were in the hospital, so we decreased your ATENOLOL from 50mg daily to 12.5mg daily. You worked with physical therapy who recommended rehab to get you better and safe as you had this stroke affecting your balance. In two weeks we would like to repeat a scan to ensure that your stroke is improving. In the meantime, do not re-start the eliquis (apixaban) until the scan is done. Once the repeat brain scan has been completed, your facility should re-start the blood thinner at that time. Thank you for involving us in your care. Sincerely, ___ Neurology Followup Instructions: ___

10054622-DS-4

DS

2155-05-09 00:00:00

2155-05-11 16:52:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Pelvic cramping Major Surgical or Invasive Procedure: Dilation and curettage Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP Pertinent Results: LABS ==================== ___ 03:15AM BLOOD WBC-5.5 RBC-3.07* Hgb-8.7* Hct-26.0* MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 RDWSD-42.3 Plt Ct-87* ___ 07:16AM BLOOD WBC-6.1 RBC-2.90* Hgb-8.3* Hct-24.5* MCV-85 MCH-28.6 MCHC-33.9 RDW-13.6 RDWSD-42.4 Plt Ct-74* ___ 07:50PM BLOOD WBC-8.8 RBC-3.22* Hgb-9.3* Hct-27.0* MCV-84 MCH-28.9 MCHC-34.4 RDW-13.5 RDWSD-41.2 Plt Ct-64* ___ 02:25PM BLOOD WBC-13.5* RBC-3.51* Hgb-10.1* Hct-30.0* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 RDWSD-41.6 Plt Ct-75* ___ 08:50AM BLOOD WBC-18.5* RBC-3.94 Hgb-11.4 Hct-33.6* MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 RDWSD-41.7 Plt Ct-86* ___ 07:00PM BLOOD WBC-14.9*# RBC-3.88* Hgb-11.4 Hct-32.9* MCV-85 MCH-29.4 MCHC-34.7 RDW-13.2 RDWSD-40.3 Plt Ct-92* ___ 07:16AM BLOOD Neuts-78.7* Lymphs-12.0* Monos-8.2 Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.80 AbsLymp-0.73* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02 ___ 07:50PM BLOOD Neuts-73* Bands-21* Lymphs-5* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.27* AbsLymp-0.44* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* ___ 07:00PM BLOOD Neuts-84.2* Lymphs-8.7* Monos-6.1 Eos-0.3* Baso-0.2 Im ___ AbsNeut-12.52*# AbsLymp-1.29 AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 ___ 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-NORMAL ___ 07:50PM BLOOD Plt Smr-VERY LOW Plt Ct-64* ___ 03:15AM BLOOD Plt Ct-87* ___ 07:16AM BLOOD Plt Ct-74* ___ 02:25PM BLOOD Plt Ct-75* ___ 08:50AM BLOOD Plt Ct-86* ___ 08:50AM BLOOD ___ PTT-27.1 ___ ___ 07:00PM BLOOD Plt Smr-LOW Plt Ct-92* ___ 07:00PM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-135 K-3.5 Cl-99 HCO3-24 AnGap-16 ___ 07:00PM BLOOD Genta-<0.2* ___ 07:50PM BLOOD Lactate-1.5 ___ 09:00AM BLOOD Lactate-1.3 ___ 09:00AM BLOOD Hgb-12.3 calcHCT-37 ___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:35PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:30PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 06:35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 08:30PM URINE RBC->182* WBC-6* Bacteri-FEW Yeast-NONE Epi-<1 MICROBIOLOGY ==================== ___ 9:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 8:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. ___ 7:50 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): ___ 6:35 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ==================== ___ Pelvic Ultrasound Final Report EXAMINATION: EARLY OB US <14WEEKS INDICATION: ___ G2P0 @ 12w p/w abdominal pain// eval for ___ trimester pregnancy LMP: ___ TECHNIQUE: Transabdominal and transvaginal examinations were performed. Transvaginal exam was performed for better visualization of the embryo. COMPARISON: None. FINDINGS: An intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of 62 mm representing a gestational age of 12 weeks 5 days. This corresponds satisfactorily with the menstrual dates of 12 weeks 2 days. The uterus is normal. The ovaries are normal. There is funnel shaped dilation of the cervix measuring 7 mm at its widest point, at the internal os. IMPRESSION: 1. Single live intrauterine pregnancy with size = dates. 2. Cervical dilation measuring up to 7 mm at its widest point, at the internal os. ___ Pelvic Ultrasound Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed.// ___ w/ SAB. Evaluate for retained placenta. Most fetal tissue has passed. TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound ___. FINDINGS: The uterus is anteverted. Previously noted gestational sac and fetus are no longer present. The endometrial cavity is distended with heterogeneous echogenic material, with vascularized products seen posteriorly at the level of the uterine body, measuring at least 5.3 x 3.8 cm in transverse ___, compatible with vascularized retained products of conception. In addition, there is heterogeneous echogenic material without vascularity in the endocervical canal concerning for blood products. Small amount of free fluid in the pelvis. Normal ovaries bilaterally. IMPRESSION: Findings consistent with vascularized retained products of conception measuring at least 5.3 x 3 8 cm in transverse ___ with additional echogenic blood products in the endocervical canal. Small amount of free fluid. Brief Hospital Course: Ms. ___ is a ___ yo G3P0 who presented to the ED at 12weeks gestational age with cramping. She underwent a pelvic ultrasound on ___ which demonstrated a live single intrauterine pregnancy. While in the ED, she developed worsening cramping and vaginal bleeding, and she passed fetal tissue. Repeat pelvic ultrasound revealed retained products of conception. In the ED, pt was noted to be tachycardic (HR max 117) with Tmax 100.2. Her labs were notable for increasing leukocytosis (14 -> 18), thought to be secondary to an inflammatory reaction to her miscarriage (differential included uterine infection i.e. endometritis). The decision was made to proceed with a dilation and curettage for complete removal of pregnancy tissue. On ___ Ms. ___ underwent an uncomplicated ultrasound-guided dilation and curettage. Please refer to the operative note for full details. She had an estimated blood loss of 350mL and received methergine and cytotec intraoperatively. She was continued on PO methergine for 24 hours post-operatively. She also received IV doxycycline intra-operatively due to concern for developing endometritis. Her hematocrit was trended: 33.6 (pre-operative) -> 30.0 (PACU) -> 24.5 (post-operative day #1)-> 26 (post-operative day #2 am). Her post-operative course was complicated by fever and thrombocytopenia: - Fever: Pt spiked a fever to 103.1 on post-operative day #1. Her CBC at the time was notable for WBC 8.8 with 21 bands. UA was negative for UTI. She was treated for presumed endometritis, and received IV gentamicin and IV clindamycin for 24 hours (___). She was then transitioned to PO doxycycline and PO flagyl. - Thrombocytopenia: Pt was noted to have downtrending platelets, with nadir of 64 (___), thought due to ITP vs. gestational thrombocytopenia. Her vaginal bleeding was minimal following the procedure, and her platelet count improved prior to discharge (platelet=87 on ___. NSAIDs were held during this admission in the setting of thrombocytopenia. Thee remainder of her post-operative course was uncomplicated. She received PO Tylenol and oxycodone prn pelvic pain. Her diet was advanced without difficulty. She voided spontaneously on post-operative day #0. By hospital day #2, pt was tolerating a regular diet, voiding spontaneously, ambulating independently, and her pain was well-controlled with oral medications. She was discharged to home with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*1 3. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 4. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate [___] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 5. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Retained products of conception 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 gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * Please avoid NSAIDs (ex. ibuprofen) in the setting of your low platelet counts * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) until your post-operative appointment * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

10054634-DS-8

DS

2181-01-28 00:00:00

2181-02-01 10:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Demerol / morphine Attending: ___ Chief Complaint: generalized weakness, muscle aches, intermittent fevers, sore throat and wakes up with HA, now with + BCx Major Surgical or Invasive Procedure: TEE (___) PICC line Insertion (___) History of Present Illness: Patient is a ___ M with PMH HLD, duodenal ulcer c/b GIB, and BPH who presents with chills, HA, and positive blood cultures. 6 weeks ago ___ developed, waxing and waning, generalized muscle aches, with subjective chills but no objective fever. bifrontal mild headache without other associated neurological signs. No recent travel other than ___ and upstate ___. No history of IVDU. He had a dental cleaning 2 weeks ago after the onset of symptoms. He did have a colonoscopy 4 days prior to developing symptoms. Per referral: Pt has gram positive cocci growing out of each anaerobic blood culture (two sets were drawn) after 14 hours. He presented with 7 weeks of headache, fatigue and myalgias. ESR=42. Has dropped his HCT to ___ yesterday from 41 on ___. I consulted with ID who recommended ED eval and likely admit for repeat cx, r/o endocarditis and imaging of head (given headache and concern for mycotic aneurysm) and abdomen to look for a source. He did have a colonoscopy with polypectomy on ___. He had dental cleaning after the onset of his sx. In the ED, initial VS were 4 98.3 92 115/70 16 98% RA . Exam notable for: Exam normal neuro, rectal heme negative ___ soft systolic murmur in RUSB. Labs showed Hgb 12.5. Imaging showed: CXR No acute cardiopulmonary process. Head CT No acute intracranial process. Received vanc/cefazolin Transfer VS were 75 122/66 18 98% RA On arrival to the floor, patient reports that he has been having myalgias and HA x 6 weeks on and off. He endorses slight fever. His HA is mild, dull, all over, and occurs in the mornings but does not wake him up. No associated photophobia, phonophobia, neck stiffness, blurry vision, dizziness, or nausea. Tylenol helps. He also endorses various wandering muscle pains but no joint pains. He was tested for lyme but it was negative and he denies tick exposure. He did have a colonoscopy around the time his sx started but denies abdominal pain, constipation, or diarrhea. HE denies chest pain or dizziness. He denies trauma or sick contacts. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: Hypercholesterolemia Rhinitis, allergic Duodenal ulcer with hemorrhage Dermatitis, seborrheic Serrated adenoma of colon Sleep disturbance BPH (benign prostatic hyperplasia) Cholecystectomy (___) Social History: ___ Family History: Mother with ___. Father with hairy cell leukemia & stroke. MI in maternal uncle and MGM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 PO 141 / 74 70 16 95 RA GENERAL: Pleasant, alert, NAD . Appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, oropharynx clear NECK: supple, intact chin-to-chest, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, + RUQ scar EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM VS: 98.4PO 116/64 R 74 18 96 Ra GENERAL: Pleasant, alert, NAD. Appears younger than stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, oropharynx clear NECK: supple, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, + RUQ scar EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ============== ___ 02:01PM BLOOD WBC-9.3 RBC-4.24* Hgb-12.5* Hct-37.4* MCV-88 MCH-29.5 MCHC-33.4 RDW-12.3 RDWSD-39.6 Plt ___ ___ 02:01PM BLOOD Neuts-84.5* Lymphs-6.2* Monos-7.9 Eos-0.9* Baso-0.2 Im ___ AbsNeut-7.83* AbsLymp-0.57* AbsMono-0.73 AbsEos-0.08 AbsBaso-0.02 ___ 02:01PM BLOOD Glucose-112* UreaN-20 Creat-1.0 Na-136 K-5.0 Cl-100 HCO3-24 AnGap-17 ___ 02:19PM BLOOD Lactate-1.7 MICROBIOLOGY: ============== ___ 2:02 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (___) GROUP | CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.12 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by ___ @ 1255 ON ___. PATIENT CREDITED. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. ==== ___ 1:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STREPTOCOCCUS ANGINOSUS (___) GROUP. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___, ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by ___ @ 1255 ON ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ==== ___ Blood Culture, Routine (Final ___: NO GROWTH. PERTINENT IMAGING: ================ CT HEAD W/O CONTRAST: No acute intracranial process. TTE: Mildly thickened aortic valve with moderate aortic regurgitation. Myxomatous mitral leaflets with mild-moderate late systolic mitral regurgitation. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. If clinically indicated, a transesophageal echocardiographic examination is recommended to better assess the aortic and mitral valve morpholgy for possible vegetations/endocarditis. TEE: Mildly thiickened aortic valve leaflets with moderate aortic regurgitation but without discrete vegetation. Mild bileaflet mitral valve prolapse with mild late systolic mitral regurgitation. DISCHARGE LABS: ============= ___ 08:20AM BLOOD WBC-7.7 RBC-4.16* Hgb-12.4* Hct-36.9* MCV-89 MCH-29.8 MCHC-33.6 RDW-12.3 RDWSD-39.8 Plt ___ ___ 03:02PM BLOOD CRP-44.3* Brief Hospital Course: Patient is a ___ M with PMH HLD, duodenal ulcer c/b GIB, and BPH who presented with chills, myalgias, and headache, admitted with viridans strep sepsis. #VIRIDANS STREP SEPSIS: Initial cultures at ___ grew GPCs that resulted in viridans strep species. Initial blood cultures on admission to ___ ___ were also positive for viridians strep. All culture sensitivities were pan sensitive (see microbiology section for specific sensitivity data). The patient was started on vancomycin empirically and ultimately narrowed to ceftriaxone based on culture sensitivities. Etiology of GPC sepsis was unclear. TTE was negative for vegetations but showed bileaflet mitrial prolapse and aortic regurgitation. A TEE was performed that was negative for vegetations. There were no localizing symptoms. Dentition was good, though patient had previous dental instrumentation prior to admission. A Panorex was performed and the result will be followed up after discharge. A PICC was placed prior to discharge. The patient will continue CTX as an outpatient for a total course of 4 weeks (D1: ___ projected end date: ___. #Normocytic Anemia: Hgb during admission was ___. Previous baseline in ___ was 14.2. No evidence of bleeding. Hgb remained stable. Workup with iron studies if anemia does not resolve after acute illness. #Headache: Patient was experiencing intermittent headaches on admission that were relieved with Tylenol. He did not experience nausea, photo/phonophobia, blurry vision, or any worrisome signs or symptoms. A CT Head was negative. He was continued on Tylenol PRN during hospitalization. CHRONIC: #HLD: Continued home atorvastatin #BPH: Continued home tamsulosin #Seasonal allergies: Continued Flonase, Claritin ===================== TRANSITIONAL ISSUES: ===================== NEW MEDICATIONS: [ ] Ceftriaxone 2mg IV Daily for a total course of 4 weeks (D1: ___ projected end date: ___ ITEMS FOR FOLLOW-UP: [ ] Follow-up final panorex read (Date of exam: ___ [ ] Lab draw every week: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK, PHOS, CRP, ESR [ ] Infectious Disease OPAT will arrange outpatient follow-up [ ] Continue CTX as an outpatient for a total course of 4 weeks (D1: ___ projected end date: ___, or instructed by infectious disease [ ] Follow-up weekly CBC, if Hgb trending down (Hgb at discharge > 12), send for iron studies and work up. Patient has had a GI bleed in the past. [ ] ECHO showed bileaflet mitrial valve prolapse and mild aortic regurgitation. Please continue to monitor patient and consider referral to cardiology for surveillance. Name of health care proxy: ___ Relationship: wife Phone number: ___ Code: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS:PRN insomnia 2. Tamsulosin 0.4 mg PO QHS 3. Atorvastatin 20 mg PO QPM 4. Loratadine 10 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 mg IV Q24H Disp #*28 Intravenous Bag Refills:*0 2. Atorvastatin 20 mg PO QPM 3. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Loratadine 10 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: -- SEPSIS, GRAM POSITIVE -- HEADACHE -- ANEMIA 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! You were admitted to the hospital because you had bacteria in your blood. You were given antibiotics through your vein. You were seen by the infection doctors who recommended ___ through your vein for four weeks. We do not know what caused the infection. We looked at your heart valves with an ultrasound and did not find an infection hiding in your heart. We did a scan of your brain because of your headaches and the scan was normal. Finally, we took XRays of your mouth. The results of the mouth XRAY are pending and you will go over these results when you follow up with your regular doctors. Someone from the infectious disease department will call you to schedule a follow up appointment. If you don't hear from them in a week, you can call at ___. It was a pleasure caring for you! Sincerely, Your Medical Team Followup Instructions: ___

10054639-DS-23

DS

2139-03-06 00:00:00

2139-03-07 11:44:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Spitting up blood Major Surgical or Invasive Procedure: Upper endoscopy ___ History of Present Illness: Ms. ___ is an ___ year-old woman with HTN, HLD, osteoporosis, possible giant cell arteritis and AAA who presenting w/ several months of intermittent spitting up blood that has worsened over the past 3 days. Patient reports that in ___ she presented to walk in clinic with a several day history of spitting up blood. Per notes, at the time pt reported concomitant epistaxis and exposure to dry air but was otherwise asymptomatic. A CXR was performed and was read as negative for any acute intrapulmonary process. Patient subsequently followed up with her PCP ___ ___, at which time her symptoms had resolved. Patient now presents with a three day history of "spitting up blood." She denies epistaxis, cough, fever, chills, night sweats, chest pain, dyspnea, orthopnea, PND, ___ edema, change in exercise tolerance, nausea, emesis, diarrhea, melena, hematochezia, weight loss, change in appetite. Denies dysphagia, denies difficulty swallowing pills, denies pain with swallowing pills. Reports that prior to ___, she had no prior similar episodes. She reports that she had a history of childhood asthma in ___, but that it resolved by the time she was a teenager. Denies any other history of respiratory issues. On arrival to the ED, initial vitals were 97.8 74 ___ 100% RA. Labs including CBC, Chem7 and Coags were reassuring. CXR showed no acute process. CTA chest showed ascending thoracic aortic aneurysm, approximately slightly increased to 5.1 cm from 4.7 cm on ___ without evidence of dissection. Scope by ER team, who did not note nasal bleeding. Vitals on transfer were 79 124/90 18 100% RA. Currently, the patient appears comfortable and is without additional complaints. Past Medical History: ___: HTN, hypercholesterolemia, h/o hyperplastic colonic polyp, h/o H. Pylori in ___ s/p rx, GERD PSH: Hysterectomy for urinary incontinence and uterine prolapse, B/l laser cataract surgeries POBHx: SVD x7 Social History: ___ Family History: Brother recently died of cancer, but doesn't know what type. No known FH of diabetes, lung disease, or cardiac disease. Daughter has hypertension. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.3 83 131/89 18 100% RA Gen: Appropriately interactive, appears comfortable HEENT: NCAT, EOMI, bright red blood in pharynx Neck: JVP 6cm, no LAD, no thyromegaly Card: RRR, no m/r/g. Resp: CTAB without wheezes or crackles. Full expansion Abd: Soft, +BS, mildly tender to palpation in the epigastrium. Ext: 2+ ___ pulses, non-tender, no edema Skin: Chronic sun changes, no rashes Neuro: Full strength throughout. Sensation intact. Toes downgoing bilaterally. DISCHARGE PHYSICAL EXAM: VS - Temp: 98.6F, BP 106-137/61-74, HR:44-52, R:18, O2-sat 97% RA Gen: Appropriately interactive, thin ___ woman who appears her stated age, appears comfortable HEENT: Pharyx benign with no blood in oral cavity, cauterized area of hard palate with no bleeding, no teeth, small white patch on right buccal mucosa, NCAT, EOMI, PERRL with b/l post-surgical cataract changes Neck: No pain on palpation, no JVD, no LAD, No thyromegaly Card: RRR, no m/r/g. Resp: Breathing comfortably, CTAB without wheezes or crackles Abd: Soft, +BS, mildly tender to palpation in the epigastrium. Ext: 2+ ___ pulses, non-tender, no edema Skin: Chronic sun changes, no rashes Neuro: CN III-XII grossly intact, ___ motor throughout, normal sensation throughout. No tremor. Pertinent Results: ___ 10:12AM WBC-6.3 RBC-4.12* HGB-12.0 HCT-37.0 MCV-90 MCH-29.0 MCHC-32.3 RDW-13.1 ___ 10:12AM NEUTS-63.2 ___ MONOS-3.5 EOS-0.8 BASOS-1.1 ___ 10:12AM GLUCOSE-91 UREA N-13 CREAT-0.9 SODIUM-138 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-11 ___ 10:12AM PLT COUNT-300 ___ 10:12AM ___ PTT-29.9 ___ ___ 07:05PM HCT-34.9* ___ 05:55AM HCT-33.9* ___ 12:55PM BLOOD Hct-37.5 ___ 06:15AM BLOOD WBC-4.6 RBC-3.68* Hgb-10.3* Hct-32.5* MCV-88 MCH-27.9 MCHC-31.6 RDW-12.8 Plt ___ ___ 01:49PM BLOOD Hct-35.1* ___ 06:50AM BLOOD WBC-4.9 RBC-3.64* Hgb-10.2* Hct-32.1* MCV-88 MCH-27.9 MCHC-31.6 RDW-12.7 Plt ___ ___ 06:45AM BLOOD WBC-5.1 RBC-3.74* Hgb-10.6* Hct-33.9* MCV-91 MCH-28.3 MCHC-31.1 RDW-12.9 Plt ___ ___ 07:15AM BLOOD Hct-30.2* ___ 03:35PM BLOOD Hct-28.9* ___ 07:10AM BLOOD WBC-3.7* RBC-2.69*# Hgb-7.9*# Hct-24.2* MCV-90 MCH-29.2 MCHC-32.4 RDW-13.0 Plt ___ ___ 01:05PM BLOOD Hct-28.0* ___ 07:05AM BLOOD Hct-27.5* ___ Chest Xray IMPRESSION: No acute cardiopulmonary process. ___ Chest CT with contrast IMPRESSION: 1. No evidence of pulmonary embolism or other finding to explain the patient's symptoms of hemoptysis. 2. Potentially slightly enlarged ascending aortic aneurysm, with no evidence of dissection. ___ CT Neck with contrast 1. Asymmetric soft tissue density along the left aspect of the lower nasopharynx, of uncertain etiology. Direct visualization is recommended. 2. Ascending aortic aneurysm, similar to prior. 3. Infundibulum of the origin of the right posterior communicating artery, similar to prior. ___ EGD Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Recommendations: Normal endoscopy. No GI cause of bleeding. Recommend ENT eval and MRI head/neck Brief Hospital Course: Ms. ___ is an ___ year-old woman with HTN, HLD, and AAA who presenting w/ several months of intermittent spitting up blood that has worsened over the past 3 days. ACTIVE ISSUES: #Spitting up blood: Patient does not report any coughing and was not observed to be coughing, but was spitting up teaspoonfuls of bright red blood on admission. CXR and CT chest were unrevealing for a source. CT neck showed a small soft tissue density in the posterior nasopharynx, but this did not correlate to an area of bleeding on direct visualization. Pulmonary consult had a low suspicion for pulmonary source and deferred bronchoscopy. GI consult performed EGD and was normal on ___. ENT consult conducted laryngoscopy and found no source in the head and neck on the first two examinations. On the third examination, they found an ectasia on the left hard palate and cauterized it on ___ and again on ___. Following the cauterizations, pt had two episodes of very small amounts of blood (about 1 tsp), but was otherwise asymptomatic. Her hematocrit was monitored throughout her admission. It was initially 37 and decreased to 28 with one reading of 24 on ___. She was hemodynamically stable and follow up was recommended for monitoring and possible treatment of anemia. # Blood pressure control/ Hypertension: Home atenolol, HCTZ and lisinopril were continued. She had low blood pressures to ___ the evening of ___ and was dizzy but otherwise asymptomatic, after taking her BP medications earlier that evening. BPs improved with IVF hydration. She reports that she often feels dizzy at home at night after taking her medications, but has not had any further symptoms. We advised proper hydration and being careful not to fall in the evenings after taking her medications. We recommended outpatient follow up with her primary care physician for further BP management. INACTIVE ISSUES: # Headache: Pt mentioned some headaches she gets at home, but did not complain of headache while in the hospital. The headaches are pulsatile, right worse than left, and associated with visual changes and muscle tension, and last hours to days. They are most likely migraines. She also describes very short, <1 minute head pains, that may be cluster headaches, but she did not experience any during her hospitalization. Tylenol was made available to her for pain, but she did not require any for headaches. #Ascending Thoracic Aortic Aneurysm: CTA visualized ascending thoracic aortic aneurysm, approximately 5.1 cm, slightly increased in size since prior CT from ___ when it measured 4.7 cm. No evidence of dissection. Patient was monitored for signs of dissection or rupture and was stable. Follow up with cardiovascular surgery is recommended after discharge, per PCP ___. # GERD: PPI was continued. # Chronic back pain: Lidocaine patch and tylenol PRN were continued. TRANSITIONAL ISSUES: Dr. ___ ENT - Bleeding from mouth- ENT outpatient follow up, consider biopsy PCP ___ - ___ ~28 - Ascending thoracic aortic aneurysm- consider CV surgery referral - Hypertension with low BPs at night Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium (Liquid) 100 mg PO BID 2. Omeprazole 40 mg PO BID 3. Atenolol 25 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Atorvastatin 20 mg PO DAILY 6. Lidocaine 5% Patch 1 PTCH TD DAILY 7. Lisinopril 20 mg PO DAILY 8. Acetaminophen 325-650 mg PO Q4H:PRN pain 9. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit Oral BID Discharge Medications: 1. Omeprazole 40 mg PO BID 2. Lisinopril 20 mg PO DAILY 3. Lidocaine 5% Patch 1 PTCH TD DAILY 4. Docusate Sodium (Liquid) 100 mg PO BID 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Atenolol 25 mg PO DAILY 7. Atorvastatin 20 mg PO DAILY 8. Acetaminophen 325-650 mg PO Q4H:PRN pain 9. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit Oral BID Discharge Disposition: Home Discharge Diagnosis: Hard palate ectasia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized at ___ because you were spitting up blood. While you were here, you received a Chest x-ray that was normal. You had a chest CTA that did not show a cause for the bleeding. The pulmonary medicine team evaluated you and felt that the cause of your bleeding was not likely your lungs. The gastroenterology team evaluated you and used a camera to look at your esophagus, stomach, and the beginning of the small intestine, and they did not find a cause for your bleeding. The ENT (Ear, Nose, and Throat) team also evaluated you and looked into your nose, mouth and throat with a camera. Initially they did not find a cause for your bleeding, but on ___ they found a small area of bleeding on the roof of your mouth. They cauterized that area to stop the bleeding. After this, there was only very minimal bleeding. Please follow up in clinic with the ENT doctor, ___. During your admission, we followed your red blood cell levels in your blood and they were low. This is called anemia. Please continue to eat a varied diet and talk to your primary care doctor about iron supplements and follow up for your anemia. The chest CT you had showed that you still have a acending thoracic abdominal aneurysm, which was increased from 4.7cm to 5.1cm since ___. Please follow up with your PCP about referral to a cardiovascular surgeon. Followup Instructions: ___

10054639-DS-24

DS

2139-04-05 00:00:00

2139-04-07 18:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year-old woman with HTN, HLD, osteoporosis, AAA, and recent ENT procedure who presented to ED with AMS after taking roxicet. Notably, she was recently admitted to ___ for hemoptysis and had ENT procedure last week to cauterize an ectatic vessel on her hard palate. Since then, she was taking pain medicaiton (roxicet) in the morning. This am, she was feeling fine and took her roxicet without eating breakfast. Few mintues later her daughter was concerned because she was lethargic, however she was responsive the entire time and breathing normally. No focal motor deficits noted. Her daughter gave her something to eat and her mental status returned to normal. Nonetheless her daughter called EMS who brought her to the ED. In the ED, initial vital signs were 97.5 58 120/73 14 100% RA. Initial labs and CXR were unremarkable. After talking to family, there was some confusion as to whether the patient was unresponsive or just lethargic and given this concern she was admitted. However, after further clarification, it was clear that she did not lose consciousness and was never unresponsive. On the floor, initial vitals were 98.1 119/74 64 16 100RA. She denied complaints. Review of Systems: (+) as per HPI (-) 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: HTN HLD h/o hyperplastic colonic polyp h/o H. Pylori in ___ s/p rx GERD Uterine prolaps s/p hysterectomy B/l laser cataract surgeries AVM on palate s/p ENT cautery Social History: ___ Family History: Brother recently died of cancer, but doesn't know what type. No known FH of diabetes, lung disease, or cardiac disease. Daughter has hypertension. Physical Exam: Admission Physical Exam: VS - 98.1 119/74 64 16 100RA Gen: Appropriately interactive, oriented x3, appears comfortable HEENT: NCAT, EOMI, 4mm diameter circular area on left palate s/p cautery, healing well. Neck: JVP flat, no LAD, no thyromegaly Card: RRR, no m/r/g. Resp: CTAB without wheezes or crackles. Full expansion Abd: Soft, +BS, NTND. Ext: 2+ ___ pulses, non-tender, no edema Neuro: CN ___ grossly intact. Full strength throughout. Sensation intact. Toes downgoing bilaterally. Discharge Physical Exam: Vitals: T98, 57-64 (57), ___ (128/74) RR16-18 98-100%RA General: NAD, alert and oriented, conversing with family members in room, ambulating to bathroom well. HEENT: EOMI, MMM with healing surgical lesion on hard palate with cautery. Cardiac: Bradycardic, regular, no m/r/g Resp: Clear bilaterally, no crackles, rhonchi or wheezes Abdomen: Nondistended, nontender, BS present Extremities: No c/c/e Pertinent Results: ADMISSION LABS: ___ 11:25AM BLOOD WBC-5.2 RBC-3.64*# Hgb-10.3*# Hct-32.9* MCV-90 MCH-28.3 MCHC-31.3 RDW-12.9 Plt ___ ___ 11:25AM BLOOD Neuts-59.1 ___ Monos-5.3 Eos-1.2 Baso-1.0 ___ 11:25AM BLOOD ___ PTT-29.3 ___ ___ 11:25AM BLOOD Glucose-81 UreaN-15 Creat-0.8 Na-139 K-4.0 Cl-101 HCO3-32 AnGap-10 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-4.8 RBC-3.57* Hgb-10.2* Hct-31.7* MCV-89 MCH-28.4 MCHC-32.0 RDW-13.3 Plt ___ ___ 07:20AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-140 K-3.9 Cl-103 HCO3-31 AnGap-10 ___ 07:20AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.3 ================= MICROBIOLOGY: NONE ECG: ___ Sinus rhythm. Diffusely low QRS voltage. Probable prior anteroseptal myocardial infarction Compared to the previous tracing of ___ the rate is faster. Other findings are similar. IMAGING: CXR ___ No evidence of acute cardiopulmonary process Brief Hospital Course: Ms. ___ is an ___ year-old woman with HTN, HLD, osteoporosis, AAA, and recent ENT procedure who presented to ED with lethargy after taking roxicet. #Altered mental status: Patient was brought into the ED by daughter following episodes of confusion. She had no loss of consciousness, and her confusion was thought to be due to roxicet. EKG and chest x-ray in the emergency department showed no acute processes. Patient was admitted for telemetry monitoring with no events overnight. She had resolution of confusion and ambulated throughout the floor without symptoms. Patient and family were told to stop roxicet or other pain medication administration other than Tylenol and tramadol. #Recent oral surgery w/hard palate cautery: The site of surgery appeared to be healing well with adequate cautery at margins. The patient was continued on amoxicillin Oral Susp. 800 mg PO/NG Q8H (5day course, from ___, and pain was managed with Tylenol. CHRONIC DIAGNOSES: #Hypertension: Patient was continued on home antihypertensives atenolol, hydrochlorothiazide and lisinopril with adequate blood pressure control. #Hyperlipidemia: She was continued on home dose of atorvastatin. # GERD: Patient was continued on home omeprazole. # Chronic back pain: Patient had no complaints of back pain during hospitalization and was continued on home lidocaine patch and tylenol PRN TRANSITIONAL ISSUES: There are no outstanding tests at time of discharge, and patient was scheduled to follow-up with PCP at appointment on ___. Family and patient were advised to refrain from roxicet and other pain medication intake other than tylenol and tramadol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 40 mg PO BID 2. Lisinopril 20 mg PO DAILY 3. Lidocaine 5% Patch 1 PTCH TD DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Atenolol 25 mg PO DAILY 6. Atorvastatin 20 mg PO DAILY 7. Acetaminophen 325-650 mg PO Q4H:PRN pain 8. Lidocaine Viscous 2% 20 mL PO TID:PRN pain 9. OxycoDONE-Acetaminophen Elixir 5 mL PO Q4H:PRN pain 10. AMOXicillin Oral Susp. 800 mg PO Q12H post surgical, 5 day rx starting ___ Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN pain 2. AMOXicillin Oral Susp. 800 mg PO Q12H 3. Atenolol 25 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Lidocaine 5% Patch 1 PTCH TD DAILY 7. Lidocaine Viscous 2% 20 mL PO TID:PRN pain 8. Lisinopril 20 mg PO DAILY 9. Omeprazole 40 mg PO BID 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Take for pain every 6 hours as needed for pain. RX *tramadol 50 mg 1 tablet(s) by mouth 4 times a day Disp #*26 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Altered mental status 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 while you were admitted to ___. You were admitted because your family was concerned about a change in your mental status. Most likely this was a result of your pain medication that you have been taking after ENT surgical procedure last week. The blood tests and heart monitoring we did in the hospital were all reassuring. When you return home, please take only tylenol or tramadol for pain control. Followup Instructions: ___

10054992-DS-19

DS

2125-02-23 00:00:00

2125-02-24 08:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Paranoia Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Ms. ___ is a ___ year old female, with prior history of Bipolar Disorder / Psychosis, now presenting with acute agitation. Patient with potentially prior late diagnosis of Bipolar Disorder / Psychosis? was previously living in ___ for the past year, and returned to ___ because of mental status changes. 6 weeks prior, Husband reports that she had become depressed secondary to potentially stress. She was also drinking alcohol, and she was being self-medicated with lorazepam and Haldol (which she had been previously described before). She now is a "basket case", and feels more paranoid and has potentially lost perception with reality. Patient thinks that everyone is against her. Her husband notes that she can be somewhat aggressive sometimes. She does endorse "emptiness" in her head, and her husband believes that she may have suffered several strokes in the past as well. She does not have any headaches, numbness/tingling, focal neurological deficits, or loss of function. Patient was first evaluated and found to have potentially an exacerbation of bipolar disorder vs. alcohol use vs. organic neurologic process. Patient was then evaluated to potentially need geriatric psych management. Past Psychiatry History: Reviewed in OMR. Patient was initially diagnosed with a bipolar disorder and had a psychotic break a few years ago. At that time, she was treated with Haldol and Ativan, and had somewhat improvement. Patient was then potentially tailored off medications, and then went into a "manic phase" that lasted ? "about a year". Patient was very energetic previously, and then mood stable. She was also drinking alcohol at that time. Last year, she and her husband then moved to ___ for financial reasons and returned to the ___ because of mental status changes. In the ED, initial vitals: 97.9 76 125/81 16 98% RA Labs were significant for: Sodium 145, Potassium 3.6, BUN 24, Cr 0.7. Serum Tox pending. TSH 1.3. Vitamin B12: Pending. Hgb 11.1. CT Head Imaging without contrast showed no acute intracranial abnormality. In the ED, she received: ___ 12:27 PO Lorazepam 1 mg Vitals prior to transfer: UA 97.9 72 124/78 18 100% RA Currently, patient is standing in the room, refusing all care. Patient states that she would like to leave the hospital. Patient states that she feels that she is being kept here against her will. ROS: Unable to assess. Patient is not able to assess. Past Medical History: 1. Bipolar Disorder, Psychotic Break Social History: ___ Family History: Declines answering questions. Physical Exam: >> ADMISSION PHYSICAL EXAM: GEN: Patient is refusing to acknowledge name, date of birth or place. She continues to state that she does not need to be here. Patient also continues to state that she would like to leave. HEENT: Anicteric scleare. no conjunctival pallor. Patient refusing mouth examination. CV: RRR, S1, S2. Lungs: Refusing exam. ABD: Refusing exam. EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, extremities grossly intact. She was able to walk to the restroom by herself, without help. Gait appears normal. . >> DISCHARGE PHYSICAL EXAM: GEN: Patient repeats name, year, declines answering more questions. HEENT: Anicteric scleare. no conjunctival pallor. CV: RRR, S1, S2. Lungs: Refusing exam. ABD: Refusing exam. EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, extremities grossly intact. She was able to walk to the restroom by herself, without help. Gait appears normal. Pertinent Results: >> Pertinent Labs: ___ 11:03AM BLOOD WBC-7.0 RBC-3.56* Hgb-11.1* Hct-35.2 MCV-99* MCH-31.2 MCHC-31.5* RDW-13.5 RDWSD-48.6* Plt ___ ___ 11:03AM BLOOD Neuts-65.1 ___ Monos-12.0 Eos-0.9* Baso-0.6 Im ___ AbsNeut-4.57 AbsLymp-1.47 AbsMono-0.84* AbsEos-0.06 AbsBaso-0.04 ___ 11:03AM BLOOD Glucose-101* UreaN-24* Creat-0.7 Na-145 K-3.6 Cl-107 HCO3-27 AnGap-15 ___ 11:03AM BLOOD VitB12-303 ___ 11:03AM BLOOD TSH-1.3 ___ 11:03AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . >> PERTINENT REPORTS: ___ Imaging CT HEAD W/O CONTRAST : There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. There is a mucus retention cyst in the left maxillary sinus with thickening of the lateral wall of the left maxilla suggesting chronic inflammation. The remaining 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. ___ Imaging MR HEAD W & W/O CONTRAS : Study is mildly degraded by motion. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There is prominence of the ventricles and sulci suggestive involutional changes. Few subcortical T2 and FLAIR hyperintensities are noted. There is no abnormal enhancement after contrast administration. The major vascular flow voids are preserved. There is partial opacification of the mastoid air cells. Mucosal thickening with an air-fluid levels noted in the left maxillary sinus. Mild mucosal thickening of the ethmoid sinuses seen. There is a 0.9 cm Tornwaldt cyst versus mucous retention cyst in the posterior nasopharynx. The orbits and visualized soft tissues are otherwise normal. Nonspecific bilateral mastoid fluid is present. Degenerative changes are noted in the upper cervical spine. IMPRESSION: 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality. 3. Few scattered white matter signal abnormalities, likely secondary to chronic microvascular ischemic changes. 4. Air-fluid level in the left maxillary sinus, which may represent acute sinusitis. Brief Hospital Course: Ms. ___ is a ___ year old female, with past history of ? bipolar disorder / psychosis, now presenting with acute on chronic paranoia. . >> ACTIVE ISSUES: # Paranoia: Patient initially presented to ___ given increased paranoia and inability to care for herself. She was brought in by her husband, and history obtained by both patient and collateral from her husband. Patient had previously been diagnosed with a Bipolar disorder syndrome, and then patient moved to ___ ___ year ago. Over the past several months, patient had worsening paranoia and agitation, and therefore presented to ___. Patient had initial blood work which was unrevealing for an organic cause of her symptoms, and evaluated by psychiatry. Psychiatry felt that much of her symptoms were likely secondary to a depression with psychotic features type diagnosis instead of worsening of a prior diagnosis of Bipolar. Patient was initially started on treatment with Zyprexa 2.5 mg QHS, and Ativan given prior history of this. She was monitored serially, and underwent CT head and MRI imaging which was also negative for an acute organic cause of her symptoms. Therefore, patient was medically clear. Patient was started on empiric therapy for depression with mirtazapine, and was continued on standing anti-psychotic. Patient was also placed under ___ on ___ given inability to make full healthcare decisions. Patient was started on thiamine given nutritional needs. . # Elevated SBP: patient was noted to have an elevated SBP on admission, however this resolved during serial vital signs as an inpatient and therefore likely secondary to stress than true hypertension. . >> TRANSITIONAL ISSUES: # Paranoia: Patient to have f/u with geriatric psych unit. Patient may benefit from further behavioral stabilization, potentially ECT, and then will require further formal neurologic workup when behavirorally stable. # Discharge Psychiatric Regimen: Patient was started on mirtazapine 7.5 mg QHS, and also Zyprexa 2.5mg QHS. # Social Situation: Patient and her husband recently moved back from ___, likely need follow-up regarding resources. # CODE STATUS: Full # CONTACT: ___, Husband, ___ Medications on Admission: None Discharge Medications: 1. Mirtazapine 7.5 mg PO QHS 2. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS 3. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Paranoia 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 hospital stay at ___. You were hospitalized here because of an acute paranoia and change in mood, and we did blood tests and head imaging with a CT scan and an MRI which were negative. Therefore, we believe that you will benefit from psychiatric treatment. Please follow up with you physicians upon discharge from the hospital. Take Care, Your ___ Team. Followup Instructions: ___

10055072-DS-23

DS

2119-03-08 00:00:00

2119-03-08 14:16:00

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, n/v Major Surgical or Invasive Procedure: ERCP History of Present Illness: Mr ___ is a pleasant ___ year old male with hx of ccy ___, prior ERCP with stone removal ___ who presented to OSH with a three day history of RUQ abdominal pain and vomiting, was found to have a 5 mm CBD stone and was therefore transferred to ___ for ERCP and stone removal. He had subjective fevers at the OSH and was therefore given cipro/flagyl. He also received pain control and fluids prior to transfer. In the ED, the patient had no additional complaints but did have ongoing pain/nausea. Initial vitals were 97.8 100 131/84 16 99% RA. He received morphine and zofran. Currently, the patient c/o sharp ___ pain in the RUQ, occassionally radiating to the L-side. It has been relatively constant for the last 2 days but worse with food. He also has had persistent vomiting which has resulted in poor PO intake. ROS: per HPI, denies 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: -cleft palate repair -knee surgery (torn ligaments) -Anxiety -GERD Social History: ___ Family History: mother - HTN, DM, No hx of malignancy in his family Physical Exam: On admission: VS - 99.3 72 18 125/78 99% RA GENERAL - uncomfortable appearing man HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, no masses or HSM. L-side non-tender, no rebound/guarding. Pt refused to let me exam the R side due to pain EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII intact, muscle grossly intact PSYCH: appropriate, nl affect Discharge exam: ViVS - 98.4 70 16 127/78 99% RA GENERAL - comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, no masses or HSM. mild tenderness in RUQ. EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII intact, muscle grossly intact PSYCH: appropriate, nl affect Pertinent Results: ___ imaging: ___ CT abd/pelvis: choledochalithiasis with 5 mm stone, 4 mm pulmonary nodule in RML, 5 mm pulm nodule in RLL. ___ labs ___: WBC: 8.9 HCT: 48.9 PLT: 206 UA: + leuk esterase, 15 WBCs Na 141 K 3.6 Cl 104 CO2 29 Alb 4.1 Ca 8.8 Cr 1.0 Discharge labs/studies: 139 ___ AGap=14 3.9 26 0.8 Ca: 8.4 Mg: 1.8 P: 2.5 ALT: 29 AP: 61 Tbili: 0.4 Alb: AST: 29 4.2 13.3 157 39.8 ___: 13.0 PTT: 29.4 INR: 1.2 ERCP ___: Impression: Evidence of prior sphincterotomy was seen. Successful biliary cannulation was achieved with the sphincterotome. Cholangiogram revealed very mild diffuse dilation, but no filling defects were noted. Several balloon sweeps were performed and no debris/stones were extracted. Because no adequate explanation for the patient's presentation was identifed within the CBD/CHD, attention was then turned towards the cystic duct. The cystic duct was selectively cannulated with the wire, and the balloon was advanced into the duct. A filling defect was seen consistent with an impacted stone near the cystic duct orifice. Several balloon sweeps were performed and a small amount of debris, as well as a moderate amount of pus was extracted from the cystic duct. The stone could not be completely cleared. Because of the cystic duct stone impaction, the angle of duct takeoff, and the resistance to instrument passage, we did not feel that stent placement into cystic duct would be feasible. We therefore placed a double pigtail biliary stent successfully into the CBD. Otherwise normal ERCP to ___ part of duodenum. Recommendations: Antibiotics x 2 weeks until next ERCP. Repeat ERCP in ___ re-evaluation and possible ___ for cystic duct stone extraction. Juices when awake and alert, then advance diet as tolerated . ___ AXR FINDINGS: No evidence of free intraperitoneal air. Minimally dilated, gas-filled loops of small bowel are seen in the upper abdomen on two of the four images obtained later in the study. The two images obtained three minutes earlier do not depict the distended loops, making it unlikely that these represent normal transit of gas as opposed to an obstruction or ileus. The gas pattern in the colon is normal and there is residual contrast in the ascending portion. The double-J biliary stent is present. There are cholecystectomy clips overlaying the liver. . CXR ___ FINDINGS: As compared to the previous radiograph, there is no relevant change of the chest x-ray. No free subdiaphragmatic air. Multiple linear opacities reflecting atelectasis. Low lung volumes. No pneumonia. No pleural effusions. No pneumothorax. . Brief Hospital Course: HX: ___ with hx of ___, prior ERCP with stone removal ___ who presented to OSH with a three day history of RUQ abdominal pain and vomiting, found to have 5mm CBD stone and biliary duct of 8mm on CT abdomen transferred for ERCP. # h/o choledocholithiasis: The patient underwent ERCP ___ and was found to have a cystic duct stone with pus. Debris was removed but the stone would not be removed. In addition, the patient had significant amount of pain post-procedure so checked lipase (normal). The patient received cipro/flagyl and will need to continue the antibiotics indefinitely until repeat ERCP in 2 weeks w/ Dr. ___. The repeat ERCP will be for re-evaluation and possible ___ for cystic duct stone extraction. Pt. tolerated BRAT diet on discharge with minimal pain. # h/o GERD with evidence of ___ on ERCP The patient was noted to have findings consistent with esophagitis on his ERCP. His ranitidine was stopped and a high dose ppi was started. The patient should follow up with a general GI physician for consideration of a EGD and biopsy. # Transitional issues: - Follow-up ERCP in ___ weeks - Follow-up regarding possible ___ esophagus. Patient needs biopsies for the same. - Follow-up with PCP regarding routine medical care . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO DAILY:PRN anxiety 2. Ranitidine 150 mg PO DAILY:PRN heartburn Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth q 6hrs Disp #*90 Tablet Refills:*1 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Q 12 hrs Disp #*42 Tablet Refills:*0 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q 8 hrs Disp #*63 Tablet Refills:*0 4. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*3 5. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 8 mg 1 tablet(s) by mouth Q 8 hrs Disp #*30 Tablet Refills:*2 6. Lorazepam 0.5 mg PO DAILY:PRN anxiety 7. Baclofen 10 mg PO TID:PRN hiccups RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Cystic duct stone Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a stone in your biliary tract. ERCP was performed on ___ and found to have cystic duct stone with pus. Cleared some debris but could not remove the stone. You are getting cipro/flagyl for 3 weeks until repeat ERCP is done by Dr. ___ to try to remove cystic duct stone. Please call your primary care doctor ___ tomorrow to schedule an appointment in 1 week and with Dr. ___ ___ in 2 weeks. PLEASE DO NOT DRINK ALCOHOL WHILE YOU ARE ON METRONIDAZOLE AS IT COULD BE DANGEROUS. PLEASE DO NOT TAKE ANY IRON OR CALCIUM SUPPLEMENTS WHILE YOU ARE ON CIPROFLOXACIN. Followup Instructions: ___

10055694-DS-18

DS

2116-10-25 00:00:00

2116-10-26 15:41:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with CHF, COPD, ESRD s/p renal transplant on MMF and Tacro, atrial fibrillation, pulmonary HTN, HTN presenting with shortness of breath. . The patient reports her symptoms initially began in ___ when she visited ___ and ate salty foods throughout her visit. She developed lower extremity edema and dyspnea when she returned to ___, and was started on Lasix. She reports her symptoms improved with the Lasix, which was titrated as an outpatient by Dr. ___ cardiologist. However, two weeks ago, she developed a cold with sore throat, cough, and laryngitis with loss of her voice for several days. She then began experiencing progressively worsening dyspnea, worse with exertion, increased lower extremity edema, and orthopnea requiring her to sit upright when sleeping at night. This is a change from her baseline 2 pillow orthopnea. She also reports significant cough productive of white sputum and wheezing, which she has not had in the past. She denies chest pain, recent fevers/chills, abdominal pain, nausea/vomiting, diarrhea, or dysuria. She does report that since her severe coughing, she has developed rib cage pain that is reproducible with palpation. She also reports she feels her heart heaving when she puts her hand to her chest, and reports her occasional chronic palpitations have become more marked in the past two weeks. . The patient was seen by her PCP ___ ___ for shortness of breath and was found to have crackles and wheezes on exam. CXR showed unchanged pulmonary vascular congestion and evidence of recent pulmonary edema but nothing acute. She was planned to have repeat PFT's and an echocardiogram for further evaluation, and was scheduled to see her cardiologist, Dr. ___ on ___. However, her progressive dyspnea, coughing, and wheezing prompted her to present to the ED for further evaluation. . In the ED, initial vitals: 98.8 75 151/82 20 99% 4L Nasal Cannula She received Lasix 20 mg IV, Azithromycin 500 mg po, Albuterol and Ipratropium nebs. CXR and EKG were obtained. Vitals prior to transfer: 98.1, 72, 142/82, 20, 99% 4LNC . Currently, the patient reports continued dyspnea, coughing, and wheezing and also reports chest wall pain with palpation. . 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: -ESRD previously on HD x ___ years, s/p renal transplant ___ on MMF and Tacro -COPD, FEV1 of 57% predicted ___ -Hypertension -Atrial fibrillation -Congestive heart failure -Pulmonary hypertension -Anemia -GERD -Depression . Past Surgical History: -L brachiobasilic AV fistula ___ -Open cholecystectomy ___ -Tubal ligation, with incision from midline to pubis -Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother was on dialysis from DM. Niece has ESRD, s/p transplant. Physical Exam: VS - 98.1 142/77 84 18 94%RA Wt 76.9kg GENERAL - Alert, interactive, NAD HEENT - Strabismus, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, JVP difficult to assess ___ continuous coughing HEART - Difficult to hear ___ prominent wheezes/coughing, RRR, nl S1-S2, no MRG LUNGS - Diffuse wheezing bilaterally, crackles at bases b/l, resp unlabored, no accessory muscle use. Tender to palpation along left rib cage and xyphoid area ABDOMEN - NABS, soft/NT/ND, no masses EXTREMITIES - WWP, 1+ pitting edema b/l, no c/c, 2+ peripheral DP pulses b/l SKIN - no rashes or lesions NEURO - A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: ___ 04:50PM GLUCOSE-101* UREA N-49* CREAT-3.5*# SODIUM-138 POTASSIUM-8.1* CHLORIDE-106 TOTAL CO2-22 ANION GAP-18 ___ 04:50PM WBC-6.6# RBC-3.91* HGB-11.4* HCT-38.7 MCV-99* MCH-29.1 MCHC-29.4* RDW-17.3* ___ 04:50PM PLT COUNT-227 ___ 04:50PM NEUTS-62.2 ___ MONOS-8.2 EOS-4.6* BASOS-2.8* ___ 04:50PM ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-5.4*# MAGNESIUM-2.2 ___ 04:50PM ALT(SGPT)-13 AST(SGOT)-36 ALK PHOS-92 TOT BILI-0.9 ___ 04:50PM LIPASE-25 ___ 04:50PM cTropnT-<0.01 ___ 04:50PM ___ ___ 05:02PM LACTATE-1.1 K+-5.5* ___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG ___ 05:30PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-13 Micro: BCx ___ pnd UCx ___ negative UCx ___ negative Imaging: EKG: Probable atrial flutter with vertrical axis. Non-specific ST-T wave abnormalities. Compared to the previous tracing atrial flutter is now seen. The axis is a bit more shifted to the right. Renal Transplant US ___: Mild upper pole caliceal dilatation. No frank hydronephrosis. Suboptimal Doppler analysis. Resistive index in the mid pole is minimally elevated measuring 0.81. Close ultrasound followup exam is recommended. PFT's ___: SPIROMETRY 2:31 ___ Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 0.72 2.66 27 FEV1 0.66 1.96 34 MMF 1.08 2.62 41 FEV1/FVC 91 74 124 CXR ___: Given differences in positioning and technique, there has been no significant interval change. There is engorgement of the central pulmonary vasculature with indistinctness of the vessels peripherally, not significantly changed from prior. There is no new confluent consolidation or pleural effusion. Cardiac silhouette is enlarged but stable compared to prior. IMPRESSION: No significant interval change since prior. CXR ___: Mild pulmonary edema has improved since ___ and ___, but the heart is still severely if not chronically enlarged and hilar vessels are also chronically dilated. There is no appreciable pleural effusion. TTE ___: IMPRESSION: Right ventricular cavity dilation with basal free wall hypokinesis ___ sign). Pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with preserved regional and global left ventricular systolic function. Compared with the prior study (images reviewed) of ___, the right ventricular cavity is now dilated and hypokinetic, the severity of tricuspid regurgitation is increased, and PA systolic hypertension is now present. The rhythm is now atrial fibrillation. Is there a history to suggest and acute pulmonary process (e.g., pulmonary embolism)? VQ Scan ___: The above findings are consistent with a pulmonary flow redistribution and low-likelihood ratio for recent pulmonary embolism. Cardiomegaly is noted. IMPRESSION: Low-likelihood ratio for recent pulmonary embolism. Brief Hospital Course: ___ with CHF, COPD, ESRD s/p renal transplant on MMF and Tacro, atrial fibrillation, pulmonary HTN, HTN presenting with shortness of breath. . #. Dyspnea: The patient first developed dyspnea in the recent past after visiting ___ and ingesting salty foods. She was started on lasix by her Cardiologist as an outpatient, with improvement of her symptoms. However, the patient currently presents with recurrence of progressive dyspnea that began after she developed a URI, which likely triggered an acute on chronic CHF exacerbation. Initial infectious workup with UA and urine culture was negative, CXR was negative for infiltrate, and blood cultures are currently pending but are negative to date. She presented in atrial flutter (rate controlled with 4:1 block) which may be ___ volume overload, less likely to have been the inciting trigger for her CHF exacerbation. She had a significant cardiac wheeze and cough due to volume overload, and she was aggressively diuresed with Lasix 80 mg IV boluses. There was low suspicion of ischemia, CE's negative x2, and she may be considered for an outpatient stress test in the future. TTE was obtained, and showed mild symmetric LVH, ___, concern for PE, given RV dilation, RV basal free wall hypokinesis, and pulmonary hypertension, but VQ scan overnight showed low probability for PE. A Heparin gtt was initiated empirically and was discontinued following return of the VQ scan results. Her symptoms improved with aggressive diuresis, and she was discharged on a higher dose of PO Lasix for further diuresis as an outpatient. She was discharged with close outpatient cardiology follow-up. . #. Atrial flutter/fibrillation: The patient was in atrial flutter with rate control in the 90's on Metoprolol. CHADS2 score of 2, on ASA 325 as an outpatient. She had been on Coumadin in the past for atrial flutter but this was discontinued due to bleeding from her fistula site, per OMR records. As she is no longer on hemodialysis following her renal transplant in ___, her outpatient cardiologist was contacted and she was started on Coumadin prior to discharge. She was set up with the ___ clinic again and she will have follow-up with her cardiologist. She was continued on her home Metoprolol 50 mg daily. Her Aspirin 325 mg daily was continued, but should be decreased in dose when her INR becomes therapeutic. . #. Acute Renal Failure/ESRD: The patient was previously on hemodialysis for ___ years, prior to receiving a renal transplant ___. She is on MMF and Tacrolimus as an outpatient. She presented with a Cr 3.5 from baseline 1.4-1.6, likely ___ CHF exacerbation and poor forward flow leading to renal hypoperfusion, as well as supratherapeutic Tacrolimus level. She was diuresed with Lasix IV and Tacrolimus was initially held, then re-started at a lower dose with decrease of Tacro levels to within goal range. Given her renal transplant, a renal ultrasound with dopplers was obtained and showed mild upper pole caliceal dilatation, no frank hydronephrosis, resistive index in the mid pole minimally elevated measuring 0.81. Close ultrasound followup exam is recommended, with an outpt ultrasound in 4 weeks. The Renal transplant team was following the patient in-house. She was continued on her home MYCOPHENOLATE MOFETIL 500 mg bid (decreased to half dose recently as an outpatient) and was discharged on a decreased dose of TACROLIMUS 5 mg bid. She was continued on Bactrim ppx. . #. Low Grade Temperature: The patient had a low grade temperature of 100.5 over the last day with continued cough. She had no white count, but given her immunosuppression, she was ruled out for infection with a UA, urine cultures, and repeat CXR. Also, VQ scan showed no abnormalities in uptake that would suggest pneumonia. She has blood cultures that are currently pending, negative to date. . #. Hyperkalemia: Patient with hyperkalemia likely in the setting of worsening renal function and supratherapeutic Tacro level, no EKG changes. She was diuresed aggressively with Lasix IV and Tacro was decreased with down-trending levels back to goal range. She was also given a dose of Kayexalate 15 gm x1 for up-trending K+ on initial presentation. Hyperkalemia resolved with the above interventions. . #. Chest Wall Pain: Patient with reproducible chest wall pain since the onset of her severe coughing, likely musculoskeletal pain and costochondritis ___ strain. Her pain was well controlled with Tylenol. . #. COPD: Patient has a history of COPD, FEV1 of 57% predicted ___ with plans for repeat outpatient PFT's. She had PFT's performed on ___. She was continued on Albuterol and Ipratropium nebs standing to help symptoms of cough and wheeze, and was discharged with nebulizers. . #. Hypertension: The patient was mildly hypertensive on presentation, and was diuresed with Lasix as above. She was continued on her home Metoprolol 50 mg daily, Hydralazine 25 mg bid, and Aspirin. . #. Diastolic congestive heart failure: The patient had multiple stress echos showing normal EF, and TTE in ___ showed mild symmetric LVH and left-to-right shunt across the interatrial septum is seen at rest consistent with a small atrial septal defect or stretched patent foramen ovale. She currently presents in an acute CHF exacerbation, likely ___ URI in the setting of diastolic CHF and chronic renal impairment. #. Anemia: Stable at baseline. #. GERD: Continued home Omeprazole 40 mg daily. . . #CODE STATUS: Full (confirmed) ==================== Transitions of Care: ==================== - Repeat renal ultrasound in 4 weeks as an outpatient to f/u on mildly abnormal renal ultrasound in-house - Evaluation of volume status on higher discharge dose of Lasix for continued diureses - f/u INR with initiation of Coumadin, goal INR ___ for atrial flutter - When INR ___, decrease Aspirin from 325 mg daily to 81 mg daily - f/u blood cultures - f/u Tacrolimus level on decreased dose Medications on Admission: ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 1 puff q6h prn FUROSEMIDE 20 mg daily HYDRALAZINE 25 mg bid (decreased from tid) METOPROLOL SUCCINATE 50 mg Extended Release daily MYCOPHENOLATE MOFETIL 500 mg bid (decreased to half dose) NYSTATIN 100,000 unit/mL Suspension - 1 tsp po qid OMEPRAZOLE 40 mg Capsule daily SULFAMETHOXAZOLE-TRIMETHOPRIM 400 mg-80 mg Tablet daily TACROLIMUS 7 mg bid (decreased from 9 mg bid) ASPIRIN 325 mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. hydralazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours. Disp:*1 inhaler* Refills:*2* 11. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation every six (6) hours for 10 days: After 10 days, switch to inhaler form of albuterol and inhaler form of ipratropium. Disp:*qs qs* Refills:*0* 12. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: Take 5 mg daily total until otherwise directed. Disp:*60 Tablet(s)* Refills:*2* 13. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: Take 60 mg total daily until follow up with Dr. ___ your primary care physician. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic congestive heart failure exacerbation Acute on chronic renal insufficiency secondary to supratherapeutic Tacrolimus levels Hyperkalemia 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 for coughing, wheezing, and shortness of breath and were found to be in a congestive heart failure exacerbation with excess fluid in your body. You were given high doses of Lasix with removal of the fluid and improvement of your respiratory status. You underwent an echocardiogram to determine the cause of your congestive heart failure exacerbation, and this showed signs concerning for a blood clot in your lungs, called a pulmonary embolism. You underwent a test called a ventilation-perfusion scan to evaluate for this, which showed that you do not have evidence for a clot. Your kidney function was also abnormal, and you were found to have a supratherapeutic level of Tacrolimus based on your blood tests. Your dose of Tacrolimus was decreased as recommended by the kidney transplant specialists. An ultrasound of your kidneys showed mild abnormalities that should be followed up in 4 weeks with a repeat ultrasound of your kidneys. Additionally, your blood tests showed a high potassium level when you were admitted, which is likely due to your worsened kidney function. This improved in the hospital, and is expected to remain normal as your kidney function improves. The following changes were made to your home medications: - Coumadin was STARTED - Lasix was INCREASED - Tacrolimus was DECREASED - Ipratropium inhaler was STARTED Followup Instructions: ___

10055694-DS-22

DS

2118-07-27 00:00:00

2118-08-02 19:21:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with a history of dCHF (65%EF, 3+TR), severe pulmonary hypertension (PASP 69+RASP), afib/flutter, COPD on 2L home O2, ESRD s/p cadaveric transplant ___ with chronic rejection, with a recent CHF admission requiring dialysis who presents today with shortness of breath and hallucinations. On ___ she presented to our ED with dyspnea and weight of 163 from baseline 158, JVD, crackles, peripheral edema, BNP 8000 and CXR c/w pulmonary edema. She was thought to have both a CHF and COPD exacerbation and was treated with IV lasix, prednisone, and azithromycin. At the time she was satting 85% on room air but she refused admission and left AMA. Per patient's husband she has had progressive dyspnea since then, with acute worsening today leading her to return to the ED today where she presented with acute respiratory distress; unable to provide history. Husband states that patient has been hallucinating as well today and "not making sense." Per daughter O2 sats were in the 60's at home. Initial VS in ED: 10 98.0 100 128/86 30 60% on RA. On exam JVP was elevated, lung exam significant for wheezes and crackles. Labs notable for K 8.1, hemolyzed and found to be 6.3, Cr 5.2 (baseline 3's in ___, trending up), Phos 8.4, HCO3 19 with gap of 16, Hct 27.8 slightly lower than baseline low ___, BNP 13,000 from 8000. ABG ___. Patient placed on BiPap. ABG at ___ 50% was 7.___. Lactate 1.4. CXR showed pulm edema and worsening L sided pleural effusion, with ?focal infiltrate. She was treated for COPD exacerbation/PNA with nebs and vanc/levo/cefepime and tried off BiPap but gas worsened. Cardiology consulted and she was given 120mg IV lasix. Renal also consulted; no acute need for HD but will start ultrafiltration via her LUE fistula if acidosis and hyperkalemia do not respond to BiPap and diuresis. Got 120mg IV lasix at 3pm and as of 16:40 only put out 50cc's. Prior to transfer she's setting 97% RR ___ FiO2 50%. Repeat ABG pending. Upon arrival to the CCU she is not able to provide additional history as she is on bipap and somnolent. Past Medical History: -dCHF, required dialysis during ___ admission -ESRD previously on HD x ___ years, s/p renal transplant ___ on MMF and Tacro -COPD, FEV1 of 57% predicted ___ -Hypertension -Atrial fibrillation -Pulmonary hypertension -Anemia -GERD -Depression Past Surgical History: -L brachiobasilic AV fistula ___ -Open cholecystectomy ___ -Tubal ligation, with incision from midline to pubis -Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother was on dialysis from DM. Niece has ESRD, s/p transplant Physical Exam: ADMISSION PHYSICAL EXAMINATION General: On BiPap, somnolent but opens eyes and converses HEENT: NCAT, PERRL Neck: supple, JVP elevated CV: irregularly irregular, ___ blowing HSM Lungs: coarse rhonci, crackles, wheezes throughout Abdomen: soft, BS+, non-tender Ext: WWP, +2 PE bilaterally to knees, 1+ distal pulses bilaterally Neuro: moving all extremities grossly, speech is fluent but inappropriate; perserverates about steroid taper = = = = = = = = = = = = = = = = ================================================================ DISCHARGE PHYSICAL EXAMINATION VS: 98.8/98.5, HR 113-121, RR 18, BP 119-139/69-71, O2 sat 97% 2L Weight 64.4 (65.8) GENERAL - well-appearing woman, no longer using accesory muscles. HEENT - NC/AT, PERRLA, strabismus NECK - JVP at mid-neck, no carotid bruits LUNGS – Scattered rhonchi, insp and exp wheeze with dec BS. \ HEART - irreg irreg, normal S1, loud S2 (P2). No m/r/g. ABDOMEN - NABS, soft/NT/ND. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. SKIN - no rashes or lesions. Neurologic: AOx3. thought process is clear. Pertinent Results: ADMISSION LABS =============== ___ 11:05AM BLOOD WBC-10.5# RBC-2.93* Hgb-8.0* Hct-27.8* MCV-95 MCH-27.3 MCHC-28.7* RDW-17.7* Plt ___ ___ 11:05AM BLOOD Neuts-76* Bands-0 Lymphs-15* Monos-9 Eos-0 Baso-0 ___ Myelos-0 NRBC-11* ___ 11:05AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-OCCASIONAL Burr-OCCASIONAL ___ 11:05AM BLOOD ___ PTT-31.1 ___ ___ 11:05AM BLOOD Glucose-119* UreaN-126* Creat-5.2* Na-134 K-8.1* Cl-99 HCO3-19* AnGap-24* ___ 11:05AM BLOOD ALT-14 AST-38 AlkPhos-97 TotBili-0.8 ___ 11:05AM BLOOD CK-MB-4 ___ ___ 11:05AM BLOOD Albumin-4.1 Calcium-9.1 Phos-8.4*# Mg-2.6 ___ 09:18PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE ___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:38AM BLOOD Type-ART Rates-/___ Tidal V-300 PEEP-5 FiO2-50 pO2-88 pCO2-69* pH-7.14* calTCO2-25 Base XS--6 Intubat-NOT INTUBA Vent-SPONTANEOU ___ 11:21AM BLOOD Lactate-1.4 K-6.3* ___ 08:20PM BLOOD Lactate-0.7 K-5.9* ___ 10:07AM BLOOD Lactate-0.9 ___ 07:11PM BLOOD O2 Sat-90 ___ MetHgb-0 NOTABLE LABS ============= ___ 05:24AM BLOOD WBC-9.9 RBC-2.47* Hgb-6.7* Hct-22.9* MCV-93 MCH-27.2 MCHC-29.4* RDW-17.8* Plt ___ ___ 04:09AM BLOOD WBC-13.1* RBC-3.23* Hgb-8.9* Hct-29.6* MCV-92 MCH-27.6 MCHC-30.1* RDW-17.5* Plt ___ ___ 04:45AM BLOOD WBC-12.8* RBC-3.15* Hgb-8.4* Hct-29.5* MCV-94 MCH-26.8* MCHC-28.6* RDW-16.9* Plt ___ ___ 04:09AM BLOOD Neuts-90.9* Lymphs-4.3* Monos-3.5 Eos-1.3 Baso-0.1 ___ 06:15AM BLOOD ___ PTT-33.6 ___ ___ 02:30AM BLOOD ___ PTT-36.9* ___ ___ 04:45AM BLOOD ___ PTT-31.1 ___ ___ 05:24AM BLOOD Glucose-100 UreaN-60* Creat-3.3*# Na-138 K-3.8 Cl-96 HCO3-29 AnGap-17 ___ 06:15AM BLOOD Glucose-106* UreaN-73* Creat-4.4*# Na-137 K-4.5 Cl-93* HCO3-26 AnGap-23* ___ 02:30AM BLOOD Glucose-125* UreaN-25* Creat-2.7* Na-136 K-4.1 Cl-95* HCO3-32 AnGap-13 ___ 04:45AM BLOOD Glucose-132* UreaN-45* Creat-4.0*# Na-132* K-4.1 Cl-91* HCO3-30 AnGap-15 ___ 11:05AM BLOOD cTropnT-<0.01 ___ 05:24AM BLOOD Calcium-8.5 Phos-4.2# Mg-2.0 ___ 04:09AM BLOOD Calcium-9.2 Phos-5.3*# Mg-2.2 ___ 04:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 Iron-18* ___ 04:45AM BLOOD calTIBC-286 Ferritn-140 TRF-220 ___ 11:57AM BLOOD Vanco-11.8 ___ 06:15AM BLOOD Vanco-29.0* ___ 06:35AM BLOOD Vanco-17.6 ___ 05:24AM BLOOD Cyclspr-71* ___ 02:30PM BLOOD Type-ART pO2-65* pCO2-68* pH-7.12* calTCO2-23 Base XS--8 Intubat-NOT INTUBA ___ 09:17PM BLOOD Type-ART pO2-69* pCO2-65* pH-7.28* calTCO2-32* Base XS-1 ___ 11:23PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.35 calTCO2-34* Base XS-4 ___ 05:38AM BLOOD Type-ART pO2-72* pCO2-57* pH-7.37 calTCO2-34* Base XS-5 ___ 10:29PM BLOOD Type-ART pO2-83* pCO2-62* pH-7.30* calTCO2-32* Base XS-1 ___ 10:07AM BLOOD Type-ART Temp-36.7 FiO2-40 pO2-52* pCO2-58* pH-7.31* calTCO2-31* Base XS-0 Intubat-NOT INTUBA ___ 09:17PM BLOOD O2 Sat-91 ___ 05:38AM BLOOD O2 Sat-92 ___ 10:29PM BLOOD O2 Sat-94 ___ 10:07AM BLOOD O2 Sat-84 DISCHARGE LABS ================ ___ 04:55AM BLOOD WBC-13.7* RBC-3.05* Hgb-8.2* Hct-28.8* MCV-94 MCH-26.8* MCHC-28.4* RDW-17.0* Plt ___ ___ 04:55AM BLOOD Glucose-102* UreaN-33* Creat-3.1* Na-137 K-4.5 Cl-101 HCO3-27 AnGap-14 ___ 05:00PM BLOOD Cyclspr-PND STUDIES ========= CXR (___): Cardiomegaly with pulmonary edema. Focal opacities in the left mid lung and right upper lung could represent infection in the appropriate clinical setting. CXR (___): Increased cardiomegaly with signs of volume overload. Opacities in the bilateral mid lungs could represent atelectasis or edema; however, superimposed infection is possible. CXR (___): The widespread, asymmetric pulmonary opacification, still responsible for a consolidation in the right upper lobe, and now more so at the right lung base. What was probably concurrent pulmonary edema in the left lung has improved. Small right pleural effusion has increased. Severe cardiomegaly persists, although another indication of improved cardiac function is a decrease in mediastinal venous engorgement. No pneumothorax. Renal Transplant US (___): FINDINGS: Transplanted kidney is seen in the right lower quadrant. The transplant measures 11.5 cm, similar to prior. There is no hydronephrosis or perinephric fluid collection. The renal sinus fat is normal in echogenicity and the cortical thickness is unchanged. There is no nephrolithiasis or mass. Doppler: The flow within the main renal artery and upper, mid and lower intraparenchymal renal arteries shows a high resistance flow with reversal during end diastole. As such, resistive indices are not applicable. The main renal vein is patent. IMPRESSION: 1. High resistance flow is consistent with transplant dysfunction. 2. No hydronephrosis. ECGs ====== Admission ECG ___: Most likely atrial fibrillation with a rapid ventricular response. Poor R wave progression. Non-specific inferolateral ST-T wave changes. Compared to the previous tracing of ___ the heart rate is faster. ECG ___: Atrial fibrillation with rapid ventricular response with some organization. Rightward axis. Compared to the previous tracing of ___ no diagnostic interim change. MICRO DATA: ============ Respiratory Virus Identification (Final ___: Reported to and read back by ___ ___ 1100. RESPIRATORY SYNCYTIAL VIRUS (RSV). Viral antigen identified by immunofluorescence Brief Hospital Course: BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ with ESRD s/p DDRT with rejection, COPD on home O2, current 1ppd smoker, afib, ___ presenting with acute decompensated diastolic heart failure and RSV and ultimately required reinitiation of hemodialysis. # Acute Decompensated Diastolic Heart Failure with mod-severe TR. Likely precipitant infection with RSV, in addition to possible medication non-compliance and/or hypervolemia from renal failure and recent prednisone administration. Had HD on ___, removed nearly 2 L and BiPap was discontinued. She was back on her baseline oxygen requirements at the time of discharge. Volume status much improved with dialysis, -6L LOS. # COPD, RSV: . Wheeze could have been cardiogenic, but patient had known COPD on home 2L O2, prolonged expiratory phase and high CO2. As she was on a prednisone taper recently, she may have stopped in the middle of the taper. In the ED she initially received vanc/cefepime/levofloxacin which was later d/c'ed since she tested + for RSV. Significantly improved O2 requirement with dialysis. # Acute on Chronic Renal Failure with chronic rejection of renal transplant. Suspect cardiorenal syndrome in addition to graft rejection. Transfused 1 unit pRBC on ___. Nitrogenated retention significatly improved with HD. She had outpatient dialysis plans initiated. # Delirium. Somnolence resolved with improving respiratory status. She was back to her baseline mental status on discharge. TRANSITIONAL: #Hemodialysis on SUN/TUE/FRI HD for holiday week. She will get HD SAT morning, then won't need it again until TUE . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 2. Aspirin 81 mg PO DAILY 3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Mycophenolate Mofetil 500 mg PO BID 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Furosemide 120 mg PO BID 8. HydrALAzine 25 mg PO Q8H 9. Diltiazem Extended-Release 240 mg PO DAILY 10. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 11. Omeprazole 40 mg PO DAILY 12. PredniSONE Dose is Unknown PO DAILY gout flares 13. Acetaminophen 650 mg PO Q8H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose one puff inhaled twice a day Disp #*1 Inhaler Refills:*2 4. HydrALAzine 37.5 mg PO Q8H RX *hydralazine 25 mg 1.5 tablet(s) by mouth three times a day Disp #*135 Tablet Refills:*2 5. Mycophenolate Mofetil 500 mg PO BID 6. Omeprazole 40 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Diltiazem Extended-Release 360 mg PO DAILY RX *diltiazem HCl 360 mg one capsule, extended release(s) by mouth daily Disp #*30 Capsule Refills:*2 9. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY RX *isosorbide mononitrate 120 mg one tablet extended release 24 hr(s) by mouth daily Disp #*30 Tablet Refills:*2 10. Nephrocaps 1 CAP PO DAILY RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg one capsule(s) by mouth daily Disp #*30 Capsule Refills:*2 11. Nicotine Patch 21 mg TD DAILY smoking cessation RX *nicotine 21 mg/24 hour one patch daily Disp #*30 Transdermal Patch Refills:*2 12. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp #*1 Bottle Refills:*0 13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 14. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 15. Aspirin 81 mg PO DAILY 16. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg one capsule inhaled daily Disp #*30 Capsule Refills:*2 17. PredniSONE 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic diastolic heart failure Acute on Chronic Kidney injury RSV infection Acute COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for ___ at ___. ___ were admitted with shortness of breath and needed diuretics to remove extra fluid. It was decided that your kidneys were not working well enough to keep the fluid from building up so dialysis was restarted. ___ are now at your goal weight of 141 pounds and will have dialysis three times a week to remove extra fluid. YOur furosemide has been stopped. ___ have a lung infection called RSV and had a large dose of prednisone for 5 days to decrease inflammation in your lungs. ___ need to make sure that ___ take your spiriva and advair every day to prevent lung inflammation and wheezing. Your diltiazem was also increased because your heart rate was high. Followup Instructions: ___

10055694-DS-23

DS

2120-10-16 00:00:00

2120-10-17 20:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___. Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with past history of ESRD s/p transplant now on dialysis ___ (anuric), last received dialsis on ___, COPD on 3L home O2, atrial fibrillation (not on anticoagulation), she presented with 2 days of shortness of breath and back pain which has been worsening. She was in her normal state of health at her dialysis on ___. On ___ she endorsed a productive cough (no sick contacts, fevers, but subjective chills) and some back pain which she initially described as a constant burning throughout her whole back. This sensation has now resolved. Denies CP, worsening orthopnea. In the ED, initial vitals: 0 99.0 ___ 18 99% Nasal Cannula. She had one rectal temp of 100.4 early on the morning of admission. - Exam notable for diffuse crackles on pulmonary examination. - Labs were notable for WBC 6.8, HgB 8.9 Hct 29, Platelet 189. INR 1.3. Serum ASA 8.4, Serum APAP 31. Lactate 1.0. - Imaging showed: Negative CTA for PE, multiple intrathoracic lymph nodes. Bedside U/S showed no pericardial effusion. - Patient was given: ___ 06:10 PR Acetaminophen 650 mg ___ 06:23 IH Albuterol 0.083% Neb Soln 1 NEB ___ 06:23 IH Ipratropium Bromide Neb 1 NEB ___ 06:23 IV Vancomycin 1000 mg ___ 06:23 IVF 1000 mL NS 500 mL ___ 07:12 IV Insulin Regular 10 units ___ 07:12 IV Dextrose 50% 25 gm ___:43 IV Calcium Gluconate 1 gm ___ 07:54 IV Levofloxacin 750 mg ___ 12:25 PO Metoprolol Succinate XL 25 mg - Consults: Renal, recommended possible CRRT vs. IHD today depending on blood pressure stability. Recommended empiric treatment for HCAP. On arrival to the MICU, she confirmed the above story stating that her burning back pain has now dissipated. She denies any increased shortness of breath. She endorses continued diarrhea ___ daily, but denies any abdominal pain. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant in - FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in ___ and treated with flagyl 500mg x 10 days; again in ___ s/p flagyl 500mg x 14 days, persistent infection still later in ___, treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother was on dialysis from DM. Niece has ESRD, s/p transplant Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vitals: T: 97.9 BP: 124/78 P: 89 Sp02: 91% on RA. GENERAL: Lethargic but arousable, falling asleep intermittently. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: On RA, mild increase work of breathing, fair air exchange, crackles and wheezes in lower to mid lung fields. CV: Irregularly irregular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, slightly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, mild ___ edema 1+ to ankles. NEURO: CN II-XII grossly intact, moving all extremities appropriately. ACCESS: LUE fistula, 2 PIVs DISCHARGE PHYSICAL EXAM: =========================== VS: 98.3, 90/47, 69, 20, 98% RA I/O: -3L during HD Gen: Well nourished appearing, dark-skinned woman, sitting up in bed in NAD HEENT: NT/AT, white hair, disconjugate gaze; mild scleral icterus, EOMI (both eyes track, but right eye unable to pass midline/this is her baseline), PERRLA, MMM moist but tongue coated in thick white/yellow plaques (improved compared to prior day) Neck: supple, symmetric, no AC, PC, or supraclavicular chain LAD; JVP difficult to assess I/s/o afib, but external jugular vein very prominent on exam today CV: variable S1, S2; regular rate; no m/r/g Pulm: breathing comfortably on NC, with slightly increased rate and mildly increased WOB; good air movement throughout posteriorly; bronchial breath sounds in b/l bases; no frank wheezes, rhonchi, or crackles Abd: Soft, mildly distended, non-rigid, mildly tender to palpation diffusely, worst in the epigastrium; no r/g; BS+ Ext: Warm, well-perfused, no pitting edema in BLE; DP palpable b/l Skin: no appreciable rashes; hyperpigmented scar in RUQ from prior cholecystectomy; hypopigmented skin over recently accessed LUE AVF Neuro: Alert, interactive on exam; no gross deficits appreciated ACCESS: PIV, LUE AVF (with palpable thrill) Pertinent Results: ADMISSION LABS: ___ 05:50AM BLOOD WBC-6.8 RBC-3.09* Hgb-8.9* Hct-28.5* MCV-92 MCH-28.8 MCHC-31.2* RDW-18.5* RDWSD-60.7* Plt ___ ___ 05:50AM BLOOD Neuts-54.3 ___ Monos-14.5* Eos-1.6 Baso-0.9 Im ___ AbsNeut-3.66 AbsLymp-1.91 AbsMono-0.98* AbsEos-0.11 AbsBaso-0.06 ___ 05:50AM BLOOD ___ PTT-34.5 ___ ___ 05:50AM BLOOD Glucose-92 UreaN-72* Creat-7.6* Na-137 K-7.0* Cl-96 HCO3-29 AnGap-19 ___ 05:50AM BLOOD ALT-14 AST-26 AlkPhos-149* TotBili-0.9 ___ 05:50AM BLOOD Lipase-31 ___ 05:50AM BLOOD cTropnT-0.01 ___ 05:50AM BLOOD Albumin-3.6 Calcium-9.7 Phos-2.6*# Mg-1.9 ___ 05:50AM BLOOD ASA-8.4 Ethanol-NEG Acetmnp-13 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:59AM BLOOD Lactate-1.0 OTHER IMPORTANT LABS: None MICROBIOLOGY: ___ Influenza A: Positive ___ Influenza B: Negative ___ Blood Culture x2: NGTD, pending ___ Blood Culture x2: NGTD, pending ___ HIV Serologies: Negative ___ H.Pylori Serologies: Pending at time of discharge IMAGING AND OTHER STUDIES: ___ CTA Chest: 1. Mild pulmonary edema. 2. Cardiomegaly, moderate with biatrial chamber enlargement. 3. Innumerable mediastinal lymph nodes, mildly enlarged, indeterminate, difficult to exclude lymphoma or other etiologies. Clinical correlation is advised. 4. No pulmonary embolism or acute aortic dissection. 5. Partially visualized abdominal ascites. ___ Portable CXR: Bilateral airspace opacities with a central predominance likely reflect pulmonary vascular congestion and mild pulmonary edema. Difficult to exclude superimposed infection in the appropriate clinical setting. ___ RUQ Ultrasound: 1. Enlarged liver along with a dilated IVC and hepatic veins is concerning for underlying fluid overload. This may also be seen in right heart failure. 2. Slightly heterogeneous and coarsened liver echotexture. No focal lesions. No intrahepatic biliary ductal dilation. 3. Trace ascites. DISCHARGE LABS: ___ 09:30AM BLOOD WBC-6.2 RBC-2.92* Hgb-8.4* Hct-28.0* MCV-96 MCH-28.8 MCHC-30.0* RDW-18.6* RDWSD-65.1* Plt ___ ___ 07:16AM BLOOD ___ PTT-32.0 ___ ___ 07:16AM BLOOD Glucose-95 UreaN-24* Creat-5.4*# Na-140 K-4.4 Cl-96 HCO3-34* AnGap-14 ___ 07:16AM BLOOD ALT-30 AST-51* LD(LDH)-214 AlkPhos-157* TotBili-0.8 ___ 07:16AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8 Brief Hospital Course: Ms. ___ is a ___ y/o woman with past history of ESRD s/p transplant on HD (___), COPD, and recurrent C. diff infection, presenting with volume overload and influenza. She had a brief FICU stay for urgent HD, was transferred to the floor with improving respiratory and volume status, and monitored closely for downtrending Hgb and reported melena prior to discharge home. ACTIVE ISSUES: -------------------- # Hypoxia of Multifactorial Etiology: The patient presented with hypoxia likely due to combination of fluid overload in setting of known CHF, ESRD, COPD, and active influenza A infection. Her active afib with intermittent RVR was likely further worsening her respiratory status. With management of these individual problems, as detailed below, her respiratory status improved and she was discharged on her home O2 requirement of ___ by NC. # Influenza A Infection: The patient was found to be FluA positive per PCR on admission and started on Tamiflu for ___ue to HD dosing (___). She did have infectious work-up for potential superinfection with PNA, but chest imaging was without notable findings. She was briefly on empiric abx and had blood cultures drawn, with no growth at time of discharge. # Anemia of unclear etiology: At baseline, the patient had a hemoglobin of ~9, likely due to ESRD. The patient did not appear malnourished on exam, but of note, nutritional studies had not been performed in several years. As detailed below, there was concern for underlying liver disease in this patient, which could have been contributing to her overall anemia. Additionally, active influenza infection could possibly have caused transient myelosuppression. During this admission, the patient further endorsed black stool (new for several days prior to and during this admission) and was found to be guaiac positive in the FICU. With trending, her hemoglobin did downtrend from her baseline to 7.7 at time of transfer to the general medicine service, concerning for upper GI bleed especially given her prior history of bleeding. She was briefly put on IV PPI and had H.Pylori serologies sent. The patient was found still to be guaiac positive but without melena on rectal exam and her hemoglobin did return to her baseline prior to discharge. The patient was arranged for outpatient follow-up with GI for further evaluation of possible GI bleed. She was also instructed to follow up with her outpatient providers regarding results of her H.Pylori serologies. # Anuric End-Stage Renal Disease s/p DCDRT complicated by allograft failure, re-initiated on HD: The patient has had a history of ESRD since ___, initially on HD. She underwent DCDRT in ___, with subsequent allograft failure and re-initiation on HD in ___. She has an estimated dry weight of ~66kg and was continued on her home ___ HD schedule. She was also continued on her home calcium supplements and phosphorus binders. She was followed closely by the renal HD service during this admission and discharged home following her last dialysis session on ___ at her dry weight of 66.2kg. # Recurrent C. Diff Colitis: The patient has failed multiple courses of treatment for C diff Colitis and was treated for another episode of recurrent C. Diff during this admission. She was initiated on Vancomycin 125mg PO q6H and Flagyl 500mg IV q8H on ___ while in the ICU and continued on a planned 14 day course of PO Vancomycin. She was discharged home with enough Vancomycin capsules to complete her 14 days course (last dose on ___. She should also follow up with her PCP and GI about potentially pursuing stool transplant given her multiple relapses. # Atrial Fibrillation: The patient has had a history of poorly controlled afib due to inability to effectively rate control in the setting of intradialytic hypotension. She was rate controlled with fractionated metoprolol equivalent in dosage to her home metoprolol XL 25mg PO daily during this admission. She was continued on ASA 81mg PO daily for stroke prophylaxis during this admission as she has been unable to tolerate systmic anticoagulation in the setting of active and prior GI bleeding as well as prior AV Fistula site bleeding (despite a CHADS2VASC of ___. # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in ___ ___s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Her CHF was felt to be a major contributor to her overall volume overload, which improved with treatment of her influenza and dialysis. # COPD on Home O2: The patient has PFTs from ___ c/w restrictive lung disease but prior PFTs showing obstructive disease. She was continued on her home inhaler regimen with added duonebs PRN and discharged on her home oxygen regimen of ___ per NC. # Mediastinal Lymphadenopathy: The patient was noted to have mediastinal LAD on chest imaging, likely reactive due to influenza. However, there was concern given poor follow that this could be due to an alternate etiology such as lymphoma or perhaps sarcoidosis. Initial work-up in the hospital was unrevealing with normal LDH and negative ACE levels. Her 1,25 hydroxy Vitamin D levels to evaluate for Sarcoidosis were still pending at time of discharge. She was instructed to follow up with her PCP regarding results of this test and she should had repeat Chest CT to re-evaluate for finding of mediastinal lymphadenopathy. # Thrush: The patient was found to have thrush on exam during this admission, likely due to underlying ESRD as well as use of oral steroid inhalers. She was provided nystatin swish and spit with improvement in her thrush. She also had HIV serologies re-sent, which were still pending at time of discharge. She should follow up with her PCP regarding results of this test. #Hypertension: The patient has history a history of hypertension with blood pressures largely within normal limits during this admission. She did have low blood pressures, likely triggered by dialysis. She responded well to gentle intravenous fluid boluses in the setting of her tenuous respiratory status. She was continued on her fractionated metoprolol and her fluid status was managed with HD as above. Her blood pressures were normal at time of discharge. CHRONIC/STABLE/RESOLVED ISSUES: # Concern for Underlying Liver Disease: The patient was admitted with elevated transaminases and INR as well as history of concern for underlying liver disease. She had CT in ___ showing nodular liver disease and perihepatic ascites. Prior Hep A,B,C studies negative with Hep A/C negative as recently as ___. The patient had RUQUS this admission, showing signs of congestive hepatopathy suggesting acute contribution from her volume overload. However, cirrhosis could not be ruled out. Her transaminases were monitored closely during this admission and she was treated for her CHF and ESRD as above. With these measures, her liver function tests downtrended prior to admission. She should have further work-up for possible cirrhosis as an outpatient. #GERD: The patient was admitted on oral PPI therapy, which was briefly changed to IV PPI due to concern over active GI bleeding. As above, her H&H stabilized and she was resumed on her home omeprazole prior to discharge. #Breast Cysts: The patient has a history of breast cysts and was continued on her home topical clindamycin throughout this admission. TRANSITIONAL ISSUES: -The patient had >1 point hemoglobin drop with self-reported melena and guaiac positive stool. As her blood counts stabilized prior to discharge, she did not receive further work-up as an inpatient. She should follow-up with GI after discharge for further evaluation. -The patient should have repeat CBC drawn on ___ with results faxed to Dr. ___ (PCP, fax number: ___ -As part of work-up for GI Bleed, the patient had H.Pylori serologies sent during this admission. Results were still pending at time of discharge and the patient should follow up on these with her PCP. -The patient was discharged with instructions to complete 14-day course of Vancomycin 125mg PO q6H for her recurrent C. Diff Colitis (First dose on ___ last dose on ___ -Given the patient's recurrent C Diff Colitis, the patient should be arranged for stool transplant evaluation -The patient should follow up with Dr. ___ (Pulmonology) for management of her Pulmonary Hypertension -The patient received hemodialysis per her home schedule of ___. Her last HD session was on ___. -On discharge, the patient's dry weight was 66.2kg -The patient should follow up with her outpatient Nephrologist regarding further management of her ESRD. Given her history of hypotension during dialysis, would consider potentially starting patient on Midodrine or other form of blood pressure support on dialysis days. -During this admission, the patient had elevated LFTs and mild markers of synthetic liver dysfunction. He had RUQ Ultrasound showing likely congestive hepatopathy but cirrhosis was not ruled out. She should have further work-up for cirrhosis as an outpatient. -The patient was found to have incidental finding of mediastinal lymphadenopathy on CTA of the Chest this admission. This should be followed up with repeat CT as an outpatient. Inpatient work-up for possible sarcoidosis was initiated with 1,25-OH Vitamin D levels (pending at time of discharge). This should be followed up with her PCP ___ pulmonologist. -The patient was discharged on her home O2 requirement of ___ liters per nasal cannula -Patient was discharged home on PO nystatin for thrush, likely due to inhaled corticosteroid use -The patient has endorsed leg pain both prior to and during this admission, concerning for possible peripheral vascular disease. She should have formal ABI's to evaluate as an outpatient. -CODE STATUS: FULL CODE -DRY WEIGHT: 66.2kg Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Nephrocaps 1 CAP PO DAILY 3. Calcium Acetate 667 mg PO DAILY 4. Cinacalcet 60 mg PO DAILY 5. Clindamycin 1% Solution 1 Appl TP DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO Q6H Will need total 14 day course. First day ___ Last day ___. RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp #*39 Capsule Refills:*0 2. Clindamycin 1% Solution 1 Appl TP DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 5. Nephrocaps 1 CAP PO DAILY 6. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Refills:*0 7. albuterol sulfate 90 mcg/actuation inhalation Q6H 8. Aspirin 81 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Outpatient Lab Work Please draw repeat CBC on ___ and have results faxed to Dr. ___ at ___. Diagnosis: Anemia (ICD10: D64.9) 11. Calcium Acetate 667 mg PO TID W/MEALS 12. Omeprazole 40 mg PO DAILY 13. terconazole 0.8 % vaginal QHS:PRN vaginitis Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS/ES: -Hypoxia due to Influenza A Infection -Recurrent Clostridium Difficile Colitis -Anemia of unclear etiology -Thrombocytopenia of unclear etiology -End-Stage Renal Disease on Hemodialysis -Diastolic Congestive Heart Failure with Right Heart Failure -Mediastinal Lymphadenopathy without Clear Etiology -Thrush -Congestive Hepatopathy SECONDARY DIAGNOSIS/ES: -Atrial Fibrillation -Chronic Obstructive Pulmonary Disease on Home Oxygen -History of Kidney Transplant with Allograft Nephropathy/Failure -Gastroesophageal Reflux Disease -Hypertension -History of Breast Cysts 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 you were having trouble breathing and were noted to have low blood pressures. You were initially cared for in the intensive care unit (ICU) because your potassium levels were high and needed urgent dialysis. In the ICU, you received 2 sessions of dialysis, which helped your breathing. As you were found to have the flu, you were treated with a medication called Tamiflu. You were also started on an antibiotic to treat your C Diff infection. Upon transferring to the general medicine service, you were found to have slowly decreasing blood counts. As you were having black stools, there was significant concern for an intestinal bleed. With close monitoring, your blood counts stabilized and you were sent home with instructions to follow up with the Gastroenterologists as an outpatient. Prior to discharge, you received 1 more dialysis session and were breathing more comfortably. You had also completed treatment for the flu. It is important that you continue to take your medications and follow up with your outpatient doctors ___ detailed in the rest of your discharge paperwork). It is also very important that you weigh yourself every morning and call your primary care physician if your weight changes by more than 3 lbs. Thank you for allowing us to be a part of your care, Your ___ Team Followup Instructions: ___

10055694-DS-25

DS

2121-03-06 00:00:00

2121-03-14 21:42:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors Attending: ___ Chief Complaint: Hypotension (SBP in ___ Major Surgical or Invasive Procedure: EGD ___ Capsule endoscopy ___ History of Present Illness: Mrs. ___ is a ___ y/o woman with past history of ESRD from focal segmental glomerulosclerosis s/p failed transplant on HD (___), COPD, GERD (w/out PUD), atrial fibrillation not on coumadin, congestive heart failure and severe right heart failure, pulmonary hypertension, recurrent cdiff infection, upper GI bleed from erosive gastritis and gastric ulcer, chronic anemia, who was transferred from her dialysis center to the ED for hypotension with SBP in ______s. She was recently admitted to ___ in ___ with melena, hypotension, and acute on chronic anemia, and was found to have upper GI bleed from two linear ulcerations in the cardia. On the day of admission, she was found to have hypotension with SBP in ___'s during dialysis, so she was sent to the ED. She reported dark stools for approximately a week, which she attributed to "recurrent C.dif". She denied dizziness, chest pain, shortness of breath, abdominal pain, diarrhea. She noted significant recent distention of her abdomen and some peripheral edema. She denied jaundice in the past. On review of her systems, she admits to shortness of breath and dyspnea on exertion. Patient was recently evaluated in outpatient ___ clinic for new liver disease. She was noted to have an enlarged liver and considered to have congestive hepatopathy. Her most recent liver function tests show an alkaline phosphatase of 162 with a normal ALT and AST of 15 and 24 respectively, negative test for her serum ACE and ___, negative hepatitis B and hepatitis C markers, normal C3 and C4. Rheumatoid factor is increased to 32. She has elevated IgG. Alpha-1 antitrypsin was mildly elevated. An ultrasound of the liver showed dilated inferior vena cava and hepatic veins, consistent with right heart failure. She had trace ascites at that time in ___. Of note, a chest CT from ___ showed innumerable mediastinal lymph nodes, mildly enlarged, indeterminate, difficult to exclude lymphoma or other etiologies. In the ED initial vitals: 97.2 82 84/49 18 98% RA Exam was notable for: Gauaic + dark stool - Labs were notable for: WBC 6.3 H/H 7.3/25.3 Platelets 260 ___: 12.8 PTT: 32.6 INR: 1.2 ALT: 10 AP: 171 Tbili: 0.7 Alb: 3.8 AST: 25 LDH: 201 Na 136 K 3.5 Cr 2.3 Ca: 8.8 Mg: 1.8 P: 1.6 Lactate:1.2 Diagnostic para: WBC 733 RBC ___ Poly 5 Lymph 30 Protein 5.0 Glucose 104 Patient was given: Octreotide Acetate 100 mcg IV Q8H Ciprofloxacin 400 mg IV ONCE Pantoprazole 40 mg IV ONCE 2units pRBCs Imaging included CT abdomen and CXR (see below for details) Vitals prior to transfer: 98.9 71 90/47 20 100% RA ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - no prior documentation, but likely group 3 - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - Initially diagnosed in ___ and treated with flagyl 500mg x 10 days; again in ___ s/p flagyl 500mg x 14 days, persistent infection still later in ___, treated with vanco 125mg PO x14days - H/O syphilis - H/O Breast Cysts PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: Mother on dialysis from diabetes mellitus Niece with ESRD, s/p transplant Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VITAL: Afebrile 100/70 80 18 99% RA GENERAL: Well appearing in NAD. HEENT: Exostropia bilaterally, sclera anicteric CARDIAC: Irregular with no excess sounds appreciated LUNGS: Unlabored resp, adequate air movement, prolonged expiratory phase ABDOMEN: soft, distended, non-tender to palpation, hepatomegaly is present EXTREMITIES: Trace pitting edema in ___ bilaterally, warm and well perfused, tender to palpation NEUROLOGY: No asterixis, no sensory or motor deficits noted PHYSICAL EXAM ON DISCHARGE: =========================== VS: 98.7 85 111/57 18 97 RA GENERAL: NAD, pleasant, sitting comfortably in chair HEENT: OP clear, anicteric sclera, apparent proptosis and exotropia, pale conjunctiva CARDS: Irregularrly irregular, no murmurs, rubs, gallops PULM: CTAB, no wheezes, rales, rhonchi ABDOMEN: Soft, mild epigastric tenderness, mild distension but soft, normoactive bowel sounds, no organomegaly EXTREMITIES: Warm, no edema ACCESS: LUE AVG; good thrill/bruits heard NEURO: No asterixis Pertinent Results: LAB RESULTS ON ADMISSION: ========================= ___ 10:45AM BLOOD WBC-6.3 RBC-2.40* Hgb-7.3* Hct-25.3* MCV-105* MCH-30.4 MCHC-28.9* RDW-20.8* RDWSD-78.9* Plt ___ ___ 10:45AM BLOOD ___ PTT-32.6 ___ ___ 10:45AM BLOOD Glucose-89 UreaN-14 Creat-2.3*# Na-136 K-3.5 Cl-95* HCO3-30 AnGap-15 ___ 10:45AM BLOOD ALT-10 AST-25 LD(LDH)-201 AlkPhos-171* TotBili-0.7 ___ 10:45AM BLOOD Albumin-3.8 Calcium-8.8 Phos-1.6* Mg-1.8 ___ 06:30PM BLOOD Hgb-8.6* calcHCT-26 ___ 12:00PM ASCITES WBC-733* ___ Polys-5* Lymphs-30* ___ Mesothe-6* Macroph-59* Other-0 ___ 12:00PM ASCITES TotPro-5.0 Glucose-104 PERTINENT INTERVAL LABS: ======================== ___ 06:08AM BLOOD CA125-276* ___ 03:10PM ASCITES TotPro-5.2 Albumin-2.5 ___ 05:47AM BLOOD Albumin-3.6 Calcium-8.6 Phos-6.6* Mg-1.9 ___ 13:11 IGG SUBCLASSES 1,2,3,4 Test Result Reference Range/Units IMMUNOGLOBULIN G SUBCLASS 1 1850 H 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL IMMUNOGLOBULIN G SUBCLASS 3 74 ___ mg/dL IMMUNOGLOBULIN G SUBCLASS 4 359 H ___ mg/dL IMMUNOGLOBULIN G, SERUM 2402 H ___ mg/dL LAB RESULTS ON DISCHARGE: ========================= ___ 06:08AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.2* Hct-28.6* MCV-105* MCH-30.0 MCHC-28.7* RDW-20.1* RDWSD-76.2* Plt ___ ___ 06:08AM BLOOD ___ PTT-31.7 ___ ___ 06:08AM BLOOD Glucose-140* UreaN-12 Creat-3.8* Na-136 K-3.6 Cl-94* HCO3-32 AnGap-14 ___ 06:08AM BLOOD ALT-7 AST-14 AlkPhos-124* TotBili-0.8 ___ 06:08AM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.8 Mg-1.7 RADIOLOGY: ========== ___ CT ABDOMEN/PELVIS: 1. Abnormal soft tissue prominence in the bilateral adnexa, right-greater-than-left. Recommend correlation with prior clinical history (including prior fallopian tube exploration?) and cytology results from recent paracentesis. If results are nondiagnostic, an MRI of the pelvis with IV contrast should be considered to exclude underlying malignancy, especially in light of enlarged retroperitoneal lymph nodes. 2. Cirrhotic liver morphology. 3. Moderate amount of nonhemorrhagic ascites. 4. Prominent intramural fat in the cecum and ascending ___, ___ reflect chronic inflammation. 5. Right lower quadrant transplanted kidney is abnormal in appearance ; atrophic with loss of normal corticomedullary differentiation. 6. Renal osteodystrophy. RECOMMENDATION(S): Correlation with clinical history and cytology results. Consider pelvis MRI for further evaluation. ___ CXR: -------------- Mild pulmonary edema. No focal consolidation. PATHOLOGY: ========== ___ CYTOLOGY, ASCITIC FLUID NEGATIVE FOR MALIGNANT CELLS. - Predominantly blood with scattered admixed mesothelial cells and lymphocytes. GI ENDOSCOPY: ============= ___ EGD -------------- Large hiatal hernia was noted Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mrs. ___ is a ___ y/o woman with complicated past history most notable for severe right heart failure, pulmonary hypertension, upper GI bleed from erosive gastritis and gastric ulcer and ESRD from focal segmental glomerulosclerosis s/p failed transplant on HD (___), who was transferred from her dialysis center to the ED for hypotension with SBP in ___ in setting of melena. CT abdomen/pelvis performed in ED is notable for abnormal soft tissue prominence in bilateral adnexa, R>L; cytology of ascitic fluid negative for malignancy, and diagnostic paracentesis was negative for SBP. ___ EGD only notable for hiatal hernia, no bleed. She had an additional episode of melena on ___ and the decision was made to proceed with capsule endoscopy on ___. The preliminary read showed some possible AVMs in the jejunum, but no active source of bleeding. She had no further episodes of melena, her blood pressure improved to SBP 100s and her hemoglobin was stable. We planned to do an echocardiogram during this admission to reassess her right heart failure, but we were unable to get this study done and she was eager to be discharged. She received 2 U pRBC throughout stay; discharge Hgb was 8.2; she was hemodynamically stable. # Hypotension/ acute on chronic anemia/ melena: One week history of melena prior to presentation, in context of recent admission for upper GI bleed with endoscopy showing linear gastric ulcer as well as erosive gastritis as well as prior history of recurrent C.diff. She was initially treated with IV pantoprazole q12H, octreotide gtt, and ciprofloxacin 400 mg IV q24H due to concern for UGIB. ___ EGD only notable for hiatal hernia, no bleed; hence octreotide was discontinued at that time. She had an additional episode of melena on ___ and the decision was made to proceed with capsule endoscopy on ___. The preliminary read showed some possible AVMs in the jejunum, but no active source of bleeding. She had no further episodes of melena, her blood pressure improved to SBP 100s and her hemoglobin was stable; 8.2 on discharge. # Ascites: CT abdomen notable for cirrhotic liver morphology, moderate ascites, and abnormal soft tissue prominence in bilateral adnexa, R>L. She has had prior work up with negative hepatitis B and C serologies, no alpha 1 antitrypsin deficiency, normal C3, C4, ___. Differential diagnosis for her includes cardiac cirrhosis given elevated protein at 5 (>2.5) and her history of R heart failure which would be consistent with elevated SAAG of 1.1 on ___. Meig's syndrome/malignancy is also under consideration given the fullness in adnexa and ascites, in setting of an elevated CA 125. Cytology negative for malignant cells. Typically would consider MRI pelvis with contrast to further evaluate however patient is very claustrophobic; please discuss further work up as an outpatient. # Elevated IgG: IgG was recently found to be elevated to 2455, raising concerns for plasma cell disorders, leukemia, and lymphoma among other disease, especially with abnormal findings on CT chest and abdomen. IgG 1 and 4 ___s total IgG were found to be elevated on the sub-type analysis. Please consider immunology referral # Anuric End-Stage Renal Disease s/p cadaveric donor renal transplant complicated by allograft failure, re-initiated on HD ___. - Continue dialysis per renal team # Atrial Fibrillation: CHADS2-VASC score 3, not currently on anticoagulation given history of GI and AV fistula bleed. Home metoprolol was held due to concern for hypotension. # Diastolic Congestive Heart Failure complicated by Right Heart Failure: The patient has moderate diastolic dysfunction with preserved EF per last TTE in ___ ___s elevated right heart pressures as well as RV systolic dysfunction (seen on TTE as well as right heart cath). Patient mildly volume up on exam, but saturating well on home O2 requirement. We had planned on obtaining a repeat echocardiogram, however this was not done and patient was eager to leave. Home metoprolol was held due to concern for hypotension. # Chronic obstructive pulmonary disease: Patient last had pulmonary function testing in ___, which showed moderately reduced FVC, moderately severe reduction in FEV1, with elevated FEV1/FVC, thought to reflect moderately severe obstructive disease. She was continued on home albuterol neb Q4H as needed and advair (250/50) twice a day # GERD: Patient takes PO omeprazole 40mg QD at home, which was switched to IV pantoprazole 40mg BID in setting of melena TRANSITIONAL ISSUES =================== [ ] Findings of new ascites and adnexal fullness on CT are concerning for malignancy especially in setting of elevated CA 125 to 276 (though it is noted that CA 125 is nonspecific and shouldn't be used as screening test for ovarian cancer). Cytology negative. Please consider MRI to further evaluate, though patient reports she is extremely claustrophobic. [ ] Capsule study results are pending at the time of discharge. Please follow up and refer to outpatient GI or book further testing/procedures as needed. Hgb on discharge is 8.2 [ ] Consider outpatient echocardiogram given new ascites, known right heart failure and last echo ___. [ ] Given recent finding of elevated total IgG on testing sent by outpatient hepatology, IgG subclasses were sent and revealed elevated IgG1 and IgG 4. Further workup per outpatient hepatology. # Code: Full # Communication: ___ (sister and HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H 2. Aspirin 81 mg PO DAILY 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 6. Nephrocaps 1 CAP PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 4 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 2. albuterol sulfate 90 mcg/actuation inhalation Q6H 3. Aspirin 81 mg PO DAILY 4. Calcium Acetate 667 mg PO TID W/MEALS 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___) 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. Pantoprazole 40 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Secondary: Congestive heart failure, ESRD 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 your blood pressure was low. As you were recently in the hospital because of a bleeding ulcer in your stomach, we wanted to make sure that you are no longer bleeding. Therefore we did a upper endoscopy, which did not show any bleeding. However, you had some more dark stools and your blood counts dropped. Hence we gave you blood, and did a capsule endoscopy, which can look further for sources of bleeding. A very preliminary look at the study did not show any active bleeding, but showed some possible culprits in the first part of your small intestine. The full report will be done soon and should be available to your PCP at your follow up appointment. We also noticed that your belly was very distended with fluid. This can happen for many reasons- for instance, right sided heart failure (which you have a history of) causing liver problems, a sick liver, or cancer. We took some of the fluid out to both take a closer look and to make you feel better. We also did a CT scan, and obtained an ultrasound of your heart (Echo). The CT scan showed that you have some fullness in your adnexa (where your ovaries and tubes are), and we are waiting for the results of the fluid we sent out to look for cancer. We also planned to check an echocardiogram (an ultrasound of your heart). Unfortunately, we were not able to get this study done for you while you were here. This can be ordered by your PCP or your cardiologist and done as an outpatient. Please follow up with your primary care doctor this week. Please also follow up with your liver doctor, ___ in the next few weeks. Best wishes, Your ___ Team Followup Instructions: ___

10055694-DS-26

DS

2121-09-24 00:00:00

2121-09-24 22:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Allopurinol And Derivatives / Penicillins / Ace Inhibitors / lisinopril Attending: ___. Chief Complaint: fistula ulceration Major Surgical or Invasive Procedure: AV Fistula Revision ___ ___ guided paracentesis ___ History of Present Illness: ___ w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presents with ulceration over her AV fistula. Patient notes that the ulcer developed one week ago after she had removed tape from the site of ulcer (note: she reports that she normally applies cream to the fistula site and covers it with tape). Ulceration then noticed by outpatient HD RN two days ago and advised patient to come in, however patient refused at that time. This morning, she went to dialysis, who referred her here as they were unable to access her HD site. Her last HD session was ___. She reports that the ulceration has been present for approximately one week and that she has been applying lidocaine-prilocaine cream to the area. It is pruritic. She denies purulence, erythema, or discharge. No fevers, chills, chest pain, shortness of breath. In the ED, initial vital signs were: T98 HR94 BP101/53 RR 15 SaO2 95% Nasal Cannula - Exam notable for: L arm fistula w/ palpable thrill, ~1 cm healed ulceration with mild tenderness, no erythema or discharge, RRR, scattered wheezes bilaterally, breathing comfortably, abdomen distended, tense, non-tender, 1+ edema bilaterally. - Labs were notable for Cr 5.9, Hgb 9.2, WBC 6.3, AP 231, LFTs normal, Albumin 3.3, INR 1.3. - Studies performed include CXR (demonstrated pulmonary vascular congestion, diffuse bilateral interstitial edema, small right pleural effusion, bilateral linear atelectasis) - Patient was given midodrine, calcium acetate, gabapentin 100 mg, albuterol neb, diskus, Tylenol. She had an HD session prior to arriving on the floor. - Vitals on transfer: 98.1, 91/50, 80, 20, 98% 3L Upon arrival to the floor, the patient was hungry and wanted to eat. Also endorsed pain and numbness in her right foot, which she often has after dialysis. Denies abdominal pain REVIEW OF SYSTEMS: (+) per HPI (-) otherwise Past Medical History: PAST MEDICAL HISTORY: - ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p DCDKD in ___ c/b chronic allograft nephropathy in ___ with reinitiation of HD (on MWF schedule). Complicated by intradialytic hypotension - Atrial Fibrillation - not on anticoagulation due to significant gastrointestinal as well as AV fistula site bleeding - Bradycardia - COPD - on ___ home oxygen; FEV1 of 57% predicted ___ - Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH, dilated RV with borderline systolic function and severe pulmonary HTN; small septum secundum - Claudication with concern for peripheral vascular disease - no formal arterial duplex studies on record - GERD - Gout - HSV II - HTN - Pulmonary HTN - Tobacco abuse - Anemia - GI Bleed - Recurrent C. Diff Colitis - H/O syphilis - H/O Breast Cysts - PELVIC MASS - ASCITES - Cryptogenic CIRRHOSIS PAST SURGICAL HISTORY: - Open cholecystectomy ___ - Tubal ligation, with incision from midline to pubis - Exploratory laparotomy for ovarian cyst, negative Social History: ___ Family History: She denies a family history of liver disease. Family history of father with atherosclerotic CVD. Mother with diabetes on dialysis. No history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.1, 91/50, 80, 20, 98% 3L GENERAL: AOx3, NAD HEENT: Scleral icterus, MMM NECK: normal ROM CARDIAC: Regular rate and rhythm, normal s1 and s2 LUNGS: Coarse crackles in left lower lung fields, otherwise clear to auscultation ABDOMEN: Distended tense abdomen, dull to percussion, +shifting dullness, nontender to palpation EXTREMITIES: 1+ lower extremity edema, pitting to mid-shins SKIN: LUE fistula with 2cm area of ulceration without active pus or overlying erythema NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: VS: 98.3, 94/58, 76, 20, 100% RA GENERAL: AOx3, NAD HEENT: Scleral icterus, significant exotropia OD, MMM NECK: normal ROM CARDIAC: Regular rate and rhythm, normal s1 and s2 LUNGS: breathing nonlabored, CTA anteriorly ABDOMEN: Distended abdomen, dull to percussion, somewhat tense, nontender, hypoactive BS EXTREMITIES: WWP, no extremity edema SKIN: LUE fistula with surgical dressing c/d/i NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS: --------------- ___ 08:05AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.2* Hct-30.5* MCV-94 MCH-28.4 MCHC-30.2* RDW-19.5* RDWSD-66.9* Plt ___ ___ 08:05AM BLOOD Neuts-61.6 ___ Monos-12.7 Eos-3.0 Baso-0.8 Im ___ AbsNeut-3.87 AbsLymp-1.36 AbsMono-0.80 AbsEos-0.19 AbsBaso-0.05 ___ 08:05AM BLOOD ___ PTT-36.5 ___ ___ 08:05AM BLOOD Plt ___ ___ 08:05AM BLOOD Glucose-111* UreaN-41* Creat-5.9* Na-139 K-4.2 Cl-98 HCO3-27 AnGap-18 ___ 08:05AM BLOOD ALT-11 AST-21 LD(LDH)-145 AlkPhos-231* TotBili-0.8 ___ 08:05AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.1 Mg-1.9 DISCHARGE LABS: ---------------- ___ 09:35AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.0* Hct-30.4* MCV-94 MCH-27.9 MCHC-29.6* RDW-19.5* RDWSD-65.1* Plt ___ ___ 09:35AM BLOOD Plt ___ ___ 09:35AM BLOOD Glucose-97 UreaN-32* Creat-6.1*# Na-135 K-5.0 Cl-93* HCO3-31 AnGap-16 ___ 09:35AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9 IMAGING: --------- CXR ___ 1. Mild-to-moderate pulmonary vascular congestion, diffuse bilateral interstitial edema, and trace right pleural effusion suggest volume overload. 2. Bilateral linear atelectasis. PARACENTESIS ___ Technically successful ultrasound-guided therapeutic paracentesis, yielding 4 L of clear, straw-colored ascitic fluid. Brief Hospital Course: ___ w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presenting with ulceration over her AV fistula. # AVF ulceration: New ulceration on site of AVF, perhaps from patient self-applying tape over the fistula. Underwent fistula revision ___. # ESRD s/p ECD kidney transplant in ___ c/b chronic allograft nephropathy: Chronic focal segmental glomerulosclerosis. Was on dialysis from ___. Had a transplant in ___, but failed in ___. Resumed dialysis in ___, MWF with LUE AVF. Continued home medications. Had session of HD ___ prior to discharge without complications. Resume MWF schedule. # Anemia: Likely from low epo and anemia of chronic disease. Continued Epo 60,000U qHD # Cryptogenic cirrhosis: Perhaps cardiac cirrhosis in setting of right-sided heart failure. Complicated by portal hypertension with ascites and splenomegaly. Up to date on variceal and HCC screening based on most recent Hepatology note. Last EGD ___ found large hiatal hernia. Has q2 week paracentesis, due again on ___. Received ___ guided paracentesis on ___ with 4L fluid removed. #Concern for gyn malignancy: Concern for ovarian or other malignancy as a cause of ascites, elevated CA-125 (276 on ___. Patient was offered MRI as an inpatient (both sedated or regular with premedication) but declined despite counseling of the risks. She reports that she did not want to be out of it with breathing support but also could not be enclosed. She raised the idea of an open MRI and discussed that image quality is not as good but patient was adamant. Primary care doctor was contacted regarding open MRI. # Aflutter # Afib: Was previously on Coumadin and carvedilol. The Coumadin was stopped in ___ secondary to frequent fistula bleeding events. It was restarted in ___. Risk of hemorrhagic stroke is higher with warfarin use in ___ HD patients. No current anticoagulation. # COPD: On 3L home O2 since ___. Continued home management. # Chronic diastolic heart failure # Pulmonary hypertension: Seen by cardiology in ___. Not on any cardiac meds due to hypotension. Unable to aggressively remove fluid with UF due to hypotension as well. # GERD: Continued home pantoprazole TRANSITIONAL ISSUES: - Patient needs open MRI to evaluate for possible malignancy #Code Status: Presumed full code #Emergency Contact/HCP: ___ (___), alternate contact is ___, sister (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Nephrocaps 1 CAP PO DAILY 5. Calcium Acetate 667 mg PO TID W/MEALS 6. Pantoprazole 40 mg PO Q24H 7. HydrOXYzine 25 mg PO Q4H:PRN pruritis Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze 3. Calcium Acetate 667 mg PO TID W/MEALS 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. HydrOXYzine 25 mg PO Q4H:PRN pruritis 6. Nephrocaps 1 CAP PO DAILY 7. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: AV Fistula Ulceration ESRD on HD Cryptogenic cirrhosis COPD on home O2 atrial fibrillation/flutter portal hypertension with ascites and splenomegaly chronic diastolic heart failure pulmonary hypertension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had a problem with your fistula. It was fixed in a procedure called a fistula revision. You had a dialysis session on ___ that went well so you can continue your regular dialysis schedule. You had a lot of fluid in your abdomen that was removed by our radiology team. You need an MRI of your abdomen to help figure out why you have all of this fluid building up. You were offered this test while you were here but you felt claustrophobic and you did not want to be sedated either. Instead you were hoping to have an open MRI. Please talk to your primary care doctor about scheduling this important test. Please see your follow-up appointments below. It was a pleasure caring for you and we wish you the best, Your ___ Team Followup Instructions: ___

10056223-DS-14

DS

2121-11-16 00:00:00

2121-11-16 20:41:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: No paracentesis History of Present Illness: ___ yo ___ speaking M with HCV, EtOH cirrhosis, ___ s/p TACE x2 and RFA, current MELD score 9, on transplant list recurrent C. diff presents with abdominal pain and hepatic encephalopathy. Of note, patient was admitted to ___ (___) x 8 days for increased hepatic encephalopathy and supposed discharged on ___. However, he was noted to have abdominal pain with tremulousness. The abdominal pain started about 1 day ago. He endorses subjective fever and chill but it is not documented. He thinks that his encephalopathy is improving. He reports having 3BM a day. In the ED, initial vitals were 98.4 81 118/52 20 100% ra. Exam was notable for A&Ox3, + abdominal distention with + fluid wave. However, ultrasound did not show drainable pocket. Paracentesis was not done. Blood culture x 1 was sent. Labs are notable for normal WBC, 10.1/31.6, Plt 123, normal neutrophils %, ALT 51, AST 77, TBili 0.5, AP 163, Albumin 2.8, normal creatinine 0.7, normal electroltyes, normal lactate. INR is 1.3. RUQ U/S showed patent portal vein, patent umbilical vein, an ecogenic focus ~ 2 cm at the right lobe correlating with previous RFA site, a 1.5 cm echogenic site along the medial right lobe without clear correlate compared to prior images. Patient was given zofran 2 mg x1 IV, lactulose 30 mL x 1. Upon transfer, VS 98.0 76 104/67 16 100% Past Medical History: 1. HCC s/p TACEx 2 with CT in ___ negative for recurrence 2. HCV 3. H/O ETOH abuse with resulting cirrhosis 4. Hypertension 5. Thrombocytopenia. 6. s/p chole ___ 7. 3 episodes of C diff infection: ___ Social History: ___ Family History: He is divorced, has two kids in ___. There is no known liver cancer or liver disease in his family. Physical Exam: ADMISSION VS: 97.5 130/83, 72, 100% RA respiratory rate is not labored or fast, GENERAL: NAD, slightly jaundiced HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, tender to palpation R>L, no guarding. + fluid wave shift. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ ___ bilaterally to knees. DISCHARGE VS: Tc 98.3 Tmax 99.2 BP 107/83 (101-113) HR 69 (69-82) RR 18 100% RA GENERAL: NAD, slightly jaundiced HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, tender to palpation R>L, no guarding. Dull to percussion. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ ___ bilaterally to knees. Pertinent Results: ___ 08:20PM BLOOD WBC-5.3 RBC-3.51* Hgb-10.1* Hct-31.6* MCV-90 MCH-28.7 MCHC-31.9 RDW-15.8* Plt ___ ___ 08:37PM BLOOD ___ PTT-35.1 ___ ___ 08:20PM BLOOD Glucose-160* UreaN-12 Creat-0.7 Na-133 K-3.9 Cl-101 HCO3-27 AnGap-9 ___ 08:20PM BLOOD ALT-51* AST-77* AlkPhos-163* TotBili-0.5 ___ 08:20PM BLOOD Albumin-2.8* ___ 06:33AM BLOOD Albumin-4.3 Calcium-8.7 Phos-1.9* Mg-1.9 ___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG IMAGING U/S ___ 1. Patent main portal vein with hepatopetal flow. Recanalized umbilical vein. 2. Echogenic focus in the right lobe of the liver, most likely correlates to patient's RFA site. Additional 1.5 cm echogenic focus along the medial edge of the right lobe of the liver, difficult to discern whether intra- or extra-hepatic, no clear correlate on recent prior CT/MRI. Correlate with nonurgent, multiphase CT or MRI for better characterization. 3. Status post cholecystectomy. Common bile duct not identified. MRI ___ Prelim 1. Stable size of the previously RF ablated lesion within the right lobe of the liver. Perilesional hyperenhancement is again noted which may be perfusional in nature; however continued surveillance is advised. 2. No lesions suspicious for hepatocellular carcinoma. 3. Features consistent with cirrhosis and portal hypertension. 4. Replaced left hepatic artery arising from the left gastric artery and replaced right hepatic artery arising from the superior mesenteric artery. 5. Stable left retroperitoneal cystic lesion, likely lymphangioma. DISCHARGE ___ 06:25AM BLOOD WBC-4.5 RBC-3.47* Hgb-10.1* Hct-31.3* MCV-90 MCH-29.0 MCHC-32.1 RDW-15.7* Plt ___ ___ 06:25AM BLOOD ___ PTT-40.9* ___ ___ 06:25AM BLOOD Glucose-138* UreaN-16 Creat-0.8 Na-131* K-4.6 Cl-98 HCO3-23 AnGap-15 ___ 06:25AM BLOOD ALT-39 AST-61* AlkPhos-131* TotBili-0.9 ___ 06:25AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.7 ___ 11:51AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-14 ___ ___ 11:51AM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-72 Brief Hospital Course: HOSPIAL COURSE ___ yo ___ speaking M with HCV, EtOH cirrhosis, HCC s/p TACE x2 and RFA, current MELD score 9, on transplant list recurrent C. diff presents with abdominal pain and possible hepatic encephalopathy. RUQ U/S showed patent portal vein and a new echogenic area in the medial aspect of the right lobe. We treated empirically for SBP with CTX and gave albumin, however repeat attempt at para found nothing to drain. CTX discontinued after one dose and patient remained afebrile. MRI done ___ to assess for the mass seen on RUQ did not show changes concerning for HCC and AFP was wnl. Lipase/Amylase also normal. Pt was maintained on lac/rif. On ___ patient developed headache and neck pain. Was afebrile. Given a dose of acyclovir overnight. LP in AM showed no evidence of bacterial or viral meningitis. RPR negative, C.diff negative. Discharged with lab draw to take place on ___ with results to be faxed to Dr. ___ in transplant clinic where he has follow up on ___. Sent out on home meds (furosemide 40, spironolactone 150, nadolol 20, omeprazole 40bid). ACTIVE ISSUES # Abdominal Pain. RUQ U/S did not show obstructive pathology as portal vein and umbilical veins are patent. However, it did show a new echogenic area in the medial aspect of the right lobe that is unable to get correlated with previous scans. In addition, given recent report of worsening mental status and abdominal pain, we are treating empirically for SBP, however repeat attempt at ___ found nothing to drain. Records from ___ ___ show he did not have a tap then. MRI showed no changes concerning for HCC. # AMS. Likely ___ hepatic encephalopathy vs. infectious (such as SBP). UA is unremarkable. RUQ U/S without portal vein thrombosis. Lung exam is benign. He denied any respiratory symptoms. Continued on lac/rif. Developed headache on ___. Initial LP unsuccessful. Overnightw as given a dose of acyclovir but LP on ___ showed no signs of meningitis. # HCV/EtOH cirrhosis and HCC w/p TACE and RFA. On transplant list. RUQ initially concerning for new mass, but AFP wnl and MRI did not show changes concerning for new cancer. # Hct Drop: On ___ had a hematocit drop. Guiaic negative. Pt did not endorse melena. Repeat Hct stable. Continued omeprazole and nadalol. INACTIVE ISSUES # Ascites. No tapable pocket found on repeat U/S. Initially held home lasix and spironolactone, but restarted him on home dose of furosemide 40mg and spironolactone 150. # RENAL: Crt stable at 0.7 TRANSITIONAL ISSUES # f/u CSF HSV PCR, BCX data (NGTD), Lyme serology, EBV IgG, IgM # f/u ___ lab draw for LFTs, CBC, ___, Chem 7 Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient discharge summary from ___. 1. Clotrimazole 1 TROC PO 5X/DAY 2. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 3. Furosemide 40 mg PO DAILY 4. Nadolol 20 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. Spironolactone 150 mg PO DAILY 7. Lactulose 30 mL PO QID 8. Rifaximin 550 mg PO BID Discharge Medications: 1. Clotrimazole 1 TROC PO 5X/DAY RX *clotrimazole 10 mg 1 troche five times a day Disp #*150 Unit Refills:*2 2. Lactulose 30 mL PO QID RX *lactulose 20 gram/30 mL 30 mL by mouth four times a day Disp #*1 Bottle Refills:*0 3. Nadolol 20 mg PO DAILY RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 4. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Tablet Refills:*2 5. Simethicone 80 mg PO QID:PRN gas pain RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*120 Tablet Refills:*2 6. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 7. Vitamin D 50,000 UNIT PO 1X/WEEK (___) RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1 capsule(s) by mouth QWeek Disp #*4 Capsule Refills:*2 8. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 9. Spironolactone 150 mg PO DAILY RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*2 10. Outpatient Lab Work Please draw LFTs, CBC, ___, Chem 7 on ___ and fax to liver transplant clinic ___ Discharge Disposition: Home Discharge Diagnosis: Alcoholic Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care. You were admitted for abdominal pain and some confusion. Initially we were concerned about infection of the fluid in your abdomen. We tried to sample fluid from your abdomen to look for infection but found none to drain. You remained without signs of infection after we stopped antibiotics. An ultrasound also showed a new mass in your liver, so we did an MRI to better assess this mass, and currently we are NOT concerned about recurrence of liver cancer. Please have laboratory studies drawn on ___ and they will fax your results to the Transplant Clinic. Also please keep your appointment with Dr. ___ primary care doctor. We have given you a medicine, SIMETHICONE for gas pain. Otherwise we have not made any changes to your medicines from admission. We have given you a prescription for all your medicines so that you can be sure of what you should be taking. Followup Instructions: ___

10056223-DS-15

DS

2121-12-17 00:00:00

2121-12-20 18:20:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___ Chief Complaint: Chest Pa Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with HCV and EtOH cirrhosis on the transplant list, complicated by ___ s/p TACE x2 and RFA and ascites, and recurrent C. difficile colitis presents with increasing abdominal distention, bilateral lower extremity swelling, and occasional non-pleuritic, non-exertional chest pain for 3 days. Patient denies fevers, chills, or cough. Patient states that he is otherwise feeling well, with mild RUQ pain. He does report medication compliance and has not had any changes in bowel or bladder habits and is passing gas. He was recently admitted from ___ with abdominal pain and ?hepatic encephalopathy. A liver mass was noted on ultrasound, but follow-up MRI and AFP were within normal limits. LP was performed due to new onset headache and altered mental status and was also within normal limits. He was maintained on lactulose and rifaximin. C. diff was negative on this admission and no etiology was ascribed to his pain. He was sent home without medication changes. In the ED, initial vitals were: 98.2 72 113/65 14 100% RA. Exam was notable for bilateral lower extremity edema and atypical chest pain. EKG was consistent with prior, showing NSR and TWI inferiorly. RUQ ultrasound ruled out PVT and bedside ultrasound did not show any ascites or pericardial effusion. KUB was done to assess the abdominal distension and the read is pending. Hepatology was consulted and recommended admission to complete rule out. 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: 1. ___ s/p TACEx 2 with CT in ___ negative for recurrence 2. HCV and EtOH abuse with resulting cirrhosis 3. Hypertension 4. Thrombocytopenia 5. s/p chole ___ 6. 3 episodes of C diff infection: ___ Social History: ___ Family History: He is divorced, has two kids in ___. There is no known liver cancer or liver disease in his family. Physical Exam: ADMISSION: VS: T 98.3, BP 122/78, BR 73, RR 18, 100%RA GENERAL: middle-aged ___ male, somewhat restless in bed, but appropriate and oriented HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with no evidence of JVD CARDIAC: RRR, S1/S2 clear with soft II/VI holosystolic murmur, no rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, mildly tender to palpation over RUQ, without rebound/guarding. No fluid wave or tympany appreciated to suggest ascites, spleen tip palpated just lateral to the umbilicus EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ lower extremity edema extending through the thighs. DISCHARGE: VS: T 98.3, BP 122/78, BR 73, RR 18, 100%RA Gen: NAD HEENT: no iceteric sclera Pulm: CTAB CV: NR, RR, no murmurs, pain with chest wall sternal palpation Abd: mild distention, minimal TTP in RUQ, soft, +BS Ext: 1+ pitting edema to knees bilaterally Neuro: A&O Psych: appropriate Pertinent Results: ___ 06:55PM BLOOD WBC-4.0 RBC-3.20* Hgb-8.6* Hct-27.6* MCV-86 MCH-26.7* MCHC-31.0 RDW-17.1* Plt Ct-80* ___ 07:50AM BLOOD WBC-2.8* RBC-3.19* Hgb-8.7* Hct-27.4* MCV-86 MCH-27.3 MCHC-31.8 RDW-17.0* Plt Ct-84* ___ 07:50AM BLOOD ___ PTT-39.3* ___ ___ 07:50AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-135 K-3.6 Cl-104 HCO3-29 AnGap-6* ___ 07:50AM BLOOD ALT-34 AST-53* LD(LDH)-185 AlkPhos-141* TotBili-1.0 ___ 06:55PM BLOOD Lipase-66* ___ 06:55PM BLOOD cTropnT-<0.01 ___ 07:50AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:50AM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.3 Mg-1.7 EXERCISE STRESS TEST ___: This ___ year old man with h/o hepatitis/cirrhosis was referred to the lab for evaluation of new onset chest pain and dyspnea prior to possible liver transplant. The patient exercised for 14 minutes of a Gervino protocol (~ ___ METS), representing a fair exercise tolerance for his age. The test was stopped due to fatigue. At minute 5.5 of exercise, the patient noted vague ___ isolated left sided chest pain, tender with palpation. This discomfort waxed and waned throughout the study with the patient noting in recovery that the discomfort was present prior to starting the test. There were no significant ST segment changes throughout the study. Rhythm was sinus with rare, isolated apbs and vpbs and one atrial couplet throughout the study. Appropriate blood pressure response to exercise. Slightly blunted heart rate response to exercise in the presence of beta blocker therapy. IMPRESSION: Atypical/non-anginal type symptoms in the absence of ischemic EKG changes. ABD Xray Supine/Erect ___: IMPRESSION: Prominent small bowel loops with air-fluid levels. Early or partial small bowel obstruction cannot be excluded. Liver Ultrasound ___ IMPRESSION: 1. Coarse liver echotexture, compatible with patient's history of cirrhosis. A hyperechoic area within the liver likely relates to patient's known RFA site. Hepatic vasculature is patent. 2. Splenomegaly. No ascites. Brief Hospital Course: Mr. ___ is a ___ year old male with history of HCV and EtOH cirrhosis, complicated by HCC s/p TACE + RFA as well as ascites, who presented with bilateral lower extremity edema in setting of mild abdominal distension and complaining of substernal chest pain for past few days most consistent with musculoskeletal etiology. # Chest Pain: Likely musculoskeletal since pleurtic and cardiac enzymes neg x2. No SOB at rest, oxygen requirements, or tachycardia that would suggest PE however cannot rule out. Patient is at increased risk with his malignancy. -cardiac exercise stress on ___ was negative for ACS/ischemic changes # Lower Ext swelling: He is clearly volume overloaded, but without evidence of worsening portal hypertension/cirrhotic decompensation or pulmonary edema. His last TTE in ___ showed an EF 60% with trivial MR, a patent foramen ovale, and elongated LA. E/A or E/E' ratios not suggestive of diastolic failure. He maintains that he is compliant with his medications, but he may need uptitration of his current diuretic regimen. -given extra dose of Lasix -continued spironolactone at 150mg daily # Abdominal Distention: SBO is less likely given good bowel sounds and normal BMs/flatus. No ascites on ultrasound. # HCV and EtOH cirrhosis: Prior decompensations include ascites with treated HCC. No evidence of current decompensation with no ascites, clear mental status, and no PVT on ultrasound with dopplers. MELD is quite low with normal creatinine, bilirubin, and INR. - continued lactulose and rifaximin - continued nadolol - diuretic management as above # HCC s/p TACE + RFA # Anemia/thrombocytopenia: Currently at his baseline, and likely due to his liver disease. # Hypertension: Currently normotensive -continued diuretics ### TRANSITIONAL ISSUES: -f/u with PCP -___ with Hepatology Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clotrimazole 1 TROC PO 5X/DAY 2. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 3. Furosemide 40 mg PO DAILY 4. Lactulose 30 mL PO QID titrate ___ BMs per day 5. Nadolol 20 mg PO DAILY 6. Omeprazole 40 mg PO BID 7. Rifaximin 550 mg PO BID 8. Spironolactone 150 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Simethicone 80 mg PO QID:PRN gas pain 11. Sodium Chloride Nasal Dose is Unknown NU Frequency is Unknown Discharge Medications: 1. Clotrimazole 1 TROC PO 5X/DAY 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Lactulose 30 mL PO QID titrate ___ BMs per day 4. Nadolol 20 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Rifaximin 550 mg PO BID 8. Simethicone 80 mg PO QID:PRN gas pain 9. Spironolactone 150 mg PO DAILY RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Sodium Chloride Nasal 1 SPRY NU BID:PRN dryness 11. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Disposition: Home Discharge Diagnosis: chest pain, likely musculoskeletal 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 while you were admitted to ___. You were admitted to the hospital because you were having chest pain and abdominal distension with lower extremity swelling. We did some blood tests and we do NOT think that you were having a heart attack. We also did another test of your heart (stress test), that was also ok. We gave you some extra Lasix to help take off some extra fluid from your legs. An XRAY of your abdomen showed that there was no obstruction. Please continue to take all of your medications as prescribed, and please follow up with your outpatient providers, as listed below. Followup Instructions: ___

10056223-DS-19

DS

2122-02-28 00:00:00

2122-03-02 01:57:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___. Chief Complaint: hematemesis Major Surgical or Invasive Procedure: None History of Present Illness: ___ ___ male with h/o HCV and alcoholic cirrhosis decompensated by jaundice, ascites, SBP, HCC s/p TACE and RFA, on transplant list presenting with hematemesis. Pt states that he had episode of hematemesis after drinking soup. His clothes were all covered in blood and he felt dizzy/lightheaded and he called his friends. He was able to open the door for his friends and then passed out and woke up on his bed. Denies fevers, melena or bloody stools. Last BM was yesterday morning and was non-bloody. Of note, last EGD and colonoscopy was on ___. EGD showed no esophageal varices, mild GAVE like antral erythema. Colonoscopy only positive for few scattered small aphthous ulcers in the rectum, sigmoid and descending colon. In the ED, initial vitals were 99.4 83 131/78 18 100 RA. Exam notable for heme pos yellow stool. Labs notable for Hct at baseline. UA was negative. He received pantoprazole IV. Vitals prior to transfer: BP 115/87 HR 78 RR 18 O2 sat 97% RA. On arrival to the floor, he reports abdominal pain in RUQ under his R ribcage. Describes pain as sharp that comes and goes. Patient with hx of multiple hospitalization for similar abdominal pain most recently from ___ without any clear etiology. Continues to report dizziness however seen ambulating to the bathroom and back to his bed without any problems. ROS: per HPI, +headache that is now improving, + nausea denies fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE, jaundice, SBP 2. biopsy-proven ___ s/p TACE ___ & TACE ___ (1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment VI/VI lesion) with CT in ___ negative for recurrence 3. Hypertension 4. Thrombocytopenia 5. s/p cholecystectomy ___ 6. 3 episodes of C diff infection: ___ Social History: ___ Family History: He is divorced, has two kids in ___. There is no known liver cancer or liver disease in his family. Physical Exam: ADMISSION PHYSICAL EXAM VS - 98.4, 118/75, 84, 18, 100% RA GENERAL - well-appearing man in NAD, comfortable, appropriate, no jaundice HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, slight dried MM, OP clear NECK - supple, no JVD, no LD LUNGS - CTA bilat, no r/rh/wh, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, no rebound/guarding, distended, no shifting dullness, no fluid wave, mild tenderness to palpation diffusely throughout but most significantly on R upper quadrant EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, no palmar erythema SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, no asterixis but mild R hand tremor DISCHARGE PHYSICAL EXAM VS - 98.3, 104/70 (104-112/56-70), 81-95, 20, 100% RA GENERAL - well-appearing man in NAD, comfortable, appropriate, no jaundice HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, slight dried MM, OP clear NECK - supple, no JVD, no LD LUNGS - CTA bilat, no r/rh/wh, resp unlabored, no accessory muscle use CHEST- no spider angiomata noted HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, no rebound/guarding, distended, no shifting dullness, no fluid wave, mild tenderness to palpation in RUQ EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, no palmar erythema SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, no asterixis but mild R hand tremor Pertinent Results: ADMISSION LABS ___ 12:40PM BLOOD WBC-4.6 RBC-3.42* Hgb-8.9* Hct-28.9* MCV-85 MCH-26.0* MCHC-30.7* RDW-18.8* Plt Ct-82* ___ 12:40PM BLOOD Neuts-55 Bands-0 ___ Monos-22* Eos-5* Baso-0 ___ Myelos-0 ___ 12:40PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Target-1+ ___ 12:40PM BLOOD ___ PTT-34.9 ___ ___ 12:40PM BLOOD Glucose-74 UreaN-12 Creat-0.8 Na-136 K-4.0 Cl-107 HCO3-24 AnGap-9 ___ 12:40PM BLOOD ALT-38 AST-61* LD(LDH)-235 AlkPhos-150* TotBili-0.6 ___ 12:40PM BLOOD Albumin-2.7* Calcium-7.8* Phos-2.6* Mg-1.9 ___ 12:57PM BLOOD Lactate-1.3 DISCHARGE LABS ___ 06:00AM BLOOD WBC-3.8* RBC-3.17* Hgb-8.1* Hct-26.5* MCV-84 MCH-25.5* MCHC-30.6* RDW-18.9* Plt Ct-80* ___ 06:00AM BLOOD ___ PTT-37.5* ___ ___ 06:00AM BLOOD Glucose-135* UreaN-9 Creat-0.7 Na-136 K-3.7 Cl-105 HCO3-27 AnGap-8 ___ 06:00AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.7 URINE ___ 03:29PM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:29PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG IMAGING ___ LIVER ULTRASOUND FINDINGS: The liver is coarse and nodular in echotexture consistent with known cirrhosis. No focal liver lesion is identified. The main portal vein is patent and displays hepatopetal flow. The gallbladder is absent. There is no intra- or extra-hepatic biliary ductal dilatation and the common bile duct measures 3 mm. The spleen is enlarged measuring 14.4 cm. The whole liver and pancreas are not well seen, likely due to overlying bowel gas and limited acoustic windows. There is no ascites. IMPRESSION: 1. Patent main portal vein with antegrade flow. 2. Cirrhosis. 3. Splenomegaly. Brief Hospital Course: ___ ___ speaking man with HCV and alcoholic cirrhosis c/b HCC s/p TACE and RFA on transplant list presents after 1 episode of hematemesis followed by dizziness. # Hematemesis/dizziness: recent EGD on ___ showed GAVE and no esophageal varices. Hematemesis was likely secondary to GAVE and hct remained stable in the mid to high ___. No other episodes of hematemesis and vital signs remained stable. RUQ ultrasound with doppler obtained and was negative for PVT and ascites. He was started on PPI gtt on admission and transitioned to high dose po PPI. He was also continued on his home SBP ppx with cipro 500mg daily and started on carafate QID. # RUQ abdominal pain: during last admission, patient had MR enterography which showed malrotation of jejunal loops located in the right upper quadrant and ileal loops located in the left aspect of the abdomen and superior mesenteric artery located immediately posterior to the superior mesenteric vein. Likely that he may have intermittent obstruction causing abdominal pain. # HCV/alcoholic Cirrhosis and HCC: c/b ascites, SBP, , hepatic encephalopathy jaundice. On transplant list. LFTs remained at baseline with INR at 1.2. No signs of HE or ascites. He was continued on cipro ppx, lactulose for goal of ___, and nadolol. # HTN: patient continued on nadolol, furosemide, and spironolactone. BP controlled, in the 110s. # iron deficiency anemia: last ferritin was 20 on ___. Patient was not started on iron therapy during last admission given persistent GI symptoms which would have been exacerbated on iron therapy. # thrombocytopenia: likely in the setting of splenomegaly in addition to his previous alcohol use # TRANSITIONAL ISSUES -patient with iron deficiency anemia, please consider starting iron supplementation once abdominal pain has resolved *) medication changes: -carafate QID was started *) CODE STATUS: Full *) CONTACT: ___ (sister): ___ (c), ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Clotrimazole 1 TROC PO 5X/DAY 3. Lactulose 30 mL PO TID Titrate to ___ day 4. Nadolol 20 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Rifaximin 550 mg PO BID 7. Sodium Chloride Nasal ___ SPRY NU BID:PRN dryness 8. Omeprazole 40 mg PO DAILY 9. Vitamin D2 *NF* (ergocalciferol (vitamin D2)) 50,000 unit Oral 1x/week (MO) 10. Furosemide 40 mg PO DAILY 11. Spironolactone 150 mg PO DAILY 12. Metoclopramide 10 mg PO TID 13. Ondansetron 4 mg PO Q8H:PRN Nausea Discharge Medications: 1. Lactulose 30 mL PO TID Titrate to ___ day 2. Nadolol 20 mg PO DAILY 3. Ondansetron 4 mg PO Q8H:PRN Nausea 4. Rifaximin 550 mg PO BID 5. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Sucralfate 1 gm PO QID RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp #*120 Tablet Refills:*0 7. Clotrimazole 1 TROC PO 5X/DAY 8. Furosemide 40 mg PO DAILY 9. Metoclopramide 10 mg PO TID 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Sodium Chloride Nasal ___ SPRY NU BID:PRN dryness 12. Spironolactone 150 mg PO DAILY 13. Vitamin D2 *NF* (ergocalciferol (vitamin D2)) 50,000 unit Oral 1x/week (MO) 14. Ciprofloxacin HCl 500 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: PRIMARY: GAVE, hematemesis, dizziness, abdominal pain SECONDARY: iron deficiency anemia, 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 at ___ ___. You were admitted to the hospital because you vomited blood and passed out. You were treated with a medication (pantoprazole) to help prevent further bleeding. Your blood count remained stable and you did not have further bleeding. Imaging of your liver showed no difference, especially not blood clots. You will need to continue to take pantoprazole and carafate to help prevent further bleeding. Make sure you follow up with your primary care physician and liver doctor. Followup Instructions: ___

10056223-DS-22

DS

2122-05-25 00:00:00

2122-06-01 19:22:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Prochlorperazine / metoclopramide Attending: ___. Chief Complaint: Chills s/p TACE Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old gentleman with ___ s/p TACE, HCV, and EtOH cirrhosis with new onset fevers/chills. MELD of 12 on ___. Was doing well at home until last night, when he developed shaking chills and rigors, and felt feverish. He presented to the ED and did not have any fevers while in ED but was admitted for infectious work-up of chills. In the ED, he was noted to have leukopenia, no pyuria, no e/o acute cardiopulmonary process of CXR. His incision site was noted to be non fluctuant and not erythematous. In the ED, initial vitals were 97.6 66 124/68 18 99% Vitals on transfer: 97.8 64 106/59 18 100% Interviewed w/ ___ interpreter. On the floor, he notes mild R sided abdominal pain at the site of his previous TACE which is not changed from his previous abdominal pain. He reports it started at the same time as teh fever. The fever (he does not have a thermometer at home but felt warm) and chills started last night. Pain is sharp, strong, not related to eating, and he's had it before. He started having scar pain. He notes dysarthria, R hand shaking which he attributes to morphine, it started the day after he started morphine as an outpatient around ___ (of note, he was dc'ed on hydromoprhone, not morphine, and on prochlorperazine prn as well). He reports he flushed his morphine/dilaudid down the toilet. He says he had difficulty w/ handwriting and speaking (speaking improved). Denies dysuria, reports a little cough, no phlegm, that sarted last night. No sick contacts, no new diarrhea except what's chronic and related to lactulose. ROS: per HPI, denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE, jaundice, SBP 2. biopsy-proven HCC s/p TACE ___ & TACE ___, (1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment VI/VI lesion) with CT in ___ negative for recurrence 3. Hypertension 4. Thrombocytopenia 5. s/p cholecystectomy ___ 6. 3 episodes of C diff infection: ___ 7. Colitis Social History: ___ Family History: (per OMR) There is no known liver cancer or liver disease in his family. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.1 - 91/60 - 68 - 18 - 100ra admission weight: 101.1 kg GENERAL: Well appearing, appears stated age, no resp distress, pleasant HEENT: Sclera anicteric. EOMI. NECK: Supple with low JVP CARDIAC: RR, no murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft. anteriorly tympanitic, very posterior dullness to percussion over obese dependent areas. mild hepatomegaly, mninimal tenderness in RUQ. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. NEURO: no asterixis. resting tremor R hand, which improves somewhat w/ intentional movements. mild resting tremor of left thumb. very mild dysmetria which improves w/ repetition. cogwheeling of R wrist only. cn ___ intact. muscfle strength ___ throughout, finger strength ___. alert, oriented x3. DISCHARGE PHYSICAL EXAMINATION: VS: 97.4 - 102/64 - 68 - 20 - 96 ra weight 100.4kg admission weight: 101.1 kg. ___ kg GENERAL: Well appearing, appears stated age, no resp distress, pleasant HEENT: Sclera anicteric. EOMI. NECK: Supple with low JVP CARDIAC: RR, no murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft. anteriorly tympanitic, very posterior dullness to percussion over obese dependent areas. mild hepatomegaly, no tenderness in RUQ. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. NEURO: no asterixis. improved resting tremor R hand, improves somewhat w/ intentional movements. mild resting tremor of left thumb. very mild dysmetria which improves w/ repetition. cogwheeling of R wrist only. cn ___ intact. muscfle strength ___ throughout, finger strength ___. alert, oriented x3. Pertinent Results: ADMISSION LABS =============== ___ 10:50AM BLOOD WBC-3.5* RBC-3.33* Hgb-10.5* Hct-32.7* MCV-98 MCH-31.7 MCHC-32.2 RDW-18.3* Plt Ct-82*# ___ 10:50AM BLOOD Neuts-67 Bands-0 Lymphs-12* Monos-17* Eos-3 Baso-0 Atyps-1* ___ Myelos-0 ___ 10:50AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ ___ 11:33AM BLOOD ___ PTT-33.3 ___ ___ 10:50AM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-132* K-5.0 Cl-101 HCO3-28 AnGap-8 ___ 10:50AM BLOOD ALT-90* AST-104* AlkPhos-154* TotBili-1.1 ___ 10:50AM BLOOD Albumin-2.2* ___ 12:54PM BLOOD Lactate-0.9 DISCHARGE LABS ================ ___ 06:35AM BLOOD TSH-4.4* ___ 06:35AM BLOOD Cortsol-6.4 ___ 06:35AM BLOOD WBC-3.6* RBC-3.36* Hgb-10.9* Hct-33.4* MCV-99* MCH-32.4* MCHC-32.6 RDW-17.9* Plt Ct-80* ___ 06:35AM BLOOD ___ PTT-44.2* ___ ___ 06:35AM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-133 K-4.3 Cl-100 HCO3-30 AnGap-7* ___ 06:35AM BLOOD ALT-68* AST-82* LD(LDH)-235 AlkPhos-143* TotBili-1.1 ___ 06:35AM BLOOD Albumin-2.5* Mg-1.9 ___ 06:35AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.7 URINE STUDIES ============== ___ 01:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG MICROBIOLOGY ============ ___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL ___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL ___ URINE CULTURE-FINAL ___ Blood Culture, Routine-FINAL ___ Blood Culture, Routine-FINAL STUDIES ======= CXR IMPRESSION: Low lung volumes with minimal bibasilar atelectasis. EKG Sinus rhythm. Poor R wave progression which may be a normal variant. Compared to the previous tracing of ___ the findings are similar. Rate PR QRS QT/QTc P QRS T 68 172 76 424/438 -3 -1 3 RUQ U/S CONCLUSION: No ascites (confirmed verbally with radiology). Brief Hospital Course: BRIEF HOSPITAL COURSE ====================== Mr. ___ is a ___ year old gentleman with HCC s/p TACE, HCV, and EtOH cirrhosis with new onset subjective fevers/chills at home after TACE two weeks ago. He was afebrile throughout his hosital course. Chills were likely due to mild bronchitis (vs. post-TACE syndrome). Blood cultures, urine culture, and chest xray were all unremarkable. He was noted to have a new right upper extremity resting tremor with mild rigidity. This was felt to be a side effect from the metochlopramide and/or prochlorperizine he got after TACE. He had mild nausea (normal TSH, cortisol) and was tolerating a low sodium diet prior to discharge. He was discharged home w/ follow up in the transplant clinic and with his oncologist, as well as neurology. He was instructed to try lidocaine jelly, tramadol BID, and acetaminophen (<2g daily) for his pain, and to avoid compazine and reglan. ACTIVE ISSUES ============== # Subjective fever and chills: Given his history of HCC and cirrhosis, he is at increased risk for infection. He reported fevers and chills at home (though did not take his temperature), but there were no documented fevers in the ED or on the floor. Cultures were negative x24 hours, and infectious work-up was unrevealing (CXR showed atelectasis). Overall this seems most consistent w/ bronchitis given his mild non-productive cough and lack of opacities on CXR. This could also be indicative of postembolization syndrome, which occurs in ~90% of patients following TACE, manifested by fever, malaise, right upper quadrant pain, nausea, and vomiting. He was never febrile, but did complain of chronic RUQ pain, nausea. # Extrapyramidal side effects of anti-emetics: He was noted to have cog-wheeling + resting tremor on exam by the accepting team. He reports that these symptoms began the day after his last hospitalization, during which he got large doses of metoclopramide and prochlorperazine. He reported initial dysarthria, which was not noted during this admission. We added both metoclopramide and prochlorperazine to his allergy list (ondansetron is less likely to cause EPS). He will follow up with neurology as an outpatient. Some studies have shown anti-cholinergics can treat EPS; as such, he was given oral diphenhydramine at night. In terms of his nausea, cortisol was normal. He tolerated a low sodium diet despite nausea (could be post-TACE picture, as above). - QTc 438 on ___. - Avoid metoclopramide and compazine. # Hepatocellular CA s/p TACE: He is currently listed on the transplant list with ___ MELD exception points. Lab MELD was ~10. He had recurrent HCC at site of prior HCC, but was still within criteria. As such, he underwent TACE ___, which was complicated by N/V, abdominal pain, severe transaminitis (which was treated symptomatically). For pain at the site of the procedure (no concerning findings on RUQ u/s), he was started on tramadol 50mg q12 hours, with lidocaine patch for flank. CHRONIC ISSUES =============== # Chronic hepatitis C and alcoholic cirhosis: Complicated by ascites, hepatic encephalopathy, SBP, and recurrent hepatocellular CA. He was continued on SBP prophylaxis. He was continued on home lactulose, rifaximin, furosemide/spironolactone, and nadolol. # Pancytopenia (Anemia/leukopenia/thrombocytopenia): Chronic, likely due to liver disease. # Hypertension: Continued home nadolol, spironolactone, and furosemide. # Ulcerative colitis: Continued home mesalamine. TRANSITIONAL ISSUES =================== - Code status: Full code, confirmed - Emergency contact: ___, sister/HCP, ___ - Studies pending on discharge: all microbiology has been finalized as negative. - If patient is amenable to continuing lidocaine patch, please help him complete prior auth for this. - QTC on ___ was 428. - Avoid metoclopramide and compazine, as well as any other medications that may cause extra-pyramidal side effects. - He will follow up with neurology and his oncologist after discharge. - Currently listed for transplant with MELD 31. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Furosemide 40 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Mesalamine 1000 mg PO BID 5. Nadolol 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Rifaximin 550 mg PO BID 9. Spironolactone 150 mg PO DAILY 10. Acetaminophen 650 mg PO Q6H:PRN fever, pain 11. TraMADOL (Ultram) 50 mg PO BID:PRN pain 12. Prochlorperazine ___ mg PO Q6H:PRN Nausea 13. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain (not taking as prescribed) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever, pain Do not take more than 2g daily to avoid further liver damage. 2. Ciprofloxacin HCl 500 mg PO Q24H 3. Furosemide 40 mg PO DAILY 4. Lactulose 30 mL PO QID 5. Mesalamine 1000 mg PO BID 6. Nadolol 20 mg PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Rifaximin 550 mg PO BID 10. Spironolactone 150 mg PO DAILY 11. TraMADOL (Ultram) 50 mg PO BID:PRN pain 12. DiphenhydrAMINE 50 mg PO HS Duration: 10 Days This can cause sedation/confusion. Do not take with tramadol. RX *diphenhydramine HCl [Allergy Relief(diphenhydramin)] 25 mg ___ capsule(s) by mouth HS Disp #*20 Capsule Refills:*0 13. Lidocaine 5% Ointment 1 Appl TP BID pain Apply to back or other area of pain RX *lidocaine HCl 3 % twice a day Disp #*30 Gram Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: viral bronchitis . Secondary: resting tremor hepatocellular carcinoma Discharge Condition: Mental Status: Clear and coherent (___). Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, . You were admitted to the hospital because you were having chills. You had no fevers while in the hospital. We checked your urine and blood and found no evidence of infection. We also did a chest xray that did not show any pneumonia. You had a cough that was due to bronchitis, inflammation of the airways that is usually due to a virus, that improved. . You have a tremor in your right arm. This is likely a side effect of medicines you were given for nasuea. You should avoid Reglan (metochlopramide) and Compazine (prochlorperizine) in the future. We have made you an appointment with Neurology to follow this tremor. The Neurology office is trying to move this appointment up if possible. You should follow up with transplant and Dr. ___ as below. Followup Instructions: ___

10056223-DS-24

DS

2122-07-13 00:00:00

2122-07-15 07:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Prochlorperazine / metoclopramide Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: HPI: ___ with history of HCV and EtOH cirrhosis complicated by episodes of hepatic encephalopathy, ascites, SBP, HCC s/p RFA and TACE x3 who now presents with 3 day history of fullness, PO intolerance, weakness, occasional abdominal pain, and possibly an episode of hematemesis. He also reports black stools since ___. He has not eaten for the past two day due to fullness and abdominal pain. On the morning of admission, he began bleeding from the mouth and nose which required many tissues. He has not had fever, nausea, vomiting, diarrhea, chest pain, constipation, BRBPR, dysuria, or. hematuria. The patient recently had a colonoscopy/EGD on ___ which revealed scattered apthous ulcers in the rectum/colon. He is currently listed for liver transplant at ___. In the ED, initial vitals:(Temp 98.2,HR 66,BP 110/65,RR 14,Sat100%RA) He reported having one episode of vomiting in ED. Stool was yellow green and guaiac positive. A liver US was notable for patent veins and moderate ascites. Hapatology was consulted and he was admitted to the ED for further managment. Vitals prior to transfer: (HR68, BP 108/67, RR 18, sat 99%RA ) Currently, the patient reports feeling abominal fullness without nausea or abdominal pain. 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: - HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE, jaundice, SBP - biopsy-proven ___ s/p TACE ___ & TACE ___ (1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment VI/VI lesion) with CT in ___ negative for recurrence - Hypertension - Thrombocytopenia - s/p cholecystectomy ___ - C diff infection: ___ - Ulcerative Colitis Social History: ___ Family History: No illnesses run in the family. Physical Exam: ADMISSION EXAM Temp 98.1. BP 108/61 , HR 67 , RR 20, Sat 100% RA. Gen: NAD, AOx0, unable to remember last name correctly, state date or location, or name days of week in order. HEENT: normocephalic / atraumatic. Conjunctiva clear. Scleral icterus. PERRL, EOM intact. Hearing intact to finger rub. Oral mucosa pink w/ MMM. Neck: Carotid pulses brisk; no bruits were auscultated. Pulm: Lungs resonant to percussion. Clear to auscultation. Cor: Nondisplaced PMI. RRR. Normal S1/S2. ___ systolic murmer at upper sternal borders. JVD at 8cm. Abd: Soft, non distended. Tenderness to palpation in RUQ. Shifting dullness present. Ext: No swelling or deformity. Extremities WWP w/o clubbing,cyanosis, or edema. Skin: Skin warm without petechiae or ecchymoses. Mild palmar erythema present. Neuro: Asterixis present. Sensation and strength grossly intact DISCHARGE EXAM Temp 98.2, BP 98/70 , HR 77 , RR 18, Sat 98% RA. Gen: NAD, comfortable HEENT: normocephalic / atraumatic. Conjunctiva clear. Mild scleral icterus. Pulm: Lungs resonant to percussion. Clear to auscultation. Cor: Nondisplaced PMI. RRR. Normal S1/S2. Abd: Soft, non distended. Tenderness to palpation in RUQ. Ext: No swelling or deformity. Extremities WWP w/o clubbing,cyanosis, or edema. Skin: Skin warm without petechiae or ecchymoses. Neuro: No asterixis. Sensation and strength grossly intact Pertinent Results: ADMISSION LABS -------------- ___ 09:40PM GLUCOSE-125* UREA N-14 CREAT-0.7 SODIUM-134 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-7* ___ 09:40PM WBC-4.7 RBC-3.37* HGB-11.1* HCT-33.5* MCV-99* MCH-33.1* MCHC-33.3 RDW-15.2 ___ 09:40PM PLT COUNT-64* ___ 09:40PM ___ PTT-36.3 ___ ___ 11:47AM ___ PTT-31.3 ___ ___ 11:38AM GLUCOSE-95 UREA N-17 CREAT-0.9 SODIUM-134 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-6* ___ 11:38AM estGFR-Using this ___ 11:38AM ALT(SGPT)-48* AST(SGOT)-87* ALK PHOS-172* TOT BILI-1.0 ___ 11:38AM ALBUMIN-2.1* ___:38AM WBC-4.2 RBC-3.36* HGB-11.2* HCT-33.7* MCV-100* MCH-33.2* MCHC-33.1 RDW-15.2 ___ 11:38AM NEUTS-64.4 ___ MONOS-9.3 EOS-2.9 BASOS-0.8 ___ 11:38AM PLT COUNT-65* DISCHARGE LABS -------------- ___ 08:56AM BLOOD Glucose-127* UreaN-11 Creat-0.8 Na-132* K-4.4 Cl-98 HCO3-28 AnGap-10 ___ 08:56AM BLOOD ALT-52* AST-84* AlkPhos-192* MICROBIOLOGY ----------- ___ Urine culture: no growth ___ Stool C.diff DNA: negative ___ Blood culture: pending IMAGING ------- ___ Liver U/S w/ doppler: Coarse, nodular liver with nodules/prior RFA/TACE sites better evaluated on prior MR. ___ hepatic veins. Patent main portal vein with slow, forward flow without clot. Study limited for evaluation of portal branches. Moderate ascites. ___ Bedside abdomone U/S: No ascites ammenable to Brief Hospital Course: ___ with history of HCV and EtOH cirrhosis with multiple complications who presented with abdominal pain and black stools who subsequently developed encephalopathy. ACTIVE ISSUES ------------- #. Encephalopathy: Upon initial arrival to the floor, the patient was initially alert and oriented (A&O) x2 but was AOx0 on repeat examination. He did not have asterixis however and the remainder of the exam was not indicative of possible underlying pathology. Liver ultrasound in the ED showed patent portal veins. He was afebrile, vital signs stable. No electrolyte abnormalities were present. Has been compliant with mediation. His lactulose dose was managed until stooling ___ times daily and he was on his home rifaxamin. Stool cultures and C. Diff PCR were sent. A bedside ultrasound did not reveal ascites, making SBP unlikely, and he was switched off ceftriazone back to his dose of ciprofloxacin. On the morning of hospital day 2 he was AOx2, but later once again developed confusion. A "trigger" was called and the patient was reassessed. Vitals were still stable and no indication of infection was present. Chest Xray, blood cultures, and urine analysis were ordered to assess for any underlying pathology but did not suggest a possible source of infection. Throughout hospitalization his abdominal pain was around baseline of mild right upper quadrant pain. On discharge, he did not exhibit confusion and asterixis was abscent. He was instructed to follow up with his regularly scheduled outpatient appointments. #. GI bleeding: The patient was admitted for report of one week of black stools, in the setting of recent known GI bleed. Stools were brown, guaiac positive. HCT was 33.5 on admission (at his baseline) and 33.8 at time of discharge. #. Cirrhosis: On admission, his LFTs were at baseline. His cirrhosis continued to be managed with his home medications while admitted. No ascitic fluid on ultrasound. No episodes of frank bleeding during admission. Continued to received ciprofloxacin after a single dose of ceftriaxone. #. Vomiting: He had one episode of vomiting late on the evening of planned discharge. He was cleared for home, was awaiting arrival of transportation, when he had non-bloody, non-bilious vomiting x1 after dinner. His vitals were stable and he was able to ambule without dizziness. He was discharged the following day. #. Depression: While hospitalized, he was noted to have a depressed affect and admitted low mood. Though possibly stemming from his chronic medical condition, he has also had less energy recently. Escitalopram was started at a reduced dose for hepatic disease of 5mg PO daily. ECG prior to start was normal without QTc prolongation (QTc 410). Given concurrent use of escitalopram with tramadol, he was educated about symptons concerning for Seratonin Syndrome. Titration and a repeat ECG should be done as an outpatient by his regular providers. INACTIVE ISSUES --------------- #. Ulcerative Colitis: He was continued on home dosing mesalamine. TRANSITIONAL ISSUES ------------------ #. Titration of escitalopram: He will be followed as an outpatient by his primary care doctor ___ at ___ ___. #. Follow-up: He was instructed to follow up with his primary doctor, ___, and hematology as scheduled. #. Code status: Full Code #. Contact: ___, ___ as his HCP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Ferrous Sulfate 325 mg PO BID 3. TraMADOL (Ultram) 50 mg PO BID 4. Rifaximin 550 mg PO BID 5. Pantoprazole 40 mg PO Q12H 6. Furosemide 40 mg PO DAILY 7. Lactulose 30 mL PO QID Please titrate lactulose to have ___ bowel movements a day 8. Nadolol 20 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Spironolactone 150 mg PO DAILY 11. Mesalamine 1000 mg PO BID Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Lactulose 30 mL PO QID Please titrate lactulose to have ___ bowel movements a day RX *lactulose 10 gram/15 mL 30 ml by mouth four times a day Disp #*480 Milliliter Refills:*0 5. Nadolol 20 mg PO DAILY RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet,delayed release (___) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Spironolactone 150 mg PO DAILY RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 9. TraMADOL (Ultram) 50 mg PO BID 10. Mesalamine 1000 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Escitalopram Oxalate 5 mg PO DAILY Depression Discharge Disposition: Home Discharge Diagnosis: abdominal pain, compensated cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while at ___. You were admitted to the liver service for belly pain and concern for bleeding. During admission, your blood counts remained stable and you had no evidence of bleed. At time of discharge, your pain had improved and you were able to eat normally. While admitted you also had episodes of confusion. The liver doctors ___ and there was no indication of worsening liver disease. Your confusion resolved on your home medications. An anti-depressant medication was added to your home medications; please take as prescribed along with the remainder of your usual home medications. This medication takes a few weeks to fully work. Call your doctor if you experience any of the side effects we discussed during your admission (listed below in warning signs). Also, please follow up with your scheduled appointments as below. Followup Instructions: ___

10056223-DS-26

DS

2122-09-01 00:00:00

2122-09-03 15:01:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Prochlorperazine / metoclopramide Attending: ___. Chief Complaint: Nausea, fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx HCV and EtOH cirrhosis complicated by episodes of hepatic encephalopathy, ascites, SBP, HCC s/p RFA and TACE x3, currently on the transplant list presents after fall this am. He describes waking up, taking a shower and feeling weak. He has been persistently nauseas (getting worse) over the past 2 weeks since discharge, and this AM vomited possibly 10 times after showering. Denies any hematemesis, vomitus was bilious. During this episode of vomiting he experienced abdominal pain that has since resolved, and denies any constipation/diarrhea. Immediately after the episode of vomiting he felt weak and states he "could not feel his legs" and fell to the ground, hitting his head without LOC. He presented to OSH where per pt they d/c'ed him, with pain meds for his HA and negative head CT. He now comes to ___ for further eval due to persistent headache and nausea. In the ED, initial vitals were Pain 8 97.8 62 97/65 16 100% RA. The pt was given zofran for n/v. Repeat head CT showed no acute process, but there was presence of findings c/w right maxillary acute on chronic sinusitus. ECG was normal. Admitted for syncope workup. Of note, pt recently admitted and discharged on ___ for lower extremity edema with uptitration of his sprinolactone from 200 mg to 300 mg daily. Past Medical History: - HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE, jaundice, SBP - biopsy-proven HCC s/p TACE ___ & TACE ___ (1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment VI/VI lesion) with CT in ___ negative for recurrence - Hypertension - Thrombocytopenia - s/p cholecystectomy ___ - C diff infection: ___ - Ulcerative Colitis Social History: ___ Family History: No illnesses run in the family. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.7 109/67 49 18 96%RA General: NAD, appears well HEENT: EOMI PERRL Neck: supple without JVD CV: RRR s1/s2 -mrg Lungs: CTAB Abdomen: soft minimally TTP in the RUQ (baseline), non distended Ext: 1+ pitting edema to the upper shins, improved per pt Neuro: AOx3. CN2-12 intact. STrength ___ ___ bilaterally. Sensation intact in the ___. Skin: no rash DISCHARGE PHYSICAL EXAM Vitals: T: 98.1 Tm 98.4 BP:106-120/59-65 ___ R:18 98% RA General: Alert, oriented, no acute distress HEENT: abrasion over right supraorbital process, Sclera minimally icteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, no MRG Abdomen: minimally tender to palpation in all quadrants, hypoactive bowel sounds, no rebound tenderness or guarding, no fluid wave Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes, petechiae or ecchymoses Neuro: II-XII grossly intact, alert and oriented x3, coordination intact, no asterixis, able to follow commands Pertinent Results: ADMISSION LABS Brief Hospital Course: ___ yo man with history of HCV and EtOH cirrhosis complicated by episodes of hepatic encephalopathy, ascites, SBP, HCC s/p RFA and TACE x3 presents after multiple vomiting episodes w presyncope and fall. # Presyncope: Episode most likely vasovagal or orthostatic given recent increase in aldactone and decreased PO intake ___ nausea/vomiting. CT head negative. No signs or symptoms concerning for arrythmia, new valvular disease, or seizure activity. Did hit his head at home. CT head negative. Small abrasion on head. Did not have syncopal episodes here. Received albumin IVF. No events on telemetry. # Nausea: persistent and worsening with vomiting. Started after his last discharge when aldactone was increased. No fevers/chills or diarrhea to suggest GI infection. Most likely secondary to portal gastropathy and gastroparesis in setting of cirrhosis. Also could have been a viral gastroenteritis v. medication effect from cipro ppx or aldactone. Infectious workup was negative. Had one positive BCx with GPC which was a contaminant. Received vancomycin until final culture available. Per our discussion with the hepatology team, symptoms will most likely be persistent until transplant. Did not have emesis during hospitalization. Had persistent nausea. Received zofran IV prn. Sent home with zofran PO. Allergic to compazine and reglan. QTc normal on discharge. Able to tolerate PO liquids on discharge. # HCC: s/p RFA and TACE x3: Did not have evidence of ascites on bedside US. Continue monitoring with ultrasound and AFP as outpatient. # Cirrhosis: c/b hepatic encephalopathy, ascites, SBP, ___ s/p RFA and TACE x3, currently on the transplant list. Admission MELD was 11. Continued home lactulose and rifaximin, nadolol, and cipro for SBP ppx. Currently on top of transplant list for his blood type. # Ulcerative colitis: Continued home mesalamine. No acute issues. TRANSITIONAL ISSUES - has outpatient f/u with transplant doctors - often returns to the hospital for persistent nausea requiring IV antiemetics - needs adequate nutrition for transplant Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Escitalopram Oxalate 5 mg PO DAILY Depression 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 60 mg PO DAILY 5. Lactulose 30 mL PO QID Please titrate lactulose to have ___ bowel movements a day 6. Mesalamine 1000 mg PO BID 7. Nadolol 20 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Rifaximin 550 mg PO BID 10. Spironolactone 300 mg PO DAILY 11. TraMADOL (Ultram) 50 mg PO BID Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H 2. Escitalopram Oxalate 5 mg PO DAILY Depression 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 60 mg PO DAILY 5. Lactulose 30 mL PO QID Please titrate lactulose to have ___ bowel movements a day 6. Mesalamine 1000 mg PO BID 7. Nadolol 20 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Rifaximin 550 mg PO BID 10. Spironolactone 300 mg PO DAILY 11. TraMADOL (Ultram) 50 mg PO BID 12. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours as needed for nausea Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Nausea Secondary Diagnosis: Pre-syncope, Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You came in with nausea and vomiting. You also had an episode where you fell at home. We admitted you because of your symptoms. A scan of your head was done which was normal. We got a number of labs to determine what was causing your nausea. We treated you with IV medication to help your nausea. We treated you with an antibiotic (vancomycin) to treat a bacteria that was found in your blood. The bacteria ended up being a contaminant and we were not concerned about it. We stopped antibiotics. You will need to follow up with your liver doctor ___ below) when you leave the hospital. You are at the top of the transplant list for your blood type. We want to encourage you to take in adequate nutrition. If you cannot take in solid foods, please try to drink nutritious shakes, like ensure. Followup Instructions: ___

10056612-DS-12

DS

2191-01-09 00:00:00

2191-01-09 17:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / clopidogrel / lisinopril / chlorthalidone Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ yo female with a history of laryngeal cancer and a right temporal mass who is admitted with headaches and hypertensive urgency. The patient states she has been having intermittent headaches, weakness, nausea, and vision changes for three days. She denies any fevers, shortness of breath, diarrhea, constipation, dysuria, or rashes. She states she is taking carvedilol twice a day and atenolol once a day for her blood pressure. She reports not taking losartan. She does seem confused about her medications and per report her daughter also is concern about her management of medications at home. She reportedly lives with her son who is bipolar and causes he significant stress. She presented to the ED on ___ and was found to be hyptertensive. A head CT was done and unchanged from prior and she was sent home. In the ED this evening she was again found to be hypertensive to 200s/100s. She was given carvedilol with improvement in her blood pressure. On arrival to the floor she states that her headache and other symptoms have significantly improved. Past Medical History: Laryngeal cancer, ___ CVA/TIA Hypertension HLD Hypothyroidism after thyroid surgery for nodule ___ stenosis status post right carotid stents Cervical cancer, hysterectomy Tonsilectomy Appendectomy Right ankle fracture, pins placed Bilateral cataracts Social History: ___ Family History: She had two brothers, one died in his ___ with liver cancer and one died in his ___ with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION EXAM: =============== General: NAD VITAL SIGNS: T 97.3 BP 149/68 HR 61 RR 16 O2 97%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits, Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed; strength is ___ of the proximal and distal upper and lower extremities. DISCHARGE EXAM: =============== VITAL SIGNS: T 98.6 BP 128/60 HR 76 RR 18 O2 98%RA General: Pleasant, animated woman, sitting up comfortably in bed. HEENT: MMM, no nystagmus. PERLL. EOMI. OP clear. CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No edema, normal bulk, wwp SKIN: No rashes on extremities NEURO: Alert and interactive. Oriented x3. No focal weakness including symmetric ___ upper extremity strength and ___ lower extremity strength. FTN intact. CN III-XII intact. Pertinent Results: ADMISSION LABS: ============== ___ 09:40PM BLOOD WBC-4.1 RBC-4.44 Hgb-12.2 Hct-38.9 MCV-88 MCH-27.5 MCHC-31.4* RDW-14.4 RDWSD-46.0 Plt ___ ___ 09:40PM BLOOD Neuts-51.4 ___ Monos-10.0 Eos-2.7 Baso-0.5 Im ___ AbsNeut-2.10 AbsLymp-1.42 AbsMono-0.41 AbsEos-0.11 AbsBaso-0.02 ___ 09:40PM BLOOD Plt ___ ___ 09:40PM BLOOD Glucose-87 UreaN-21* Creat-0.8 Na-142 K-3.9 Cl-106 HCO3-24 AnGap-16 ___ 07:44AM BLOOD ALT-21 AST-19 LD(LDH)-179 AlkPhos-108* TotBili-<0.2 ___ 09:40PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1 ___ 10:15PM BLOOD CRP-3.0 DISCHARGE LABS: =============== ___ 07:44AM BLOOD WBC-4.6 RBC-4.16 Hgb-11.5 Hct-35.8 MCV-86 MCH-27.6 MCHC-32.1 RDW-15.2 RDWSD-47.3* Plt ___ ___ 07:18AM BLOOD Glucose-77 UreaN-25* Creat-0.8 Na-141 K-3.7 Cl-112* HCO3-18* AnGap-15 ___ 07:18AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 IMAGING: ======== ___ Imaging MRV HEAD W/O CONTRAST 1. No evidence of cerebral venous thrombosis. 2. Unchanged 13 x 7 mm enhancing right middle cranial fossa extra-axial lesion. 3. Previously noted subtle area of right medial occipital leptomeningeal enhancement is not well appreciated on the current examination, likely due to difference in technique. 4. No new enhancing lesion. 5. Multiple chronic infarcts, as described. 6. Confluent areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease. ___ Imaging MR HEAD W & W/O CONTRAS 1. New small evolving acute or early subacute infarct within the left posterior inferior cerebellar hemisphere. 2. Stable enhancing extraaxial mass along the medial right temporal lobe. 3. Stable small area of leptomeningeal enhancement along the medial right occipital lobe dating back to ___, etiology uncertain. 4. Stable chronic infarctions within bilateral cerebellar hemispheres and left pons. 5. Stable extensive confluent white matter changes in right greater than left temporal white matter, and bilateral frontal and parietal white matter, as well as in the middle cerebellar peduncles and bilateral pons, likely a combination of posttreatment changes and sequela of chronic small vessel ischemic disease. 6. Stable left frontal developmental venous anomaly. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: ___ w/ CAD, TIA, HTN, DL, brainstem CVA, h/o submandibular cystic carcinoma, diagnosed in ___, followed by modified radical neck dissection, R temporal mass (most likely XRT necrosis) stable since ___, carotid stenosis s/p ___ stents, and history of hypertensive emergency causing headaches due to medication noncompliance, p/w HA dizziness and nausea, found to have hypertensive emergency and new cerebellar CVA. Now with persistent/intractable headache. # Hypertensive emergency: # Hypertension: Etiology of hypertensive emergency thought due to noncompliance of her home medications, and she improved with resumption of home carvedilol 12.5 and losartan 50. However, her headache persisted, and after staring IV dexamethasone, her blood pressures again worsened. We uptitrated her carvedilol to 25mg bid and increased losartan to 100mg daily. She continued to require intermittent po labetolol and IV hydralazine. On ___ we restarted her on chlorthalidone 25mg daily (she had previously taken this, but was stopped due to urinary frequency). Day of discharge blood pressure was better controlled in the 120's-130's. She was discharged with these medications and po potassium 10 meq daily. She should have blood pressure and chemistry panel checked on ___ consider investigating secondary causes of hypertension, at her primary team's discretion. # Stroke: Etiology thought from HTN disease. 48 hours of telemetry were unremarkable and prior carotid imaging was normal. Last LDL ___ was 124; last A1c 5.5%. No clear/focal neurologic deficits despite new CVA on imaging. Patient was previously on ASA and plavix but she discontinued plavix due to dizziness some time ago. Unclear if she was taking ASA at home. We restarted Plavix. Statin was held given patient's reported statin allergy, although this should continually be discussed with her PCP. # Persistent L sided HA # Status migranosis: Etiology of headache initially thought due to uncontrolled HTN. However, headaches persisted despite better BP. Head MRI revealed small Cerebellar ischemic stroke, as above, which was out of proportion to her headaches. MRV was negative for venous thrombosis. CRP/ESR not indicative of temporal arteritis. Deferred LP given no suspicion for infection. She was initially treated with fioricet and tramadol. Received small amounts of IV morphine. Ulitmately opiods and tramadol limited due to concern for rebound headache/overuse headache. She was given 3 days of IV dexamethasone starting ___ and started acetazolamide 500mg twice daily on ___. Headache broke on evening of ___ and patient was discharged pain free. She will continue acetazolamide indefinitely per her neuro-oncologist, Dr. ___ should follow up with him in ~2 weeks. # Metabolic acidosis: Patient developed non-gap hyperchloremic metabolic acidosis, likely due to acetazolamide. Will continue acetazolamide and continue to monitor. # Hypothyroidism: Continued home synthroid. Last TSH 30, rechecked TSH here and 0.3 # GERD: Continued home omeprazole. # Social: On admission there was some concern regarding patient's safety at home. SW was consulted and safe discharge plan was developed. Ultimately felt to be safe for home discharge in light of her extensive support system and ability to call ___ should there be an emergency. This plan was made in accordance to the patient's wishes, as well. Please see SW noted for further information. # Billing: >30 minutes spent planning and executing this discharge plan TRANSITIONAL ISSUES: =================== - Close monitoring of blood pressures and medication compliance - Increased losartan to 100mg daily and carvedilol to 25mg twice daily - Started chlorthalidone 25mg daily on ___ and discharged with 10meq potassium supplements - Please recheck Chemistry on ___ - Resumed Plavix. Currently holding aspirin - Discuss statin use with patient given recurrence cerebrovascular disease Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Topiramate (Topamax) 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Aspirin 81 mg PO DAILY 6. Carvedilol 12.5 mg PO BID 7. Atenolol Dose is Unknown PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Losartan Potassium 50 mg PO DAILY Discharge Medications: 1. AcetaZOLamide 500 mg PO Q12H RX *acetazolamide 500 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Potassium Chloride 10 mEq PO DAILY Hold for K > RX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Losartan Potassium 100 mg PO DAILY RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 650 mg 1 tablet(s) by mouth q6 hours Disp #*60 Tablet Refills:*0 8. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff IH q4 hours Disp #*1 Inhaler Refills:*0 9. Levothyroxine Sodium 100 mcg PO DAILY RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 11. Topiramate (Topamax) 50 mg PO DAILY RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CVA Hypertensive Emergency Status Migraine 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 ___ ___. You were admitted for severe headaches. You were found to have a hypertensive emergency and your blood pressures improved with restarting your home carvedilol and losartan. We ultimately increased your carvedilol and losartan doses and started an new medication called chlorthalidone. You cannot miss these medications, and you must follow up with Dr. ___ very close monitoring of your blood pressure and blood work. Additionally, ___ had a brain MRI which revealed a small stroke. You continued to have very severe headaches, so we gave you a three day course of IV dexamethasone (steroids) and started a medication called acetazolamide. You will need to follow up with Drs. ___. Sincerely, Your ___ Care Team Followup Instructions: ___

10056612-DS-13

DS

2191-01-17 00:00:00

2191-01-17 16:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Influenza Virus Vaccines / latex / atorvastatin / Ativan / lisinopril / chlorthalidone Attending: ___ Chief Complaint: Headache and dizziness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with history of laryngeal cancer and L temporal lesion as well as history of multiple lacunar infarcts and microvascular disease as well as recent admission for hypertensive emergency and headache during which she was found to have small L cerebellar infarct who presents to the ED with headache and dizziness. Ms. ___ was recently admitted from ___ through ___ to the medicine service after presenting with hypertensive emergency. Course complicated by status migrainosus, which resolved after 3 days of IV dexamethasone and for which she was started on acetazolamide. Course also complicated by incidental tiny left cerebellar infarct thought by medicine team to be likely related to hypertension. This was treated as an aspirin failure and she was switched to Plavix. She is not on a statin due to reported statin allergy. During admission she was evaluated by her outpatient neuro-oncologist, Dr. ___. At that time neurologic exam is documented as normal except brisk but symmetric reflexes, as well as moderate ataxia and aphasia with ambulation. Ms. ___ reports that her headache had resolved after discharge, but returned this afternoon. The headache started at the vertex at approx 1700, and became severe by 1800, and also spread to the R hemicranium. The headache is sharp in character. Associated with photophobia and nausea, no phonophobia, no emesis. She states that she has had headaches like this in the past, though they all started after age ___. She also describes 'dizziness' that started around the same time as the headache. She has great difficulty describing the dizziness, but states it was episodic, lasting seconds at a time, and is best described as vertigo when given choices. She says that the last time she had the vertigo was "when I was upstairs in a bed like this one". She is unable to provide an answer when asked if there are any provoking factors. She also reports chest pain, and states she did not tell the emergency room doctors because she did not want to stay overnight. Unable to complete ROS due to mental status. Past Medical History: Right submandibular cystic carcinoma diagnosed in ___, treated with modified radical neck dissection and radiation Hypertension Hypothyroidism Anemia Right ICA stenosis status post right carotid stenting Cervical cancer status post hysterectomy Tonsillectomy Appendectomy Dyslipidemia Pontine lacune Bilateral cataracts Social History: ___ Family History: She had two brothers, one died in his ___ with liver cancer and one died in his ___ with lung cancer. Multiple elder family members developed severe vision loss. Physical Exam: ADMISSION PHYSICAL EXAM: General: Sleepy, lying in bed covered up in multiple blankets. Intermittently appears to be in pain, stated secondary to chest discomfort. HEENT: no scleral icterus, dry MM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: Skin warm, well-perfused. Tenderness to palpation at right costochondral junction. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Sleepy, keeps eyes closed during most of the examination, opening only when necessary. Requires repeated stimulation to participate in exam. Oriented to 'hospital' but not which. States date is ___, though I needed to ask her the year, month, and date multiple times each because she kept replying ___. Difficulty providing history; provides few details, answers to direct questions are at times tangential or absent, states she is still working even though prior records indicate that she has retired. Attention severely impaired, unable to name days of week forward nor repeat a forward digit span of 4. Anomia to low frequency words though interpretation is limited by the fact that ___ is her second language. Repetition intact. Comprehension intact to simple but not complex commands. Perseverative. -Cranial Nerves: PERRL 3->2. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue protrudes in midline. - Motor: Normal bulk, increased tone bilateral lower extremities. Keeps arms outstretched for pronator drift testing only momentarily, during which bilateral pronation without downward drift is noted, before putting her arms down despite coaching. Patient has significant difficulty participating in the confrontational motor testing, but gives at least some resistance in all muscle groups, and the resistance reaches full strength for the first 3 muscle groups tested (Delt Bic Tri), and then patient has progressive difficulty cooperating with exam and symmetric 4 range effort is noted throughout the remainder of the exam. -DTRs: Bi Tri ___ Pat Ach Pec jerk Crossed Abductors L 2 2 2 2 2 + + R 2 2 2 2 2 + + Plantar response was obscured by marked withdrawal bilaterally. -Sensory: Intact to LT, temperature throughout. Unable to participate in vibration or proprioceptive testing - Coordination: Subtle dysmetria with left finger to nose testing. - Gait: Patient refuses. DISCHARGE PHYSICAL EXAM: Neurologic: - Mental Status: alert and oriented x3, attention: states DOWB without difficulty, memory: ___ recall ___ with MCQ/cue), speech: normal rate, rhythm, volume, comprehension and naming intact. Able to follow complex commands - Cranial Nerves: I: not tested II: left lower quadrantopia on visual field examination III, IV, VI: EOMI without nystagmus, PERRL, no ptosis V: sensation intact to light touch VII: no facial musculature asymmetry VIII: hearing diminished but equal bilaterally IX, X: palate elevates symmetrically XI: ___ strength in trapezii and SCM bilaterally - Motor: Normal bulk and tone. No pronator drift. [___] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response showed withdrawal b/l -Sensory: Intact to LT throughout. - Coordination: Subtle dysmetria with left finger to nose testing. - Gait: Deferred. Pertinent Results: ___ 05:45AM BLOOD WBC-4.5 RBC-4.17 Hgb-11.5 Hct-34.8 MCV-84 MCH-27.6 MCHC-33.0 RDW-15.1 RDWSD-45.8 Plt ___ ___ 08:40PM BLOOD WBC-5.8 RBC-4.56 Hgb-12.7 Hct-40.2 MCV-88 MCH-27.9 MCHC-31.6* RDW-15.4 RDWSD-49.3* Plt ___ ___ 06:10AM BLOOD ___ PTT-29.2 ___ ___ 05:45AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-138 K-3.6 Cl-105 HCO3-20* AnGap-17 ___ 08:40PM BLOOD Glucose-108* UreaN-36* Creat-1.2* Na-138 K-3.7 Cl-105 HCO3-16* AnGap-21* ___ 08:40PM BLOOD ALT-18 AST-16 AlkPhos-120* TotBili-0.3 ___ 12:00PM BLOOD cTropnT-<0.01 ___ 05:45AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 ___ 08:40PM BLOOD Albumin-4.3 Calcium-8.9 Phos-4.4 Mg-2.3 ___ 10:02AM BLOOD %HbA1c-5.4 eAG-108 ___ 10:02AM BLOOD Triglyc-80 HDL-51 CHOL/HD-4.3 LDLcalc-150* ___ 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ CTA H&N Notable finding - Atherosclerotic vascular calcifications resulting in mild-to-moderate luminal narrowing of the petrous segment of the right ICA, similar to the prior study. Moderate luminal narrowing of the proximal to mid basilar artery again seen, likely atherosclerotic. ___ MRI head w/o contrast - Acute to subacute infarction is seen involving the right parieto-occipital lobe, left parietal lobe, and right cerebellum. Possible punctate focus of infarction is seen within the left cerebellum. Distribution appears to be embolic in etiology. - Stable extensive confluent white matter changes, right greater than left temporal white matter, bilateral frontoparietal white matter as well as middle cerebellar peduncles likely combination of posttreatment changes and sequelae of chronic small vessel ischemic disease. Brief Hospital Course: Ms. ___ is a ___ year old woman with PMH hypertension, carotid stenosis s/p R ICA stent, multiple prior strokes, CAD c/b MI, laryngeal cancer s/p surgery and radiation therapy who was admitted to Neurology stroke service with headache and dizziness. She was evaluated on telemetry and started on aspirin therapy. She was seen to have elevated LDL and due to previous statin intolerance was started on Zetia. She was seen on MRI to have ischemic stroke in the right parieto-occiptal lobe, left parietal lobe and left cerebellar lobe as well as moderate narrowing of basilar artery. These findings were suggestive of thrombotic etiology of her stroke. She underwent echocardiogram without concern. She was started on dual anti-platelet therapy with aspirin and Plavix. Her deficits (left visual field impairment, dysmetria) improved prior to discharge. She was discharged home with outpatient ___ and ___ services. Transition Issues: -Pt will need to continue taking Aspirin and Plavix for secondary stroke prevention -pt will need to continue taking Zetia for hyperlipidemia -Will f/u pt's Echocardiogram final results; if anything concerning that is pertinent to patient's recent stroke, will contact pt to inform -Pt will need to f/u with PCP and ___ ___ on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation aerosol inhaler. ___ puffs(s) inhaled every four (4) hours as needed for cough/wheeze/chest congestion/short of breath mdi with dose counter CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth twice daily - ___ DC med rec) LEVOTHYROXINE - levothyroxine 100 mcg tablet. 1 tablet(s) by mouth once a day - ___ DC med rec) LOSARTAN - losartan 50 mg tablet. 1 tablet(s) by mouth daily - ___ DC med rec) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth qday SERTRALINE - sertraline 25 mg tablet. 1 tablet(s) by mouth - (Prescribed by Other Provider: per pt in ___ Therapist f/u So End, w/plan for ___ MD) (Not Taking as Prescribed: last filled in ___) TOPIRAMATE - topiramate 50 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider: ___. ___ TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical cream. apply to rash, hands three times a day Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth daily - ___ admission med rec) Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 2. Ezetimibe 10 mg PO DAILY RX *ezetimibe 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 4. Carvedilol 12.5 mg PO BID 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Dao;u Disp #*30 Tablet Refills:*2 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of headache and dizziness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: High blood pressure High cholesterol We are changing your medications as follows: - Aspirin 81 mg daily (for stroke prevention) - Clopidegrel (Plavix) 75mg daily (for stroke prevention) - Ezetimibe (Zetia) 10mg daily (for cholesterol) Please take your other medications as prescribed. Please follow up 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 Sincerely, Your ___ Neurology Team Followup Instructions: ___

10056612-DS-8

DS

2189-09-04 00:00:00

2189-09-06 10:28:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Influenza Virus Vaccines Attending: ___. Chief Complaint: Headache, dizziness, nausea. Major Surgical or Invasive Procedure: There were no major surgical or invasive procedures during hospitalization. History of Present Illness: ___ year who was sent in by ___ on ___ after experiencing headache and emesis. The headache was acute in onset however no headstrike or injuries were reported. She also developed bilateral lower extremity weakness requiring her to have to walk as she was unsteady on her feet. There was concern regarding her presentation as she experienced similar symptoms when she had a prior stroke. In the ED, initial vitals were: Pain 8, Temperature 96.8, HR 101, BP 155/93, RR 16, Pulse Ox 99% on RA. Urine/serum toxicology screen was negative. UA was negative. Chemistry panel was normal except for a BUN of 24. LFT's were normal except for an alk phos of 144. CBC was within normal limits. She underwent a CTA head and neck with preliminary reading showing "no flow limiting stenosis in the intracranial and cervical vessels. No evidence of aneurysm greater than 3 mm or dissection. Patent stent graft in the right common carotid artery. Calcified and non-calcified plaque at the left carotid bifurcation causing mild narrowing. Atherosclerotic calcification involving the left greater than right cervical vertebral arteries. Severe atherosclerotic disease of the aortic arch and descending aorta with both calcified and non-calcified plaque. Unchanged 8 mm right upper lobe pulmonary nodule, follow up per prior chest CT's." The patient was evaluated by neurology who suspected that the patient's current presentation was due to sub-acute spinal pathology coupled with ongoing medical illness and stress due to home situation. The patient was evaluated by ___ in the ED who recommended ___ visits or discharge to rehab. The patient was admitted to medicine for coordination of care and symptomatic management. On the floor, the patient reports improvement in her nausea and abdominal pain. She has some persistent left lower extremity weakness compared to right. She reports intermittent dizziness which she describes as the sensation that the room is spinning around her. She reports stress regarding her son and his issues with addiction, which she has dealt with for some time. She reported headache on presentation bi-temporal, which has improved. The patient does not remember the exact events when she was walking to her closet yesterday morning, but she did not experience any prodromal symptoms, nor changes in vision. Past Medical History: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER ___, FOLLOWED AT ___ THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___ BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT ___ ? SEASONAL AFFECTIVE D/O ___: Admitted to ___ for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. Social History: ___ Family History: - Strong family history of malignancy. One brother deceased in his ___ with liver malignancy, another in his ___ with Lung Cancer. Mother deceased (reportedly at ___) in the setting of multiple medical problems plus a stroke. Her father died at ___. - Patient denies other neurologic family history other than the above. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 97.1, 138/70, 64, 18, 98% on RA General: alert, oriented, tearful when discussing son, otherwise not in acute distress HEENT: pale conjunctiva, JVP not visualized, hard post-surgical/post-radiation changes in left submandibular area, left cheek not tender to light palpation, no oropharnygeal lesions visualized CV: RRR, nl S1 S2, no murmurs, rubs, gallops; no carotid bruit b/l Lungs: CTA b/l, 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 edema Neuro: CNII-XII intact (though patient refuses to extend tongue for testing of CN12), ___ strength upper/lower extremities, grossly normal sensation, upgoing babinskin on left, downgoing on right, gait deferred, ___ negative b/l, mild left lateral end-gaze nystagmus DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.2 ___ 44-70 18 95-100%RA General: AOx3, lying in bed, appears comfortable, very pleasant HEENT: MMM, hard post-surgical/post-radiation changes in left submandibular area, left cheek not tender to light palpation CV: RRR, normal S1 and S2 no m/r/g. Lungs: Clear to auscultation bilaterally. Abdomen: soft, nt, nd, no rebound or guarding. Ext: Warm, well perfused, no edema. Neuro: AOx3, EOMI, CNII-XII intact, strength/sensation grossly intact Pertinent Results: ADMISSION LABS ============== ___ 01:45PM BLOOD WBC-4.6 RBC-5.18 Hgb-13.8 Hct-43.4 MCV-84 MCH-26.6 MCHC-31.8* RDW-16.2* RDWSD-49.3* Plt ___ ___ 01:45PM BLOOD Neuts-67.6 ___ Monos-7.4 Eos-0.4* Baso-0.7 Im ___ AbsNeut-3.10 AbsLymp-1.08* AbsMono-0.34 AbsEos-0.02* AbsBaso-0.03 ___ 01:45PM BLOOD Glucose-99 UreaN-24* Creat-1.1 Na-140 K-3.8 Cl-101 HCO3-29 AnGap-14 ___ 01:45PM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.9 Mg-2.1 ___ 01:45PM BLOOD ALT-31 AST-26 AlkPhos-144* TotBili-0.4 DISCHARGE LABS ============== ___ 07:32AM BLOOD WBC-3.8* RBC-5.17 Hgb-13.7 Hct-42.5 MCV-82 MCH-26.5 MCHC-32.2 RDW-16.2* RDWSD-48.2* Plt ___ ___ 07:32AM BLOOD Glucose-95 UreaN-17 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-29 AnGap-13 ___ 07:32AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.0 SERUM TOXICOLOGY ================ ___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE TOXICOLOGY ================ ___ 03:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE STUDIES ============= ___ 03:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG IMAGING ======= ___: CTA HEAD AND CTA NECK IMPRESSION: 1. Extensive periventricular and subcortical white matter hypodensities, relatively unchanged compared to the prior MRI allowing for the differences in technique. Please note that evaluation for an underlying acute infarct is limited given the extensive hypodensities. MRI of the brain can be performed for further evaluation as clinically indicated. 2. Vasogenic edema in the inferior right temporal lobe. The previously known enhancing lesion in the right temporal lobe is not well visualized on the CT scan. 3. Patent right internal and common carotid artery stent. 4. Atherosclerosis involving the left carotid bifurcation without any stenosis by NASCET criteria. 5. Atherosclerosis involving V2 segment of left vertebral artery causing focal areas of mild luminal narrowing. 6. Stable 9 mm nodule in the right upper lobe. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. ___: PELVIS (AP ONLY) FINDINGS: No fracture or dislocation. Bilateral hip joint spaces are relatively well preserved with only minimal degenerative change. Pubic symphysis and SI joints are preserved. No radiopaque foreign body. Contrast is seen within the bladder. IMPRESSION: No fracture or dislocation. Brief Hospital Course: ASSESSMENT AND PLAN: ___ with PMH of HTN, hypothyroidism, head and neck cancer s/p neck dissection x2 who presented with complaints of vertigo and leg weakness after fall with complex social situation concerning for abuse. # Vertigo secondary to BPPV versus Social Stressors/Anxiety: Ms. ___ presented with nausea and dizziness. Based on description it appeared the vertigo appeared to be position in nature. Given her history of carotid stenosis, a CTA head and neck was obtained which did not show any evidence of new acute stroke. Neurology was consulted during hospitalization who did not believe symptoms could be explained by an acute stroke. Rather, they believed the symptoms were consistent with benign paroxysmal positional vertigo as neurologic exam was completely benign. During hospitalization, it was also noted that Ms. ___ symptoms occurred when she was talking about her stressful home situation (a son at home who has a drug addiction and is verbally abusive to her). When talking to her son on the phone, Ms. ___ would experience the dizziness and nausea. She also experienced these symptoms when she described her stressful home situation to the medical team. These symptoms would resolve after she had time to relax. Neurology did not believe any further work-up was necessary as an inpatient and recommended follow up with her Neurologist, Dr. ___. # Social Stressors/Verbal Abuse: Ms. ___ described her stressful home situation with her son. She describes her son as addicted to crack. She also described numerous episodes of verbal abuse to her. She denied any physical abuse. Elder services had been involved in the past. Given this description, social work was heavily involved during this hospitalization and initial mandated reporting was done upon admission. She was hesitant to be discharged from the hospital until ___ discharge plan was in place. Social work attempted to find other places for her to stay, however, patient elected to be discharged home. To facilitate a safe discharge plan, plans were made with ___ Police if any abuse at home (plan would be contact Police at Precinct B2 with ___ ___ ___ cell). These plans were also communicated with patient's daughter (___) to instruct on when to call the police. Prior to her discharge, Elder Protective Services were called for wellness and home safety evaluations to occur at home. Ms. ___ was able to voice back the safety plan that was developed and reported she felt comfortable with the safety plan. Attempts were made to locate safe housing prior to discharge,but patient denied further services. # Bacterial pneumonia: patient recently diagnosed with atypical pneumonia at PCP, started on course of levofloxacin ___. She completed her 10 day course of levofloxacin on ___. She was not experience cough or fever, and remained hemodynamically stable during hospitalization. # Hypertension: Continued atenolol, chlorthalidone, and aspirin during hospitalization. # Hypothyroidism: Continued levothyroxine during hospitalization. TRANSITIONAL ISSUES =================== - Stable 9 mm nodule in the right upper lobe. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. Of note, this lesion has been documented on previous CT scans of the chest. - CTA Head and Neck: Marked atherosclerosis involving the aortic arch with penetrating atherosclerotic ulcer as seen on image 5:27. Further evaluation with dedicated CT of the chest can be performed as clinically indicated. - Please continue to follow up with patient's safety situation at home - If further concerns for elder abuse, please contact Elder Services. - Patient was noted to have mild leukopenia on labs. Please consider repeat CBC as outpatient and consider further evaluation. -Code Status: DNR/DNI. - Safety Plan: Patient will be calling Officer ___ ___ cell) if there are any further safety issues. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Chlorthalidone 25 mg PO QAM 3. Levofloxacin 500 mg PO Q24H 4. Aspirin 81 mg PO DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Acetaminophen 1000 mg PO Q4H:PRN headache/cold 7. Fish Oil (Omega 3) ___ mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q4H:PRN headache/cold 2. Aspirin 81 mg PO DAILY 3. Atenolol 100 mg PO DAILY 4. Chlorthalidone 25 mg PO QAM 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Fish Oil (Omega 3) ___ mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= -Benign Paroxysmal Positional Vertigo -Post-traumatic stress disorder thought to be secondary to verbal abuse at home. Secondary Diagnosis =================== -Hypertension -Hypothyroidism -Prior CVA -Throat Cancer ___ -s/p Thyroidectomy -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 ___ ___ due to nausea and dizziness. You were seen by the Neurologists who recommended you undergo a CT scan of your head and neck. This did NOT show evidence of a new stroke. The dizziness you experienced seemed to be related to the movement of your head. This is known as "Benign positional vertigo." This usually resolves on its own. We also noticed that your symptoms of nausea/dizziness occurred when you were talking about your very stressful home situation. Stressors can make your symptoms worse. To help find a safe place for you to be discharged to, you were seen by Social Work. Their recommendations included a safety plan to contact the Police if you feel unsafe at home. Your friend, Officer ___ ___, can be reached at ___ cell), and was contacted to ensure you have more safety checks at home. Further, Elder Services were also contacted so that they can see you at home to ensure that it is a safe environment. Please follow up with your primary care physician and your specialists upon discharge from the hospital. It was a pleasure taking care of your during your hospitalization! We wish you all the best in the upcoming new year! Sincerely, Your ___ Care Team Followup Instructions: ___

10056612-DS-9

DS

2189-11-13 00:00:00

2189-11-14 17:55:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Influenza Virus Vaccines Attending: ___. Chief Complaint: Episodes of confusion, dizziness, subjective lower extremity weakness and "out of body" experience Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ is a ___ year-old right-handed woman with PMH significant for laryngeal cancer s/p neck dissection and radiation therapy (___) with a chronic stable right temporal brain lesion felt to be radiation necrosis who presents with multiple transient episodes of ___ weakness, dysarthria and headache. The patient reports that the first of these episodes was in ___ (see Neurology ED consult note by ___ ___ The then restarted about 2 weeks ago (shortly after she missed a neurology appointment because she was at a court hearing - having her son evicted from her house and placed in an inpatient psych facility). She reports having about 5 events in the last 2 weeks with 2 today. She describes the events as follows: The onset always starts with a sense of dizziness - which she describes as a floating detached feeling "like im in the air" or "like I don't have a body". She denies a ___ out-of-body experience or vertigo. She then will feel "shaky" especially in her legs followed by a feeling of fear/anxiety. She feels like "I don't have any legs", describing them as numb and weak. Her speech will then sound funny. The event concludes in a non-pulsatile headache with nausea and occasional emesis. each event lasts about 10 min. She also describes a very similar episode (which she calls her stroke) at ___ in the months following her CA treatment. She denies any significant headache history. On neuro ROS: the pt denies loss of vision, blurred vision, diplopia, oscilopsia, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, paresthesias (outside of the events). No bowel or bladder incontinence or retention. Denies difficulty with gait. On general ROS: 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: ? CVA, ? MI ANEMIA APPENDECTOMY BACK PAIN, RIGHT SCIATICA CATARACTS HYPERTENSION HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on levothyroxine. RIGHT ANKLE SURG/PINS THROAT CANCER ___, FOLLOWED AT ___ THROAT CANCER SURGERY, THYROIDECTOMY TOBACCO ABUSE TONSILECTOMY STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___ BRAIN TUMOR ADENOID CYSTIC CARCINOMA DEPRESSION DYSPNEA ON EXERTION RECHECK CHEST CT ___ ? SEASONAL AFFECTIVE D/O ___: Admitted to ___ for dizziness, thought to be secondary to Benign Paroxysmal Positional Vertigo. Also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son. Social History: ___ Family History: - Strong family history of malignancy. One brother deceased in his ___ with liver malignancy, another in his ___ with Lung Cancer. Mother deceased (reportedly at ___) in the setting of multiple medical problems plus a stroke. Her father died at ___. - Patient denies other neurologic family history other than the above. Physical Exam: ADMISSION MEDICAL EXAMINATION T: 97.8 HR: 76 BP: 164/107 RR: 18 Sat: 99% on RA GENERAL MEDICAL EXAMINATION: General appearance: alert, in no apparent distress, conversing/interacting appropriately HEENT: Sclera are non-injected. Mucous membranes are moist. CV: Heart rate is regular Lungs: Breathing comfortably on RA Abdomen: soft, non-tender Extremities: No evidence of deformities. No contractures. No Edema. Skin: No visible rashes. Warm and well perfused. NEUROLOGICAL EXAMINATION: Mental Status: Alert and oriented to person place and time. Able to relate history without difficulty. Attentive to conversation. Language is fluent and appropriate with intact comprehension, repetition and naming of both high and low frequency objects. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. No neglect, left/right confusion or finger agnosia. During a witnessed event the patient's speech became slow and effortful but not dysarthric. She was still able to repeat and follow complex commands. She did not demonstrate any weakness during the event. Cranial Nerves: I: not tested II: visual fields full to confrontation III-IV-VI: pupils equally round, reactive to light. Normal conjugated, extra-ocular eye movements in all directions of gaze. No nystagmus or diplopia. V: Symmetric perception of LT in V1-3 VII: Face is symmetric at rest and with activation; symmetric speed and excursion with smile. VIII: Hearing intact to finger rub bl IX-X: Palate elevates symmetrically XI: Shoulder shrug ___ bl XII: No tongue deviation or fasciculations Motor: Normal muscle bulk and tone throughout. No pronator drift or rebound. Strength: Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5- 5 5 5 5 R 5 ___ ___ 5 5 5- 5 5 5 5 Reflexes: brisk and symmetric. Toes are equivocal bilaterally. Sensory: decreased perception to pin on the left (80%) (documented in prior exams). normal and symmetric perception of light touch, vibration and temperature. Proprioception is intact. Coordination: Finger to nose without dysmetria bilaterally. No intention tremor. RAM were slow but with regular cadence and good accuracy. Gait: Good initiation. Narrow-based, normal stride and arm swing. **DISCHARGE PHYSICAL EXAMINATION:** General: awake, alert woman in bed reporting mild headache in no acute distress HEENT: No conjunctival injection or discharge, MMM Resp: Breathing comfortably in room air CV: no cyanosis Abd: Non-distended Ext: WWP Neuro: Mental status: Awake, alert, oriented to place; conversant, able to answer basic history questions CN: PERRL, EOMI, face grossly symmetric with grossly normal facial sensation Motor: at least anti-gravity throughout with no orbiting Gait: deferred Pertinent Results: EEG: preliminary report (see full, final report for further details) multiple push button events without evidence of electrographic correlate (no evidence of seizure), no sharp waves; intermittent right temporal slowing as expected given known lesion ___ 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85 MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt ___ ___ 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85 MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt ___ ___ 01:00PM BLOOD WBC-4.4 RBC-5.08 Hgb-13.8 Hct-43.0 MCV-85 MCH-27.2 MCHC-32.1 RDW-15.7* RDWSD-47.8* Plt ___ ___ 06:50AM BLOOD Neuts-54.6 ___ Monos-8.8 Eos-1.7 Baso-0.7 Im ___ AbsNeut-2.22 AbsLymp-1.37 AbsMono-0.36 AbsEos-0.07 AbsBaso-0.03 ___ 01:00PM BLOOD Neuts-58.3 ___ Monos-9.1 Eos-1.8 Baso-0.7 Im ___ AbsNeut-2.56 AbsLymp-1.29 AbsMono-0.40 AbsEos-0.08 AbsBaso-0.03 ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD ___ PTT-30.8 ___ ___ 01:00PM BLOOD Plt ___ ___ 01:00PM BLOOD ___ PTT-29.5 ___ ___ 06:50AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-141 K-3.5 Cl-104 HCO3-26 AnGap-15 ___ 01:00PM BLOOD Glucose-89 UreaN-21* Creat-1.1 Na-137 K-4.8 Cl-97 HCO3-29 AnGap-16 ___ 06:50AM BLOOD ALT-20 AST-25 LD(LDH)-212 AlkPhos-95 TotBili-0.6 ___ 06:50AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7 ___ 06:50AM BLOOD TSH-36* ___ 01:06PM BLOOD Lactate-1.2 Brief Hospital Course: Patient was admitted to the Neurology Service where she was placed on long term EEG to capture events. Multiple episodes were captured and were typical of the events of interest. There were multiple push button events for these episodes without EEG correlate (no evidence of seizure). As a result, these episodes were felt to be most likely due to stress (e.g. possible panic attacks). No medication changes were made, and no new medications were added. She was discharged home with a plan to follow up with her primary care physician, ___, and psychiatry. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam: non focal Discharge Instructions: Dear Ms. ___, You were admitted for episodes of feeling dizzy, confused, "floating" and scared. We placed you on EEG to look at your brain waves. You had a few of these episodes while under EEG monitoring and they were not seizures. We think that your episodes are most likely from anxiety. Please talk to your primary care doctor to arrange for a psychiatry appointment for management of your anxiety. Followup Instructions: ___

10057005-DS-22

DS

2175-03-01 00:00:00

2175-03-01 12:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Malfunctioning DBS batteries. Major Surgical or Invasive Procedure: ___- Bialteral removal and replacement of DBS internal pulse generators. History of Present Illness: Mr. ___ is a ___ y/o gentleman with a long standing history of ___ who has been managed with DBS for aprox ___ years. Per patient's wife the patient has had a subacute decline over the past few months and in the past three weeks the patient has had a significant decline and has been unable to swallow solid foods w/o vomiting. His wife took him to ___ because of their proximity to the hospital. Patient was admitted to ___ from ___ for care. Records from ___ state that the patient has had a rapid decline over the past two weeks. He was previously able to ambulate with two person assist, but now is bed or chair bound with increased dysphagia complicated by choking, gagging and occasional emesis. Patient has a history of complicated UTIs and is followed by urology. Wife stated at the time of admission to ___ that the patient's presentation was much like his UTIs. patient underwent a fever ___ and had pyuria and urine cultures that grew low CFU enterococcus, he was treated with IV ampicillin, but his mental status did not improve. Neurology was consulted at ___ and his DBS batteries were interrogated and his left chest wall unit was found to be completely depleted and the right unit was low. At this time Neurosurgery was consulted and was prepared to replace the batteries, but patient's wife request transfer to ___ for continuity of care and to have Dr. ___ the surgery. Past Medical History: BPH ___ Disease Urge Incontinence Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: Gen: cachetic HEENT: NcNT Neck: UA Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic, non verbal, not making eye contact or following commands. Attempts to mumble inaudible words. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,4 to 3 mm bilaterally. Remainder of exam difficult to asses Motor: Some rigidity in all four extremities, able to maintain arms off the bed briefly with assistance, some spontaneous movement of the lowers L>R PHYSICAL EXAMINATION ON DISCHARGE: Gen: cachetic HEENT: NcNT Neck: UA Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic, non verbal, not making eye contact or following commands. Attempts to mumble inaudible words. Cranial Nerves: Patient is non-verbal but follows commands. Pupils equally round and reactive to light, 3-2 mm bilaterally. Motor: Rigidity in all four extremities, able to maintain arms and legs off the bed briefly with assistance Chest wall incision has steri strips placed over it. Clean, dry and intact. Pertinent Results: Cardiovascular Report ECG Study Date of ___ 2:38:26 ___ Sinus rhythm with baseline artifact. Frequent atrial premature depolarizations. Low QRS voltage in the limb leads. Diffuse non-specific repolarization abnormalities. No previous tracing available for comparison. TRACING #1 Read by: ___ Intervals Axes Rate PR QRS QT/QTc P QRS T 83 0 84 404/444 0 0 -30 ________________________________________________ Cardiovascular Report ECG Study Date of ___ 9:31:56 ___ Sinus rhythm with frequent atrial premature depolarizations and baseline artifact. Compared to the previous tracing there is no diagnostic change. TRACING #2 Read by: ___ Intervals Axes Rate PR QRS QT/QTc P QRS T 79 0 94 ___ __________________________________________________ Radiology Report CHEST (PORTABLE AP) Study Date of ___ 6:58 ___ FINDINGS: Nasogastric tube tip terminates at the thoracoabdominal junction, with the side port several cm above this level. Cardiomediastinal contours are stable in appearance with persistent tortuosity of the thoracic aorta. Lungs are grossly clear, and there are no pleural effusions or pneumothoraces Radiology Report CHEST (PORTABLE AP) Study Date of ___ 12:35 ___ FINDINGS: As compared to the recent radiograph of 1 day prior, a nasogastric tube has been advanced into the stomach, but the side port is still above the level of the diaphragm. No other changes since recent study. Radiology Report CHEST (PORTABLE AP) Study Date of ___ 4:37 ___ IMPRESSION: Nasogastric tube is been advanced, now ends in the upper stomach with also reports beyond the gastroesophageal junction. Heart normal. Lungs clear. No pleural abnormality. Bilateral pectoral generators send leads superiorly and of view. Radiology Report PORTABLE ABDOMEN Study Date of ___ 10:32 AM IMPRESSION: Preliminary Report: NG tube terminates over the stomach. No evidence of bowel obstruction. ___ CXR As compared to ___ radiograph, pulmonary vascular congestion has developed. Additionally, a new patchy bibasilar opacities are present, and may correspond to provided clinical history of acute aspiration event. Followup radiographs are suggested to evaluate for resolution. ___ CXR There has been interval appearance of mild pulmonary and interstitial edema. In addition, there is increasing consolidation in the retrocardiac region which would be concerning for aspiration pneumonia. There is likely a small left effusion. No pneumothorax. Overall cardiac and mediastinal contours are unchanged. Stimulator generators overlie both upper lungs limiting evaluation in this vicinity. Brief Hospital Course: The patient was transferred from ___ to the Emergency Department at ___ on ___ with malfunctioning bilateral DBS batteries. He was admitted and underwent a pre-operative evaluation in anticipation for going to the operating room the following day. On ___, the patient underwent a bilateral removal and replacement of DBS internal pulse generators. He tolerated the procedure well and was transferred to the PACU from the operating room for close monitoring. His pulse generators were reprogrammed. On ___, his urine cultutre grew yeast, but his WBC was 7 and he was afebrile. After talking to ID, there was no need for treatment. His foley was replaced with a new foley. The patient was neurologically unstable. The Nutritionist reccomended a nasogastric tube for feedings. The patient was alert but uncooperative. Placement of a peg tube for feeding was discussed as the patient had not recieved any nutrition for the past one week. A nasogastric tube was placed but patient pulled it back and tybe feedings were unable to be initiated. On ___, The ___ Gastric tube was advanced. The Acute Care Service was consulted for PEG tube placement. Subcutaneous heparin was held for elevated INR. The foley catheter was not exchanged due to clots and bleeding into urine. The intravenous fluid was increased and the foley catheter irrigated. On ___, The patients K and magnesium were repleated. The patient's left chest wall incision draining sanguinous drainage. A urine analysis was resent with plan to not change out the foley given recent clots and bleeding noted in urine. The patient was made NPO at midnight for peg tube by acs in am. On ___, The patient was mobilized oob to chair. The serum potassium was low and was repleated. The INR was stable at 1.6. The foley catheter was discontinued and at 1800 the bladder was scanned for 1 liter. A foley catheter was replaced. A urine analysis was resent for culture and was consistent with NO GROWTH. The phosphorus was repleated. On ___, The INR was 1.8. The patient went to the OR to have a peg placed by the ___ team. On ___ TF were restarted. INR 2.2. Hematology curbsided- given long period of poor nutrition this is likely the cause of elevated INR. Recommended repeating level in a few days. They did not recommend no reversal of INR and recommended to continue holding SQH upon discharge. On ___ Seroquel was started for agitation. On ___ Febrile to 100.3 axillary overnight. TF noted in patient mouth. New O2 requirement. CXR revealed Development of pulmonary vascular congestion. Additionally, a new patchy bibasilar opacities are present, and may correspond to provided clinical history of acute aspiration event. Medicine was consulted who recommended repeat CXR in 24 hours. On ___, CXR consistent with pulmonary edema but no obvious focal opacity to suggest a pneumonia. Patient was stable on room air, afebrile, downtrending WBC. As such, he was started on gentle diuresis and maintenance IV fluids were turned off in order to keep him net negative. On ___ His tube feeds were restarted. Cleared for discharge from a medical standpoint. Wrist restraints were discontinued. ___, Mr. ___ was discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES DAILY 2. Finasteride 5 mg PO DAILY 3. Amantadine Syrup 100 mg PO BID 4. Myrbetriq (mirabegron) 50 mg oral qd 5. Oxybutynin 2.5 mg PO BID 6. Hyoscyamine 0.125 mg SL BID Discharge Medications: 1. Amantadine Syrup 100 mg PO BID 2. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES DAILY 3. Finasteride 5 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN PAIN 5. Bisacodyl 10 mg PO/PR DAILY 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID:PRN mouth care 7. Docusate Sodium 100 mg PO BID 8. Heparin 5000 UNIT SC TID 9. HydrALAzine 20 mg IV Q6H:PRN for SBP > 160 10. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN agitation 11. Ondansetron 4 mg IV Q8H:PRN vomiting / nausea 12. QUEtiapine Fumarate 12.5 mg PO BID 13. Senna 8.6 mg PO BID 14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: ___ Disease 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: You are being discharged after undergoing a DBS battery change. ¨ Have a friend/family member check your incision daily for signs of infection. ¨ Take your pain medicine as prescribed. ¨ Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨ Dressing may be removed on Day 2 after surgery. ¨ **Your wound was closed with non-dissolvable sutures then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ¨ Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ¨ Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ¨ Clearance to drive and return to work will be addressed at your post-operative office visit. ¨ Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨ New onset of tremors or seizures. ¨ Any confusion or change in mental status. ¨ Any numbness, tingling, weakness in your extremities. ¨ Pain or headache that is continually increasing, or not relieved by pain medication. ¨ Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ¨ Fever greater than or equal to 101.5° F. Followup Instructions: ___

10057009-DS-10

DS

2150-02-12 00:00:00

2150-02-15 12:41:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH of HTN, HLD who presents with cough and SOB. This has been developing over several weeks. She denies fever, chills. Found to have an elevated BNP to >15000 with EKG showing atrial fibrillation, LAD, mildly prolonged QRS c/w LAFB, 1mm STE in III with STD in I - unchanged from prior; TWI in V1-V5, new from prior, w/ new T wave flattening in II, V6. Trops x 3 negative. Also found to have hyponatremia to 129. Started on IV heparin for ? ACS vs. afib, transitioned to apixiban. ECHO pending. Getting IV diuresis Past Medical History: 1. Hypertension. 2. Osteoarthritis. 3. Hypercholesterolemia. Social History: ___ Family History: Father had prostate surgery at ___ years and passed away at ___. Mother died at a younger age with MI, a brother had myocardial infarction as well and he was a smoker. No history of dementia in the family. Physical Exam: ADMISSION EXAM: Physical Exam: Vitals- T:97.3 BP:128 87 HR:94 RR:16 O2:94 RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE EXAM: Vitals- T:98.2 BP:107-126/65-84 HR:80's RR:16 O2:95 RA General- Alert, oriented, sitting up in bed and eating breakfast. No acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, 1+ edema in lower extremities bilaterally. Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 07:39PM ___ PO2-39* PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 ___ 07:39PM LACTATE-2.2* ___ 07:30PM ALT(SGPT)-47* AST(SGOT)-65* ALK PHOS-94 TOT BILI-1.1 ___ 07:30PM ___ ___ 07:30PM CALCIUM-9.4 MAGNESIUM-2.0 ___ 07:30PM ___ ___ 05:25PM GLUCOSE-106* UREA N-22* CREAT-0.9 SODIUM-129* POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-17* ANION GAP-23* ___ 05:25PM estGFR-Using this ___ 05:25PM cTropnT-<0.01 ___ 05:25PM CALCIUM-9.4 MAGNESIUM-2.1 ___ 05:25PM WBC-9.7 RBC-4.90 HGB-13.8 HCT-42.6 MCV-87# MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-44.0 ___ 05:25PM NEUTS-69.7 ___ MONOS-9.1 EOS-0.1* BASOS-0.2 IM ___ AbsNeut-6.78* AbsLymp-1.99 AbsMono-0.88* AbsEos-0.01* AbsBaso-0.02 ___ 05:25PM PLT COUNT-210 DISCHARGE LABS: ___ 06:00AM BLOOD WBC-5.6 RBC-4.40 Hgb-12.7 Hct-39.0 MCV-89 MCH-28.9 MCHC-32.6 RDW-14.7 RDWSD-45.8 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 03:24PM BLOOD Glucose-116* UreaN-25* Creat-1.1 Na-136 K-5.1 Cl-99 HCO3-24 AnGap-18 ___ 03:24PM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0 Imaging: IMPRESSION: Limited exam without definite acute cardiopulmonary process. Specifically, no visualized focal consolidation concerning for pneumonia. Brief Hospital Course: Ms. ___ is an ___ with PMH of HTN, HLD who presented to the ___ ED with cough and DOE for 2 weeks. She was found to have hyponatremia, an elevated AG, changes on ECG concerning for ischemia, new onset atrial fibrillation and elevated BNP concerning for CHF. She was discharged on ___. # Dyspnea/cough: most likely multifactorial, related to new AF, possibly cardiac ischemia and some element of volume overload given elevated BNP. Of note pt endorsed a chronic dry cough for years which was, per notation by cardiology likely related to lisinopril. This episode was more acute. However, we changed to losartan to simplify future clinical presentations. CXR did not show evidence of pulmonary edema or infection, though exam was limited given patient's habitus w/kyphosis. Possibly new diagnosis of CHF, perhaps provoked by cardiac ischemia (see below) vs. tachycardia induced cardiomyopathy in the setting of AF and h/o of intermittent palpitations with PACs. The latter seems less likely as patient's HR has been controlled throughout admission and she is on metoprolol at baseline. Lactate was slightly elevated to 2.2 on admission, at 1.4 on ___. Acutely decompensated CHF was less likely as she was warm on exam. Beta blockers were continued. Prior cardiology note described cough as possibly being ACEI-induced. She was switched from lisinopril to losartan given concern for ACEI-induced cough. She was given IV Lasix 10 mg boluses and had good urine output. She will need a TTE as an outpatient and cardiology follow up. Patient stated if she were to have evidence of ischemia on her echo she would not want a stent, however with son in the room he stated she did not fully understand the implications. They had many questions which will need to be concretly and clearly stated at follow up visits. -started on 10mg furosemide -pt with follow up ___ for weight, lytes. # Atrial Fibrillation: patient with AF on ECG at presentation and was never noted on prior ECGs. Patient does have history of "skipped beats" for which she was evaluated by cardiology and treated with metoprolol. It is possible that this may have represented AF, not captured on ECG. Her current presentation may be AF-provoked in the setting of CHF vs. cardiac ischemia or vice versa. Patient with CHADSVASC 4 given age, HTN and female sex. Heparin was initiated on admission for anticoagulation. She was switched to apixaban 2.5 mg BID and continued on home metoprolol. # TWI on ECG: patient had TWI on ECG at admission, may be rate related changes in the setting of new AF vs. related to cardiac ischemia. She was without symptoms of chest pain, but did have DOE. Trops x 3 were negative, MB 7. In discussion regarding further work-up, patient indicated that she would not like to have any invasive procedure should she be found to have CAD. She was continued on ___, statin. Will follow up with her cardiologist as an outpatient. # Hyponatremia: her hyponatremia on admission was likely hypervolemic in the setting of elevated BNP and possible volume overload. She had a prior history of hyponatremia which was attributed to poor PO intake and improved with IVF. Na was 129 on admission and improved to 137 on ___ with diuretics. # Transaminitis: Elevated AST and ALT on admission, possibly due to congestion in the setting of possible CHF. Transaminitis resolved on ___. # Elevated AG: Patient with AG 18 on admission that resolved on ___. Had normal pH on VBG. Lactate was slightly elevated. Delta/Delta 1 suggestive of pure AG process. Evaluated with serum ___ to r/o salicylate toxicity in the ED, which was negative. Patient with no history of other exposure of ingestion. Other possible etiology is ketonemia in the setting of decreased PO intake. This resolved on admission. # Hypertension: H/o HTN. Swtiched from lisinopril 10 mg to losartan 50 mg given concern for ACE-induced cough. # HLD: Continued on statin. Transitional Issues: - Will need outpatient ECHO for ? diagnosis of CHF - Discussed with patient and son the need for assistance with ___ services, however, declined at this time over what he described were privacy issues of the patient and would need to discuss slowly over time. We would like to be offered this option at a later time. - Provided with a script for outpatient ___ - Will need outpatient cardiology evaluation and possible stress test # CODE STATUS: Full Name of health care proxy: ___ Relationship: sons Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Simvastatin 5 mg PO HS 4. Vitamin D 800 UNIT PO DAILY 5. ammonium lactate 12 % topical DAILY:PRN 6. Ketoconazole 2% 1 Appl TP BID 7. Metoprolol Succinate XL 75 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NS DAILY RX *fluticasone 50 mcg/actuation 1 spray nasal daily each nare Disp #*1 Spray Refills:*0 3. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 4. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. ammonium lactate 12 % topical DAILY:PRN 6. Aspirin 81 mg PO DAILY 7. Ketoconazole 2% 1 Appl TP BID 8. Metoprolol Succinate XL 75 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN constipation 10. Simvastatin 5 mg PO HS 11. Vitamin D 800 UNIT PO DAILY 12.Outpatient Physical Therapy ___ with PMH of HTN, HLD who presents with cough and SOB, new dx of afib Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation Hypervolemia 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 ___ with trouble breathing and a cough. We found you to have extra fluid in your body so we gave you an intravenous form of the water pill to help you pee it out. We thought your cough might be related to one of your medications, called lisinopril, so we switched it to another blood pressure medication, losartan. You were also found to have an abnormal heart rhythm called atrial fibrillation. We started you on a medication called Eliquis (apixaban)to thin out your blood and decreases your risk of having a stroke. It was a pleasure caring for you. Wishing you the best, Your ___ Team Followup Instructions: ___

10057482-DS-12

DS

2145-04-26 00:00:00

2145-04-26 13:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: sulfa drugs / Coumadin / lisinopril / Celebrex Attending: ___ Chief Complaint: Fatigue, weakness, dyspnea on exertion Major Surgical or Invasive Procedure: ___: Emergent Right femoral cannulation, Emergent repair of type A dissection with 30mm straight gelweave graft with sidebranch. Repair of small liver laceration. ___: Chest re-exploration and washout, sternal closure ___: Percutaneous tracheostomy (8 cuffed tracheostomy), percutaneous endoscopic gastrostomy tube (___) ___: RUE PICC placement (Hub Rt. ___. 40 cm. DLumen) History of Present Illness: Ms. ___ is an ___ year old woman with a history of amyloid angiopathy, atrial fibrillation, cerebrovascular accident, hypertension, osteoarthritis, and Sjogren's syndrome. She presented to ___ with back pain radiating to her left arm and jaw. She underwent a CTA of the chest and abdomen. The visualized portion of the ascending thoracic aorta is dilated measuring up to 6.3 cm. An intimal flap is also seen at the visualized portion of the ascending thoracic aorta. Great vessels are not evaluated. She was transferred to ___ for surgical intervention. Past Medical History: Amyloid Angiopathy Atrial Fibrillation Cerebrovascular Accident with left sided weakness/pronator drift Chronic Back Pain Hyperlipidemia Hypertension Osteoarthritis Peripheral Neuropathy Rheumatic Fever Sjogrens Syndrome PSH: Breast biopsy x 2 (negative) Ex-lap for SBO Lumbar surgery ___ Social History: ___ Family History: Mother - died ___ ? cause Father - died ___ with skin ca and ___ stroke Sibs - 1 brother ___ on dialyssi for renal failure, sister age ___ Children - 2 sons with T1dm and 1 daughter with T2DM and has had some seizures There is no history of developmental disability, learning disorders, migraine headaches, strokes less than 50, neuromuscular disorders, dementia or movement disorders. Physical Exam: Admission Exam: BP: 74/40, HR 100 General: 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 [x] ___none__ Varicosities: None [x] Neuro: Left sided upper and lower extremity weakness Pulses: DP Right: 2+ Left: 2+ ___ Right: 2+ Left: 2+ Radial Right: 1+ Left: 1+ Discharge Exam: 110/49 79SR 16 95% trach collar . General: NAD [x] Neurological: Moves all extremities spontaneously[x] Chemically paralyzed [] sedated [] Follows commands: weak L hand grasp and bilat toe wiggle/extension [x] HEENT: PEERL [x] MMM[x] Cardiovascular: RRR [x] Irregular [] Murmur, II/VI upper LSB [x] Respiratory: Clear but decreased L>R [x] No resp distress [x] Intubated [] trach site c/d/I [x] increased secretions [x] GU/Renal: Urine clear [x] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] mild tenderness w/deep palp LUQ [x] flexiseal ___ place [x] PEG c/d/i-no erythema [x] Extremities: Right Upper extremity Warm [x] Edema tr Left Upper extremity Warm [x] Edema tr Right Lower extremity Warm [x] Edema tr Left Lower extremity Warm [x] Edema tr Pulses: DP Right:1 Left:1 ___ Right:1 Left:1 Radial Right:1 Left:Aline ___ place Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] R SC TLC: c/d/I [x] Pertinent Results: STUDIES: PA/LAT CXR ___ (Preliminary): RUE PICC line placed with tip ___ mid SVC. PA/LAT CXR ___ ___ comparison with the study ___, the monitoring support devices are unchanged, as is the left pleural effusion with compressive basilar atelectasis and enlargement of the cardiac silhouette. Indistinctness of pulmonary vessels is consistent with some elevation of pulmonary venous pressure. Chest CTA ___ 1. Type A dissection originating at the aortic root with extension into the right brachiocephalic and extending into the abdomen, inferior extent not included on the images. On this study, extends beyond the SMA. Relative decreased enhancement of the left kidney and left adrenal gland suggests that they are supplied by the false lumen. 2. Small to moderate amount of hemopericardium. Mediastinal blood/hematoma exerts mass-effect with resultant narrowing of the main left and right pulmonary arteries. No active extravasation seen. Transesophageal Echocardiogram ___ PRE-OPERATIVE STATE: Sinus rhythm. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Normal RA size. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Moderate symmetric hypertrophy. Normal cavity size, though the ventricle is significantly underfilled. Normal regional & global systolic function Normal ejection fraction. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: SEVERE ascending dilation. Type A ascending, arch and descending DISSECTION. Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet calcification. Mild (>1.5cm2) stenosis. Mild-moderate [___] regurgitation. Central jet. The dissection flap does not involve the aortic valve. Mitral Valve: Normal leaflets. No stenosis. Moderate annular calcification. Mild [1+] regurgitation. Central jet. Tricuspid Valve: Normal leaflets. Pericardium: Moderate effusion. RA systolic collapse/early tamponade. Miscellaneous: Left pleural effusion. POST-OP STATE: The TEE was performed at 21:00:00. Atrial fibrillation. Support: Vasopressor(s): epinephrine. Left Ventricle: Similar to preoperative findings. Global ejection fraction is normal. LV remains underfilled. Right Ventricle: New/worse global dysfunction. RV function is mildly depressed. Aorta: Aortic tube graft ___ position. Dissection ___ aortic arch and descending aorta unchanged. Aortic Valve: No change ___ aortic valve morphology from preoperative state. No change ___ aortic regurgitation. Mitral Valve: No change ___ mitral valve morphology from preoperative state. No change ___ valvular regurgitation from preoperative state. Pericardium: No effusion. Miscellaneous: No pleural effusions. Notification: The surgeon/proceduralist was notified of the findings at the time of the study. Renal Artery Ultrasound ___ Magnitude of vascularity of the left kidney is lower on the left than on the right, suggesting the left renal artery arises from the false lumen and right renal artery from the true lumen as seen on prior CT imaging. However, it was not possible to directly visualize the renal artery origins sonographically due to poor visualization at this time. Left upper extremity ultrasound ___ 1. Deep vein thrombosis with complete occlusion of flow involving the mid to low left internal jugular vein. 2. No evidence of additional deep vein thrombosis ___ the left upper extremity. MR ___ ___ 1. Numerous, scattered acute or early subacute infarcts, majority of which are punctate, however there is a larger approximately 3.0 cm left frontal area of acute or early subacute infarct. No evidence of hemorrhagic conversion. Chronic lacunar infarcts are also noted. 2. Innumerable areas of susceptibility on gradient echo imaging, compatible with amyloid angiopathy. 3. Moderate paranasal sinus disease, as detailed above, including air-fluid levels, suggestive of acute sinusitis. ___ CT ___ 1. Evolving acute infarct ___ the left frontal lobe. No evidence of hemorrhagic conversion. 2. Additional smaller infarcts ___ the bilateral cerebral hemispheres and cerebellar hemispheres are better appreciated on prior MRI. Chest CT ___ 1. Multifocal bilateral ground-glass, nodular opacities and consolidation ___ both lower lobes, worse on the left are likely secondary to multifocal pneumonia. 2. New small bilateral pleural effusions. 3. Type A aortic dissection incompletely characterized ___ this study, with new hyperdense material at the ascending aorta, likely related to the repair. Atherosclerotic plaque CT outline the true lumen ___ the remainder thoracic aorta which appears not significantly changed ___ caliber from prior. Chest CT ___ 1. Nodular peribronchovascular airspace disease ___ the dependent aspect of the right upper lobe and basal aspects of the right middle and lower lobes most likely represents bronchopneumonia. The overall disease burden is decreased (especially ___ the dependent aspect of the right upper lobe) compared to prior CT studies. 2. Please note that it is difficult to differentiate atelectasis from consolidation on a non contrasted study. However, airspace opacification ___ the dependent aspect of the left upper lobe and superior segment of the left lower lobe most likely represents atelectasis. Ground-glass airspace opacification ___ the left lower lobe is nonspecific. 3. Small left-sided pleural effusion. 4. Patient is status post aortic root repair. Residual post dissection changes are difficult to assess on a noncontrast study. CT Aorta and branches ___ The aorta measures 3.5 cm ___ the proximal portion, 3.5 cm ___ mid portion and 3.4 cm ___ the distal abdominal aorta. There is suboptimal visualization of the mid and distal aorta due to overlying bowel gas, tortuosity of the aorta, and body habitus. The known aortic dissection is re-demonstrated. There is echogenic material within the distal aorta which is consistent with thrombus, however size comparison to prior exam is difficult due to limited sonographic windows. The iliac arteries are not visualized. IMPRESSION: Technically limited assessment of the distal abdominal aorta however intraluminal echogenic material corresponds to the known thrombus, however size comparison is difficult. If further comparison is desired and the patient cannot tolerate a CTA, non-contrast MRI with multiplanar imaging could be performed. MICRO: ___ 1:08 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 CFU/mL. YEAST. ___ CFU/mL. ___ 11:15 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. ___ 8:39 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. >100,000 CFU/mL. ___ 9:41 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. ~5000 CFU/mL. ___ 11:30 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. MODERATE GROWTH. ASPERGILLUS FUMIGATUS COMPLEX. SUSCEPTIBILITIES REQUESTED PER ___ ___ (___) ON ___. Refer to sendout/miscellaneous reporting for results. SENT TO ___ ON ___. LABS: Admit: ___ 02:05PM BLOOD WBC-10.7* RBC-3.83* Hgb-10.8* Hct-34.4 MCV-90 MCH-28.2 MCHC-31.4* RDW-14.2 RDWSD-46.2 Plt ___ ___ 02:05PM BLOOD ___ PTT-27.2 ___ ___ 08:15AM BLOOD HIT Ab-NEG HIT ___ ___ 08:15AM BLOOD HIT Ab-NEG HIT ___ ___ 02:05PM BLOOD Glucose-141* UreaN-21* Creat-0.9 Na-137 K-4.7 Cl-103 HCO3-20* AnGap-14 ___ 03:45AM BLOOD ALT-12 AST-40 LD(LDH)-476* AlkPhos-27* Amylase-23 TotBili-0.7 ___ 03:26PM BLOOD Lipase-1429* ___ 03:45AM BLOOD Albumin-2.5* Calcium-8.7 Phos-3.7 Mg-2.4 ___ 08:15AM BLOOD Triglyc-187* ___ 03:00AM BLOOD Cortsol-20.9* Discharge: ___ 03:04AM BLOOD WBC-10.0 RBC-2.64* Hgb-7.9* Hct-25.6* MCV-97 MCH-29.9 MCHC-30.9* RDW-16.5* RDWSD-56.2* Plt ___ ___ 03:04AM BLOOD ___ PTT-85.3* ___ ___ 12:52AM BLOOD ___ PTT-68.7* ___ ___ 02:06AM BLOOD ___ PTT-66.2* ___ ___ 09:38AM BLOOD ___ PTT-70.2* ___ ___ 02:40AM BLOOD ___ PTT-82.5* ___ ___ 01:37PM BLOOD ___ PTT-76.1* ___ ___ 03:03AM BLOOD ___ PTT-77.7* ___ ___ 03:04AM BLOOD Glucose-126* UreaN-45* Creat-0.8 Na-139 K-4.3 Cl-99 HCO3-24 AnGap-16 ___ 12:52AM BLOOD Glucose-147* UreaN-51* Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-25 AnGap-15 ___ 02:06AM BLOOD ALT-16 AST-24 LD(LDH)-259* AlkPhos-97 Amylase-368* TotBili-0.2 ___ 03:08AM BLOOD ALT-8 AST-19 LD(LDH)-390* AlkPhos-69 Amylase-716* TotBili-0.6 ___ 02:06AM BLOOD Lipase-403* ___ 02:58PM BLOOD Calcium-8.3* Phos-4.8* Mg-1.8 Brief Hospital Course: She was admitted emergently on ___. A CTA of the chest confirmed a type A dissection originating at the aortic root with extension into the right brachiocephalic and extending into the abdomen. On this study, extends beyond the SMA. Relative decreased enhancement of the left kidney and left adrenal gland suggests that they are supplied by the false lumen. She was taken to the operating room and under went Emergent repair of type A dissection with 30mm straight gelweave graft with sidebranch and repair of small liver laceration. Please see operative note for full details. She tolerated the procedure and was transferred to the CVICU on multiple pressors and inotropes and paralytics with an open sternotomy for recovery and invasive monitoring. She was volume overloaded on arrival and was started on a Lasix infusion for aggressive diuresis. She returned to the OR for chest closure on ___. She was weaned off of paralytics and sedation. The patient remained lethargic and given her prior history of CVA neurology was consulted. An MRI was obtained which revealed a frontal CVA. A follow up ___ CT showed no evidence of hemorrhagic conversion. Given her embolic CVA, evidence of left IJ thrombus on ultrasound and clot seen on CTA ___ the abdominal aorta, she was started on heparin. The patient's mental status continued to wax and wane and she had persistent encephalopathy and weakness. On ___ an EEG showed discharges consistent with early seizure activity. She was loaded with Keppra. A repeat CT did not show evidence of further CVA. The patient developed fevers and cultures were sent. A chest CT showed evidence of PNA and she had continued difficulty weaning from the ventilator. She was started on empiric Vanco/Cefepime which was then narrowed to an empiric course of cefepime per the ID team. She grew Aspergillus from sputum cultures and the decision was made to treat this with Voriconazole then changed to Isavuconazole due to a prolonged QTc. Cefepime was stopped due to her seizure activity. She was extubated on ___ however she became acutely short of breath and was reintubated. Given her other comorbities the decision was made to proceed with Trach/PEG on ___. She gradually continued with trach collar trials. She has a history of atrial fibrillation and developed intermittent atrial fibrillation that was treated with Lopressor, Amiodarone was held due to prolonged QTc. During this prolonged ICU stay she also developed ___. Nephrolgy was also consulted, her diuretics were limited and she was started on free water flushes via PEG. Slowly her renal function trended back to her baseline levels. She continues to receive free water flushes for hypernatremia. She continues to be encephalopathic but this has been improving slowly, she is responsive and follows some simple commands. She has been tolerating progressively longer periods of time on trach collar (daytime trials began ___ and she began 24h ATC TC ___. She is ___ sinus rhythm and has not had any post-op Afib for several weeks. Her anticoagulation is for afib/DVT and aortic thrombus, continues on heparin bridging and slowly being converted to Coumadin. Goal INR is ___, goal PTT is 50-70. She is tolerating her tube feeds, did have elevated pancreatic enzymes initially. These trended down when she was placed on elemental tube feeds and have continued to trend down for the past 2 weeks. She had yeast ___ both BAL and urine and was started on antifungals (Isavuconazole), this therapy will continue for 6 weeks from start date of ___ with end date ___ and she requires weekly CBC/LFTs per ID recs. Regarding her Keppra and Coumadin duration, these will be reviewed by her neurologist Dr. ___ at a 1 month ___ clinic visit with CTA Torso. She will also need 1 month clinic visit with Vascular team. On, ___ LUE PICC was attempted but could not thread wire and then successfully placed RUE PICC. CXR at that time showed L collapse, so recruitment maneuver done and placed back on PEEP 10. Speech recommdation is that she will likely need trach downsize prior to tolerance of PMV. She was discharged POD 34 to ___ ___ ___ with follow up instructions. Medications on Admission: 1. Diltiazem Extended-Release 180 mg PO Q12H 2. Gabapentin 300 mg PO BID 3. Gabapentin 600 mg PO QHS 4. amLODIPine 1.25 mg PO DAILY 5. Simvastatin 10 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze 4. Artificial Tears GEL 1% 1 DROP BOTH EYES Q4H 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 8. Glucose Gel 15 g PO PRN hypoglycemia protocol 9. HydrALAZINE 10 mg IV Q6H:PRN HTN 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 12. Isavuconazonium Sulfate 372 mg PO DAILY Aspergillus PNA Duration: 6 Weeks start date ___ expected finish date ___ 13. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 14. LevETIRAcetam 500 mg PO Q12H 15. Metoprolol Tartrate 25 mg PO TID Hold for HR<60,SBP<90 16. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash 17. Nystatin Oral Suspension 5 mL PO TID 18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 19. Ramelteon 8 mg PO QHS:PRN insomnia 20. Senna 8.6 mg PO BID:PRN Constipation - First Line 21. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 22. ___ MD to order daily dose PO DAILY16 23. Warfarin 5 mg PO ONCE Duration: 1 Dose (h/o: postop Afib, aortic thrombus and LIJ DVT) goal INR ___ 24. Simvastatin 10 mg PO QPM 25. HELD- Aspirin 325 mg PO DAILY This medication was held. Do not restart Aspirin until cleared by neurology (Dr. ___ 26. HELD- Diltiazem Extended-Release 180 mg PO Q12H This medication was held. Do not restart Diltiazem Extended-Release until you see cardiologist Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: Type A Aortic Dissection s/p ascending aortic replacement Hosp acquired pneumonia/Resp failure s/p trach & PEG placement Acute kidney injury CVA-left frontal infarct w/associated seizure activity postop Atrial Fibrillation Deep Vein Thrombosis Liver Laceration Hypernatremia Aspergillus Pneumonia elevated Pancreatic enzymes Secondary: PMH: CVA(left sided weakness/pronator drift), Sjogrens syndrome, HLD, HTN, peripheral neuropathy. PSH: Ex-lap for SBO, Lumbar surgery ___, breast biopsyx2 (negative) Discharge Condition: Neuro: opens eyes to voice, moves UE spontaneously, lightly squeezes both hands Full care and lift Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace PICC RUE- c/d/i 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 ___ 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** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: ___

10057731-DS-7

DS

2155-12-13 00:00:00

2155-12-19 09:09:00

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, jaundice Major Surgical or Invasive Procedure: ERCP/EUS with biopsies and Biliary stenting ___ History of Present Illness: ___ yo M with seizure disorder and chronic low back pain who presents with abdominal pain and jaundice. Pt reports abdominal pain that started in the LUQ on ___ and progressed to include the RUQ over the following day. He noticed that he was jaundiced on ___ w/ tea colored urine and pale stools. He also endorses pruritus. He went to the ED at ___ on ___ and reportedly was found to have a mass at the head of the pancreas and hepatic lesions. He saw his PCP today who referred him to ___ for evaluation. In the ED, pt afebrile w/ WBC 8.5k. Labs notable for ALT 79, AST 43, Alk 829, Tb 22.6. ERCP was consulted who recommended NPO for ERCP tomorrow and antibiotic ppx w/ cipro/flagyl. Pt otherwise denies any weight loss, chronic abdominal pain, or diarrhea. ROS: As above. Denies headache, lightheadedness, dizziness, sore throat, sinus congestion, chest pain, heart palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, constipation, urinary symptoms, muscle or joint pains, focal numbness or tingling, skin rash. The remainder of the ROS was negative. Past Medical History: PMHx: - Distant ex-lap ___ stabbing - chronic back pain w/ prior lumbar discectomy - seizure disorder, currently off meds - HTN - depression Social History: ___ Family History: No family history of GI illness or malignancy. Pertinent Results: HBsAg: NEG HBs Ab: NEG HBc Ab: NEG HAV Ab: NEG Hep C Ab: POS** --> Viral load negative *Cytology Pending ___ ALT: 48* AST: 37 AlkPhos: 649* TotBili: 24.4* ___ ALT: 46* AST: 51* AlkPhos: 587* TotBili: 23.9* MRCP ___: Results IMPRESSION: 1. 6.0 cm centrally necrotic mass in the tail the pancreas obliterating the splenic vein, intimately associated with the splenic artery, and abutting but not clearly involving the inferior aspect of the stomach, consistent with primary pancreatic neoplasm. No extension to the splenic hilum. 2. Numerous hepatic metastases including to the hepatic hilum causing diffuse intrahepatic biliary ductal dilation and multifocal areas of intrahepatic iliary ductal tree stricturing, including involving the left and right anterior and posterior hepatic ducts as well as more distal segmental biliary tree branches. 3. Peribiliary enhancement is concerning for superimposed cholangitis. 4. Enlarged periportal lymph nodes are concerning for nodal metastases. 5. Right portal vein is occluded. Patent left and main portal vein. Patent SMV. 6. Upper abdominal varices are noted including along the lesser curvature of the stomach. No splenomegaly or ascites. 7. 2 cm right adrenal adenoma. Other incidental findings, as above. ERCP ___ The scout film was normal. •There was mild duodenitis. •The bile duct was deeply cannulated with the sphincterotome. •Contrast was injected and there was brisk flow through the ducts. •Contrast extended to the entire biliary tree. The CBD was 6 mm in diameter. •Opacification of the gallbladder was incomplete. •There was evidence of a hilar stricture involving both the CHD, as well as left and right main intrahepatic ducts. •The total length of the stricture was 3 cm. •This is compatible with a Type IV hilar stricture. •A biliary sphincterotomy was made with a sphincterotome. •There was no post-sphincterotomy bleeding. •Both the right and left IHD were cannulated with wires using standard double-wire technique. •A 6 mm hurricane dilation balloon was used to dilaton the right and left main ducts as well as CHD. Cytology brushings of the hilum were performed. •A ___ x 15 cm biliary plastic straight stent was placed into the right IHD. •An 8.5 F x 14 cm biliary plastic straight stent was attempted to be placed into the left IHD but was unable to traverse the stricture and thus was removed with a snare. •A ___ x 14 cm biliary plastic straight stent was then placed into the left main IHD successfully after repeat hurricane dilation with 6 mm balloon. •Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. •Otherwise normal ercp to third part of the duodenum EUS ___ Impression: •A focused EUS was performed using a linear echoendoscope at ___ MHz frequency: The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The body and tail [partially] were imaged from the gastric body and fundus. •Pancreas Tail Mass: A 6 cm X 7 cm ill-defined mass was noted in the tail of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. •FNB was performed of the mass. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge Sharkcore needle with a stylet was used to perform biopsy. Four needle passes were made into the mass. •25 gauge FNA was also performed of the mass with two passes. •No appreciable liver lesions were identified for biopsy. •Otherwise normal upper eus to third part of the duodenum Brief Hospital Course: ___ yo M with h/o HTN, chronic back pain, who presents with jaundice and outside imaging with finding of mass within the pancreas # Necrotic Pancreatic Mass - Pancreatic tail mass with possible metastasis to liver and regional lymph nodes. EUS/ERCP done on ___ and obtained FNA of tumor and cytology brushings of bile duct for pathology (with preliminary findings of adenocarcinoma; Onc aware and will be followed up outpatient). At time of discharge d/c'd home with PO oxycodone for moderate pain (increased from home dose of 10mg to 15mg) # Hyperbilirubinemia and Elevated LFTs - Most likely from mass and obstruction from lymph notes. Stenting ___. To follow up with ERCP team in 4 weeks # Periportal enhancement on MRCP - Possible Cholangitis? Will treat for duration of Cholangitis course ___ days - intervention on ___. Cipro/flagyl - End date ___ # Portal vein thrombosis as above - STarted on heparin ggt due to thrombosis. Restarted on Subcutaneous lovenox prior to discharge. # Hep C Ab + - Viral Load negative # HTN - continue metoprolol 50 daily. Restart losartan and chlorthalidone on discharge # Depression/Anxiety - continue sertraline. Started Alprazolam inpatient due to overwhelming anxiety during diagnosis stage of his pancreatic cancer # Adrenal Adenoma - Incidental 2cm mass. If indicated, repeat imaging in ___ months Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 5. Sertraline 100 mg PO DAILY Discharge Medications: 1. ALPRAZolam 1 mg PO TID:PRN Anxiety RX *alprazolam 1 mg 1 tablet(s) by mouth Three times a day as needed for anxiety Disp #*15 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Every 12 hours Disp #*12 Tablet Refills:*0 3. Enoxaparin Sodium 110 mg SC Q12H RX *enoxaparin 100 mg/mL 110 mg Subcutaneous injecton Every 12 hours Disp #*60 Syringe Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Every 8 hours Disp #*18 Tablet Refills:*0 5. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings RX *nicotine (polacrilex) [Nicorette] 2 mg Every 4 hours as needed for craving Every 4 hours as needed for craving Disp #*60 Lozenge Refills:*0 6. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour 1 patch daily for smoking cravings 1 patch daily for smoking cravings Disp #*30 Patch Refills:*0 7. Chlorthalidone 25 mg PO DAILY 8. Losartan Potassium 25 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 11. Sertraline 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pancreatic Cancer Hyperbilirubinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, You were admitted for abdominal pain and jaundice. It was found that you had a large mass in your pancreas that looks like it had spread to your lymph nodes and to your liver. During you stay you had an MRI of your biliary system and also a procedure called an ERCP in which we took biopsies of your lesion and also brushings of your bile duct. We stented your bile duct so it should be draining OK. The ERCP team want to see you back in 4 weeks to re-evaluate and pull the stent. The final results of the brushings and samples taken will be followed up by oncology. Please expect a call from them or call them within 1 week of discharge. You were also started on Lovenox for a clot in your right portal vein. It was a pleasure being part of your care Your ___ Team Followup Instructions: ___

10058150-DS-11

DS

2161-11-05 00:00:00

2161-11-10 19:21:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old woman with DMII, HTN, HLD, depression/anxiety who presented to the ED after one episode of syncope that lasted minutes in duration while she was eating at a restaurant with family. The patient reports sitting at the table eating with family members when she spontaneously lost consciousness without dizziness or any other prodrome. She denies any other symptoms that she has experienced in recent days. The patient does report decreased PO intake during the days prior to her presentation. No fevers, malaise, cough, N/V, abdominal pain, changes in urination, leg pain, leg swelling. She denies a recent travel history or recent prolonged periods of immobility. There is no evidence that she became incontinent during the syncope event. Past Medical History: Past Medical History -DM -HTN -Hyperlipidemia -Depression -Anxiety -right hip trochanteric bursitis/gluteus medius tendinosis -lumbar spinal stenosis Social History: ___ Family History: No pertinent cardiac history or sudden cardiac death. Physical Exam: Admission Physical Exam = = = = = = = = = = = = = = = = ================================================================ Vitals: 98.2 158/88 105 18 100%RA GENERAL: Pleasant, well appearing Hispanic female. ___ only in NAD. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: irregularly irregular. Normal S1, S2. ___ SEM at LUSB. JVP low LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Normal coordination. Gait assessment deferred Discharge Physical Exam = = = = = = = = = = = = = = = = ================================================================ Vitals: 97.6 130/60 64 18 100%RA Exam: GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, HEART - RRR, nl S1-S2, no significant murmur appreciated LUNGS - CTAB ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c, no edema, 2+ DP pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Labs on Admission = = = = = = = = = = = ================================================================ ___ 07:30PM BLOOD WBC-8.6 RBC-4.26 Hgb-11.7 Hct-39.9 MCV-94 MCH-27.5 MCHC-29.3* RDW-13.6 RDWSD-46.5* Plt ___ ___ 07:30PM BLOOD Neuts-53.5 ___ Monos-9.1 Eos-2.1 Baso-0.8 Im ___ AbsNeut-4.61 AbsLymp-2.90 AbsMono-0.78 AbsEos-0.18 AbsBaso-0.07 ___ 07:30PM BLOOD ___ PTT-35.4 ___ ___ 07:30PM BLOOD Plt ___ ___ 07:30PM BLOOD Glucose-146* UreaN-18 Creat-1.8* Na-134 K-3.8 Cl-96 HCO3-15* AnGap-27* ___ 07:30PM BLOOD ALT-11 AST-14 TotBili-0.3 ___ 07:30PM BLOOD Lipase-66* ___ 07:30PM BLOOD proBNP-2689* ___ 07:30PM BLOOD cTropnT-<0.01 ___ 04:29AM BLOOD cTropnT-<0.01 ___ 07:30PM BLOOD Albumin-4.3 Calcium-11.2* Phos-2.8 Mg-1.5* ___ 07:30PM BLOOD D-Dimer-1365* ___ 11:10PM BLOOD Osmolal-305 ___ 07:30PM BLOOD TSH-4.7* ___ 07:30PM BLOOD ASA-NEG Ethanol-15* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:41PM BLOOD Lactate-9.1* ___ 11:09PM BLOOD Lactate-5.7* Discharge Lab Results = = = = = = = = = = = ================================================================ ___ 05:16AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.0* Hct-32.6* MCV-90 MCH-27.6 MCHC-30.7* RDW-13.7 RDWSD-44.7 Plt ___ ___ 05:16AM BLOOD Plt ___ ___ 05:16AM BLOOD ___ PTT-69.8* ___ ___ 01:10PM BLOOD Na-133 K-5.3* Cl-99 ___ 05:16AM BLOOD Glucose-332* UreaN-22* Creat-1.5* Na-132* K-4.5 Cl-98 HCO3-23 AnGap-16 ___ 05:16AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7 ___ 04:29AM BLOOD PTH-80* ___ 04:29AM BLOOD 25VitD-33 ___ 04:43AM BLOOD ___ pO2-106* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 ___ 04:43AM BLOOD Lactate-1.7 ECHO ___ EF=65% IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild-moderate aortic regurgitation. Mild mitral regurgitation. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. CTA ___. No evidence of pulmonary embolism or aortic abnormality. 2. Dilated main pulmonary arteries suggestive of pulmonary artery hypertension. 3. Although this exam is not tailored for the evaluation of the airways note is made of anterior motion of the posterior membrane of the trachea and narrowing of the left mainstem and right bronchus intermedius which can be seen in the setting of tracheobronchial malacia. 4. Cholelithiasis Brief Hospital Course: ___ female w/PMH significant for HTN, DM, HLD, depression/anxiety who presents by EMS for syncope thought to be due to orthostatic hypotension ___ poor PO intake. # Syncope: Possible etiologies explaining her syncope include neurologic, cardiogenic, and orthostatic. Patient interview and collateral story from family members did not suggest any seizure activity at the time of the syncope and was most consistent with vasovagal event. TTE did not reveal AS, and EKG was notable for sinus rhythm with RBBB and frequent PACs which was unchanged from prior EKGs ___ years ago (provided by PCP's office). The patient was orthostatic upon arrival to the floor, even after receiving 1 liter on IVFs in the ED. The patient was given another liter O/N into hospital day 2. Her orthostatics improved by the time she was discharged such that she was no longer orthostatic with ambulation. Given the patient's RBBB appreciated on EKG in the ED and her syncope, a ddimer was ordered and found to be elevated. Without a another plausible explanation for an elevated ddimer, a PE was ruled out. A V/Q scan was attempted before giving the patient IV contrast, however the results were inconclusive due to inadequate inspiration so a CTA was pursued. The patient was hydrated with IV fluids prior to the start of the study per protocol given her CKD. CTA did not show PE. # Tachycardia: The patient was found to be tachycardic in the ED. This was likely a result of hypovolemia. EKG in the ED was read as AFib with RVR, however subsequent examination with additional EKGs and comparison with prior EKGs suggest the patient has stable sinus rythym with PACs. The RBBB was also stable from prior EKGs. The patient's atenolol was stopped given its dependence on renal clearance and the patient was started on metoprolol. She was monitored on telemetry without evidence of afib or other arrythmia. #CKD: Her baseline Cr is 1.4-1.6 with a GFR of 27. She was given IV fluids before CTA chest per protocol to protect her renal function. She was treated with her home valsartan throughout her hospital stay. At discharge her Cr was stable at 1.5. #hypercalcemia: The patient was admitted with a Ca of 11.2. With an elevated PTH, this would most consistent with primary hyperparathyroidism. Given the patient was not symptomatic during this hospitalization, further workup deferred to the outpatient setting. #Hyperkalemia: The patient was noted to have potassium of 5.3 prior to discharge without EKG changes, likely related to holding Lasix for orthostasis. The patient should have this repeated on ___ at her follow up appointment with her PCP. Her home lasix was restarted upon discharge. # Anion Gap metabolic acidosis: The patient was admitted with an anion gap of 23 in setting of elevated lactate. The patient's home medication list included metformin thus acidosis may have been due to metformin use in addition to global hypoperfusion related to syncope as above. The patient had evidence of DKA at admission and no evidence of uremia on exam, although patient has CKD, as above. The patient also came in with a positive EtOH on serum tox. Her VBG was relatively benign, not significant for alkalosis or acidosis. And her serum osm gap was only 10.37 suggesting against ingestion. Her metformin was stopped on this admission and at discharge. #HTN: Her hypertension was controlled using her home doses of valsartan and amlodipine. She was switched from atenolol to metoprolol given her CKD. Her furosemide was initially held and restarted at discharge. #DM: The patient's last A1c was 9.4 in ___. She is on Levemir 30U daily at home. Patient was not clear on her dosing initially and received OMR dosing of 35u BID of glargine with occasional lows into the ___. Per further discussion with patient, she was started back on 30u long acting insulin (levemir) as she stated she never took BID dosing, she should continue taking insulin as she has been at home. ============================= Transitional Issues ============================= [] Please repeat sodium, potassium and glucose at PCP on ___ ___. Na 133 on discharge with K of 5.3 (likely from holding Lasix for orthostasis) [] switched patient from atenolol to metoprolol 50mg PO extended release [] stopped metformin given lactic acidosis on presentation [] Noted to have hypercalcemia with elevated PTH on admission. Please trend calcium as outpatient and consider further work-up if persistent. Calcium and vitamin D held on discharge given hypercalcemia []TSH elevated to 4.7 on admission. Consider repeat TSH in 6 weeks to evaluate for hypothyroidism [] Ongoing medication education, assistance with administration # CONTACT: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Valsartan 320 mg PO DAILY 3. Gabapentin 100 mg PO BID 4. Atenolol 100 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Alendronate Sodium 70 mg PO Frequency is Unknown 7. Amlodipine 10 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Levemir 30 Units Breakfast 10. Furosemide 20 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Fluticasone Propionate 110mcg 1 PUFF IH BID 13. Cilostazol 100 mg PO BID 14. Omeprazole 20 mg PO DAILY 15. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 16. Aspirin 81 mg PO DAILY 17. Sertraline 50 mg PO DAILY 18. GlipiZIDE 10 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Cilostazol 100 mg PO BID 6. Fluticasone Propionate 110mcg 1 PUFF IH BID 7. Gabapentin 100 mg PO BID 8. Levemir 30 Units Breakfast 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Valsartan 320 mg PO DAILY 13. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet by mouth Daily Disp #*30 Tablet Refills:*0 14. Alendronate Sodium 70 mg PO QTHUR 15. GlipiZIDE 10 mg PO BID 16. Furosemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: syncope likely secondary to orthostasis Lactic Acidosis Sinus tachycardia Hypercalcemia Hyponatremia 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 ___ after you lost consciousness while eating dinner with family. You were evaluated to determine the cause of your loss of consciousness. You heart was examined and it had normal rhythm and normal contractile function. You were not found to have a blood clot in the lungs. The most likely cuase of your loss of consciousness is dehydration and decreased intake of food and liquid prior to the event. Your symptoms of dehydration improved with fluids in the hospital. You were also noted to have a low sodium level in your blood. This was likely from fluids that you received in the hospital. You will need to get your blood sodium level checked at your PCP's office on ___. You were also found to have an elevated blood calcium level. It is important that you stop taking your calcium and vitamin D supplements for now until you follow-up with your primary care physician. For your diabetes, we have stopped one of your oral medications called metformin because this can cause elevated lactate levels due to your poor kidney function. Please STOP taking metformin when you return home. Finally, for your blood pressure, we stopped atenolol and started metoprolol which is better for patients with kidney disease. Please continue to take all of your medications as prescribed below. It was a pleasure taking care of you. Your ___ Care Team Followup Instructions: ___