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19971094-DS-14 | 19,971,094 | 27,853,347 | DS | 14 | 2187-03-12 00:00:00 | 2187-03-15 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right rib pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ yo ___ male with a history of
cholelithiasis, HTN, HL presenting with ruq pain. History is
unclear, but daughter first noticed the patient was holding his
right side yesterday, and complained of right sided
abdominal/rib pain. Unclear when it started. Not associated with
eating. Nonexertional. Had chest pain last ___ that
reportedly resolved, sharp quality, woke up with it in the
middle of the night. Apparently was having chest pain about a
year or so ago when living in ___, which prompted a cardiac
w/u at ___ with exercise stress test. This was about a year ago.
She said that the results suggested a small blockage somewhere,
but was medically managed. Has never had a catheterization.
Denies shortness of breath, although daughter has noticed that
he gets tired more easily with exertion, although doesn't seem
more short of breath, although has noted wheezing at times. No
recent fevers, chills, cough. Denies n/v/d. Daughter also notes
Of note, per discussion with cardiologist Dr. ___, had
pharmacologic nuclear stress test in ___ showing mild
inferolateral defect but with normal EF. Treated medically as he
was asymptomatic. Subsequently had a SAH with a R supraclinoid
aneurysm, so decision was made with patient, family and
providers to stop treatment with antiplatelet agents. Had
myalgias with atorvastatin, so has been managed medically with
lovastatin and metoprolol.
Scheduled for follow-up appointment with Dr. ___ tomorrow
to discuss elective cholecystectomy.
In the ED, initial vitals were: 5 97.5 64 139/99 16 100% RA
Labs notable for WBC 5.9, H/H 12.8/38.4, BUN/CR ___, LFTs
WNL, Trop-T: <0.01.
Imaging notable for RUQ with Cholelithiasis with a gallstone
seen at the gallbladder neck. No other evidence of acute
cholecystitis. CXR w/ no acute cardiopulmonary process.
Vitals on transfer: 3 70 112/50 16 96% RA
On the floor, he continues to endorse pain that is very
localized to the lateral right lower rib.
Past Medical History:
- hypertension
- CAD (nuclear stress test ___ at ___: mild inferolateral
defect, normal EF)
- Subarachnoid hemorrhage related to R supraclinoid aneurysm
(___)
- H/o TIA
- hypothyroidism
- anxiety
- left hip replacement ___
- bilateral cataract surgery
Social History:
___
Family History:
Family history is negative for coronary artery disease or
cancer.
Physical Exam:
ON ADMISSION:
VS: 97.3 126/73 74 18 97% on RA
General: Pleasant elderly gentleman laying comfortably in bed in
NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mild expiratory wheeze in the mid to upper lung fields
bilaterally, otherwise clear to auscultation bilaterally.
CV: Somewhat distant heart sounds, but regular rate and rhythm,
normal S1 + S2, no murmurs, rubs, gallops appreciated. Point
tenderness over the lateral right lower rib.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Neg murhpys
sign.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No notable rashes or lesions
Neuro: Moving all extremities equally with purpose.
ON DISCHARGE:
VS: afebrile ___ 138/36 (94-138/59-86) 18 97%RA
General: Pleasant elderly gentleman laying comfortably in bed in
NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mild expiratory wheeze in the mid to upper lung fields
bilaterally, otherwise clear to auscultation bilaterally.
CV: RRR. II/VI systolic ejection murmur heard best at the right
___ ICS.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Neg murhpys
sign.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No notable rashes or lesions
Neuro: Moving all extremities equally with purpose.
Pertinent Results:
ADMISSION LABS:
___ 03:45PM BLOOD WBC-5.9 RBC-4.33* Hgb-12.8* Hct-38.4*
MCV-89 MCH-29.6 MCHC-33.3 RDW-13.9 RDWSD-44.6 Plt ___
___ 03:45PM BLOOD Neuts-50.0 ___ Monos-10.2 Eos-5.8
Baso-0.3 Im ___ AbsNeut-2.95 AbsLymp-1.96 AbsMono-0.60
AbsEos-0.34 AbsBaso-0.02
___ 03:45PM BLOOD ___ PTT-32.1 ___
___ 03:45PM BLOOD Glucose-96 UreaN-21* Creat-1.1 Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
___ 03:45PM BLOOD ALT-11 AST-19 AlkPhos-53 TotBili-0.6
___ 03:45PM BLOOD Lipase-34
___ 03:45PM BLOOD Albumin-4.1
PERTINENT LABS:
___ 03:45PM BLOOD cTropnT-<0.01
___ 12:26AM BLOOD cTropnT-<0.01
___ 05:56AM BLOOD cTropnT-<0.01
___ 07:11PM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 03:00PM BLOOD WBC-6.5 RBC-4.42* Hgb-12.9* Hct-39.4*
MCV-89 MCH-29.2 MCHC-32.7 RDW-13.8 RDWSD-44.7 Plt ___
___ 03:00PM BLOOD Glucose-167* UreaN-20 Creat-1.2 Na-137
K-4.7 Cl-101 HCO3-26 AnGap-15
___ 03:00PM BLOOD Calcium-9.8 Phos-3.5 Mg-2.0
IMAGING/STUDIES:
RUQUS ___
IMPRESSION: Cholelithiasis with a gallstone seen at the
gallbladder neck. No other
evidence of acute cholecystitis.
CXR PA+LAT ___
FINDINGS: There is evidence of right apical scarring and
possible calcified node at the
right hilum. Opacity at the right cardiophrenic angle is felt
most likely to
be a fat pad as seen on the lateral view. Elsewhere, lungs are
clear. The
cardiomediastinal silhouette is within normal limits. No acute
osseous
abnormalities.
IMPRESSION: No acute cardiopulmonary process.
Pharmacologic Stress test ___
RESTING DATA
EKG: SR, LEFTWARD AX, ERWP
HEART RATE: 62BLOOD PRESSURE: 164/100
PROTOCOL /
STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP
(MIN)(MPH)(%) RATEPRESSURE
___ ___
TOTAL EXERCISE TIME: 4% MAX HRT RATE ACHIEVED: 63
SYMPTOMS:NONE
ST DEPRESSION:NONE
INTERPRETATION: This ___ year old man with hx of HTN and HL was
referred to the lab for evaluation of chest discomfort. He was
infused
with 0.142/mg/kg/min of dipyridamole over 4 minutes. He did not
report
any chest, arm, neck or back discomfort throughout the study. No
ST
segment changes were seen throughout the test. Rhythm was sinus
with no
ectopy. Baseline HTN with appropriate hemodynamic response to
the
infusion. The dipyridamole reversed with 125 mg aminophylline
IV.
IMPRESSION : No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
Pharmacologic perfusion study ___:
TECHNIQUE: ISOTOPE DATA: (___) 10.7 mCi Tc-99m Sestamibi
Rest; (___)
31.6 mCi Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM admin)
Dipyridamole.
Resting images were obtained approximately 45 minutes following
the intravenous
injection of tracer.
Stress images were obtained after resting images and
approximately 30 minutes
following the intravenous injection of tracer.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
FINDINGS: Left ventricular cavity size is normal
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 56%.
IMPRESSION: Normal myocardial perfusion study including the
inferolateral wall.
Normal wall motion with an estimated ejection fraction of 56%.
Brief Hospital Course:
___ yo male with a history of cholelithiasis, HTN, HL presenting
with one day of right sided rib/right upper quadrant pain.
#Costochondritis: Pain localized to lower right rib and
reproduced with palpation. ECG on presentation with no acute
ischemic changes. Trop neg x 3. CXR with no acute process. RUQ
US showed cholelithiasis with stone in the gallbladder neck, but
no e/o cholecystitis. Likely musculoskeletal/rib pain from
costochrondritis. Pain improved on standing tylenol. Had episode
of new vague chest discomfort the day prior to discharge. ECG
unchanged. Trop neg x 1. Low concern for cardiac etiology, but
given previous abnormal stress test and consideration of
elective cholecystectomy, pt underwent pharm nuclear stress test
to assist with pre-op cardiac risk assessment. No anginal type
symptoms or ST segment changes with stress and normal myocardial
perfusion study with normal wall motion and EF 56%. Discharged
with PCP, cardiology and surgery follow-up.
#Cholelithiasis: On presentation RUQUS with stone noted in the
gall bladder neck, no e/o cholecystitis. Symptoms on
presentation thought unlikely to be related to biliary colic.
Seen by surgery team while inpatient to discuss option of
elective cholecystectomy, with plan on discharge to follow-up in
several weeks with Dr. ___ in clinic.
#HTN: continued home metoprolol
#HL: continued home statin
===================
TRANSITIONAL ISSUES:
===================
- Cholelithiasis: gallstone seen in neck of gallbladder this
admission, but current symptoms unlikely related. Will require
further discussion of benefits versus risk of elective
cholecystectomy. Plan for outpatient follow-up with cardiology
and surgery.
-CAD: Continued on home metoprolol and lovastatin for medical
management, without ASA per prior discussion with outpatient
providers given history of SAH and decision to avoid treatment
with anticoagulants/antiplatelet agents. Pharm nuclear stress
test showed no evidence of reversible ischemia. Recommend formal
preoperative evaluation by PCP prior to proceeding with surgery.
- CONTACT: ___ (daughter, HCP): ___
- CODE: Full code (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lovastatin 20 mg oral DAILY
2. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO BID
5. FLUoxetine 20 mg PO DAILY
Discharge Medications:
1. FLUoxetine 20 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Metoprolol Succinate XL 25 mg PO BID
4. Lovastatin 20 mg oral DAILY
5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Costochondritis
SECONDARY DIAGNOSIS: cholelithiasis, HTN, HL, CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you were having right sided
chest wall pain. You had blood tests and an EKG done which
showed that this pain was not from a heart attack. It is most
likely pain from a rib or muscle strain. Because you had an
episode of chest pain recently, you had a stress test which was
negative. You should continue to talk with your family,
cardiologist and primary care provider to decide on whether to
proceed with surgery to remove the gall bladder.
It was a pleasure being involved in your care!
Your ___ Care Team
Followup Instructions:
___
|
19971290-DS-7 | 19,971,290 | 21,456,551 | DS | 7 | 2122-03-05 00:00:00 | 2122-03-05 22:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, broken rib, found to have pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
============================================================
MEDICINE ADMISSION NOTE
Date of admission: ___
===========================================================
PRIMARY CARE PHYSICIAN: ___
CHIEF COMPLAINT: Fall, rib fracture, found to have bilateral
PE.
HISTORY OF PRESENT ILLNESS:
___ is a ___ year old veteran from ___
with
past medical history of hypertension, hyperlipidemia, PTSD, left
total knee replacement in ___ who presents after fall
with
rib fracture found to have incidental bilateral pulmonary
embolism. Patient reports he was in his usual state of health
when on ___ his foot slipped on the carpet of his stairs as
he walked down the stairs. Patient states he fell backwards onto
his back down 3 stairs. He states he did not hit his head and
was
able to protect his head as he was falling down. He endorses
this
was a mechanical fall and denies room spinning or passing out.
He
denies palpitations or chest pain.
Patient went to urgent care on ___ due to pain associated with
fall. He reports that due to findings on chest x ray (?fluid,
?hemothorax)he was sent to ___ where he underwent CT
scan
of head, chest abdomen. CT chest with contrast demonstrated
right
subsegmental and left main pulmonary emboli. He was transferred
to ___ for management of possible hemothorax.
Upon presentation to ___, patient was noted to have BPs in the
160s/70s with HRs in the ___ and satting high ___ on 2L NC
(93% on RA). His exam was notable for crackles in the right base
extending half way up the lung fields and large ecchymosis on
the
left flank. A second opinion read of the CT chest was requested
and is still pending (per ___ -- "left PE in left main pulm
art into segmental and subsegmental, on right a segmental PE.
Density of effusion is simple and not c/w hemothorax"). Trauma
surgery was also consulted who did not think this was consistent
with hemothorax.
A CXR showed moderately extensive left lower lobe infarction or
atelectasis and small pleural effusion unchanged with new
abnormality at the right lung base, which may represent
atelectasis, developing infarction, or coincidental pneumonia.
Labs were notable for Hgb 11.5, INR 1.2, proBNP 904, and trop <
0.01.
He received IV morphine, acetaminophen, and oxycodone for pain.
He was also started on a heparin gtt.
Upon arrival to the floor, the patient describes above story. In
regards to risk factors for PE, patient had left knee
replacement
in ___. He reports he took warfarin for 3 weeks after the
surgery and that he has had some swelling of left leg attributed
to surgical changes. He underwent colonoscopy ___ years ago when
he had polyps. He states he is due for repeat colonoscopy. He
denies recent air travel. He denies prior blood clots.
REVIEW OF SYSTEMS:
Endorses night sweat x 1 week ago, denies weight loss, denies
nausea, denies vomiting, denies chest pain, denies shortness of
breath, denies abdominal pain. Review of systems otherwise
negative, except as reviewed above.
Past Medical History:
Hypertension
Hyperlipidemia
Post traumatic Stress disorder
Osteoarthritis s/p left total knee replacement
Cataract surgery bilaterally
Deviated septum
Obstructive sleep apnea not on home CPAP
Social History:
___
Family History:
Father died of MI in his ___
Mother with HCV from blood transfusion, died of complications
No family history of PE or DVT.
Multiple family members with cerebral aneurysms.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ 1540 Temp: 97.4 PO BP: 169/80 R Sitting HR: 62
RR: 16 O2 sat: 97% O2 delivery: 2L Dyspnea: 0 RASS: 0 Pain
Score:
___
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL, neck
supple, JVP 8cm, no LAD, bilateral supraclavicular fullness
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rales on right side from lower lobe to middle back, left
is clear to air; no wheezing
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, no rebound or guarding
Back: tenderness to palpation of left midline back, large bruise
of left flank that is mildly indurate
Ext: Warm, well perfused, Left leg slightly larger than right,
has midline well healed incision over left patella
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength of bilateral biceps,
triceps, hip flexion, hip extension, knee flexion, knee
extension, plantarflexion, dorsiflexion
DISCHARGE PHYSICAL EXAM:
___ 0000 Temp: 98.2 PO BP: 164/85 HR: 62 RR: 20 O2 sat: 97%
O2 delivery: 2l
General: Alert, oriented, appears his age, conversant,
interactive, but very anxious
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rales on right side from lower lobe to middle back, left
is clear to air; no wheezing
Abdomen: Soft, non-tender to light and deep palpation, mildly
distended, bowel sounds present, no hepatosplenomegaly, no
rebound or guarding
Back: tenderness to palpation of left midline back, large bruise
of left flank that is mildly indurated
Ext: Warm, well perfused, left leg slightly more swollen than
right with mild pitting edema, has midline well healed incision
over left patella
Skin: Warm, dry, no rashes or notable lesions
Pertinent Results:
ADMISSION LABS:
___ 02:56AM GLUCOSE-83 UREA N-15 CREAT-0.9 SODIUM-143
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
___ 02:56AM cTropnT-<0.01 proBNP-904*
___ 02:56AM WBC-5.1 RBC-4.17* HGB-11.5* HCT-35.8* MCV-86
MCH-27.6 MCHC-32.1 RDW-14.8 RDWSD-46.4*
___ 02:56AM NEUTS-69.6 ___ MONOS-7.7 EOS-2.2
BASOS-0.6 IM ___ AbsNeut-3.54 AbsLymp-0.98* AbsMono-0.39
AbsEos-0.11 AbsBaso-0.03
___ 02:56AM PLT COUNT-156
___ 02:56AM ___ PTT-39.6* ___
IMAGING:
CXR ___:
FINDINGS:
The large area of peripheral consolidation at the left lung
base, accompanied
by small left pleural effusion, comparable to the appearance on
chest CTA
___, is in the area of greatest arterial thrombosis and
could be a large
pulmonary infarction. Peribronchial opacification at the right
lung base is
new. This could be atelectasis, early infarction, or even early
pneumonia.
Heart size may be slightly larger today than on the chest CTA
but there is
abundant mediastinal fat making at determination difficult. The
upper lungs
are clear and there is no pulmonary edema. No pneumothorax.
IMPRESSION:
Moderately extensive left lower lobe infarction or atelectasis
and small
pleural effusion unchanged.
New abnormality at the right lung base could be atelectasis,
developing
infarction or coincidental pneumonia.
Duplex ultrasound of lower extremities ___
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
There is a right popliteal ___ cyst which measures 1.9 x 1.2
x 1.1 cm.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins.
2. 1.9 cm right popliteal ___ cyst.
Transthoracic echo ___:
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 suboptimal image
quality to assess regional left ventricular function. There is
no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. 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 with a
normal descending aorta diameter. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (?#) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be
estimated. There is a moderate loculated pericardial effusion.
There are no 2D or Doppler echocardiographic evidence of
tamponade.
IMPRESSION: Suboptimal image quality. Moderate loculated,
predominantly posterior pericardial effusion without
echocardiographic evidence of tamponade. Normal biventricular
cavity sizes, and global systolic function (cannot rule out
regional wall motion abnormalities due to suboptimal image
quality). No valvular pathology or pathologic flow identified.
DISCHARGE LABS:
___ 04:52AM BLOOD WBC-5.3 RBC-3.95* Hgb-11.1* Hct-33.9*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.7 RDWSD-46.3 Plt ___
___ 04:52AM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-143
K-3.6 Cl-105 HCO3-25 AnGap-13
___ 05:56AM BLOOD calTIBC-324 Ferritn-53 TRF-249
Brief Hospital Course:
___ is a ___ year old man with past medical history
of HTN, HLD, PTSD who presented after fall and found to have rib
fracture, submassive pulmonary embolism, pleural effusion and
pericardial effusion.
ACUTE ISSUES
#Submassive Pulmonary Embolism
Hemodynamically stable with no hypoxia, normotension, no
tachycardia. Clot burden involved left main pulmonary artery and
right subsegmental arteries on CT angiogram. EKG with no
evidence of right heart strain, troponin negative though mildly
elevated BNP to 900. Echo performed that did not demonstrate
right heart strain, but was significant for moderate loculated
pericardial effusion, discussed below. Patient managed with
heparin initially and transitioned to rivaroxaban.
#Loculated pericardial effusion
Measured as 1.8 cm on ultrasound. No tamponade on exam.
Cardiology consulted who felt given position and size it was not
amenable to drainage. Pulsus paradoxus not elevated and with
elevated systolic blood pressures. Unclear etiology, but could
represent occult malignancy vs. post infectious.
#Left pleural effusion
Seen on CT at OSH with initial concern for hemothorax. Seen by
thoracic surgery in the ED and radiology reviewed imaging with
low suspicion for hemothorax. Patient with no hypoxemia while in
house. Patient evaluated by interventional pulmonology, who did
not tap effusion due to small size.
#Rib fracture
In setting of mechanical fall. Pain control managed with
standing Tylenol and lidocaine patch. Oxycodone 5mg PO PRN
severe pain.
#Normocytic anemia
#Thrombocytopenia
Hgb 11.1 from 11.5. Iron studies within normal limits, though
iron borderline low. Unclear etiology of mild anemia, though
malignancy vs. other underlying inflammatory process is on the
differential.
CHRONIC ISSUES
#Hypertension
Continued home Lisinopril.
#Hyperlipidemia
Continued home simvastatin.
#GERD
Continued home pantoprazole.
#PTSD
Continued home buproprion, sertraline, lorazepam.
TRANSITIONAL ISSUES:
[ ] Patient being discharged on rivaroxaban with plan for
possibly indefinite anticoagulation pending further workup of
effusions, as this may be unprovoked
[ ] Pulmonary embolism appears to be unprovoked given orthopedic
surgery was 7 months ago; will need further workup as above and
below
[ ] Given fluid collections (pleural, pericardial) with
Pulmonary embolism alongside symptoms of night sweats does
warrant additional outpatient work up for occult cause
(malignancy or otherwise), including colonoscopy
[ ] Would recommend hematology/hypercoag workup if no occult
provocation of PE found
[ ] Patient being discharged with 12 tablets of oxycodone for
pain associated with rib fracture, patient prescription history
reviewed on ___ with no concerns
[ ] Patient needs repeat echocardiogram (TTE) within one week to
evaluate interval change of loculated pericardial effusion;
should be scheduled via PCP at ___
[ ] Patient has an appointment to follow up with ___ clinic on
___ to evaluate for interval increase in pleural effusion.
[ ] Discharge anti-coagulation: rivaroxaban 15mg BID for 21
days, then 20mg daily indefinitely
[ ] Discharge Hgb: 11.1
#Code status: Full, Confirmed
#Emergency Contact: Daughter ___,
Nurse at ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. LORazepam 1 mg PO BID
4. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
5. Zolpidem Tartrate 5 mg PO QHS
6. Sertraline 100 mg PO QHS
7. BuPROPion 150 mg PO BID
8. Sucralfate 1 gm PO BID
9. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth Every 6 hours Disp
#*120 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % Apply 1 patch for 12
hours daily Disp #*12 Patch Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth PRN Q8H Disp #*12
Capsule Refills:*0
4. Rivaroxaban 15 mg PO DAILY
RX *rivaroxaban [Xarelto] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth Twice daily Disp #*1 Dose Pack Refills:*0
5. BuPROPion 150 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. LORazepam 1 mg PO BID
8. Pantoprazole 40 mg PO Q12H
9. Sertraline 100 mg PO QHS
10. Simvastatin 20 mg PO QPM
11. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
12. Sucralfate 1 gm PO BID
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Pulmonary embolism
Pleural effusion
Pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- You were admitted because you were found to have blood clots
in your lungs
What happened while I was in the hospital?
- We treated your blood clots with a blood thinner
- Tests of your legs did not show evidence of blood clot
- You underwent imaging of your heart which demonstrated normal
function, but did demonstrate some fluid around your heart
- We continued your home medications
- We treated the pain associated with your rib fracture
What should I do now that I am leaving the hospital?
- You should take the blood thinner medication rivaroxaban twice
a day for the first 3 weeks; you will then take this medication
daily
- You should continue to take Tylenol for rib pain and oxycodone
as needed for severe pain
- Do not take zolpidem sleep aide if you require oxycodone for
pain
- You should continue to take your other medications as
prescribed
- Please continue to use the incentive spirometer to help with
your breathing
- Please make sure to go to your primary care appointment on
___
- You will need a repeat echocardiogram (ultrasound of the
heart) in the next week; your primary care doctor should
coordinate this
- Please go to your appointment with the lung doctor on ___ at
1pm
- If you have fevers, chills, chest pain, problems breathing, or
generally feel unwell, please call your doctor or go to the
emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19972355-DS-6 | 19,972,355 | 25,983,396 | DS | 6 | 2114-03-16 00:00:00 | 2114-03-27 15:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall, back and chest wall pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ sustained fall from approximately 10 feet from attic
door today. Fell onto left side, no LOC, immediately complained
of L-sided pain and was assisted by friend. Taken to OSH and
films identified rib fractures and L2-L4 lumbar transverse
process fractures; she was transferred to ___ for further
management.
On arrival to ___ ED she is complaining of left rib pain but
otherwise denies complaints. Her husband accompanies her and
states she appears to have normal speech and affect. On ROS she
denies headache, visual changes, shortness of breath, weakness
or
numbness in the extremeties.
Past Medical History:
scoliosis, HTN, hypothyroidism, right piriformis syndrome
(s/p steroid injection to R hip by PCP), IBS
Social History:
___
___ History:
nc
Physical Exam:
O: T: 99 BP: 140/90 HR: 88 R 18 O2Sats 100 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA, EOMs intact b/l
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Chest: + chest wall tenderness to left side, + midline
tenderness to L spine
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: CN2-12 intact, UEs and LEs ___ strength b/l, sensation
equal and intact b/l, proprioception intact, cerebellar intact
to
finger-nose-finger
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right + + + + +
Left + + + + +
Propioception intact
Toes downgoing bilaterally
Pertinent Results:
___ 10:14PM PH-7.40 COMMENTS-GREEN TOP
___ 10:14PM GLUCOSE-122* LACTATE-1.4 NA+-143 K+-3.7
CL--106 TCO2-24
___ 10:14PM freeCa-1.13
___ 10:07PM UREA N-24* CREAT-0.7
___ 10:07PM estGFR-Using this
___ 10:07PM LIPASE-39
___ 10:07PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 10:07PM WBC-12.2* RBC-4.27 HGB-13.6 HCT-39.1 MCV-92
MCH-31.9 MCHC-34.9 RDW-12.5
___ 10:07PM PLT COUNT-248
___ 10:07PM ___ PTT-24.3* ___
___ 10:07PM ___
CT Torso: 1. Anterolateral left 4, ___ acute rib fractures.
2. Left L2 and L3 transverse process fractures, better
delineated on the same
day lumbar spine CT scan.
3. 6mm cavitary nodule in the left upper lobe anterior segment
with vague
surrounding ground-glass opacity. Recommend ___ month followup.
4. Small bleb at the left lung with no evidence of pneumothorax.
5. Bilateral renal hypodensities, some of which are too small to
characterize
but likely representing renal cysts; the largest in the left
interpolar region
measures 16 mm.
6. Right kidney angiomyolipoma. Renal cysts.
7. Hepatic hypodensity within the left lobe of the liver is too
small to
characterize but statistically likely represents a simple cyst
or hemangioma.
MR C-spine: No evidence of ligamentous disruption seen but mild
increased
signal in the posterior soft tissues and interspinous ligaments
indicate mild
traumatic injury. No evidence of spinal cord compression or
intrinsic spinal
cord signal abnormalities or intraspinal hematoma seen. Mild
multilevel
degenerative changes noted.
Brief Hospital Course:
Pt was admitted to the ACS service for multiple rib
fx/transverse process fractures. Her pain was well controlled,
and neurosurgery was consulted for spine evaluation. An MRI of
her C-spine revealed no evidence of acute pathology. Pt's pain
was well controlled in house, and she remained stable, with good
breath sounds b/l and O2 sats >95% throughout. Pt is comfortable
on day of discharge. She was kept in a c-collar until cleared by
neurosurgery on day of discharge. She will follow up with her
primary care physician and in ___ clinic for follow-up of rib
fractures.
Medications on Admission:
levoxyl 750mcg PO daily, Toprol
XL 25mg PO daily, meloxicam 15mg PO daily, cymbalta 60mg PO
daily, prempro 0.45/1.5mg PO daily, HCTZ 12.5mg PO daily
Discharge Medications:
levoxyl 750mcg PO daily, Toprol
XL 25mg PO daily, meloxicam 15mg PO daily, cymbalta 60mg PO
daily, prempro 0.45/1.5mg PO daily, HCTZ 12.5mg PO daily
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 1 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L2-4 Left transverse process fractures, ___ and 5th rib
fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you here at ___
___. You were admitted to the hospital here
after having a fall, during which you fractured ribs and
extensions of your vertebrae in your lumbar spine. We performed
multiple imaging tests, and you were evaluated by our
neurosurgeouns. You are now safe to return home.
Please return to the ER if you have:
* Your pain gets worse.
*worsening cough
*difficulty breathing
*fever over ___
* You develop pain, numbness, tingling or weakness in
your arms or legs.
* You lose control of your bowels or urine ("passing
water").
* Trouble walking.
* Your pain is not getting better after 2 days.
* Anything else that worries you.
Followup Instructions:
___
|
19972371-DS-5 | 19,972,371 | 26,223,444 | DS | 5 | 2155-08-19 00:00:00 | 2155-08-22 23:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is a ___ Y F with a history of progressive, metastatic
melanoma presents to the ER with acute encephalopathy , fever
and hypotension. History is obtained via the ER physicians and
the patient's husband. The patient was in her usual state of
health until 2 days prior to admission when she attended an
event with her husband; she felt fatigued and was warm to the
touch. This progressed and the day of admission, she also was
very fatigued, hot to thr touch, and difficult to aurouse. She
was taken to the ER where initial vitals: 102.1 80 90/52 16 96%
ra. She was treated for sepsis with Vancomycin, Cefepime,
Hydrocortisone (for Hx of adrenal insufficiency), Tylenol, and
6L IVF. Her SBP fell to the ___ with a MAP in the ___ as she
was being prepared to travel to the ICU. When the team informed
the husband that she she would need to be intubated, have a line
placed, and started on pressors, he stated that these decisions
would not produce a quality of life that she would want. After
husband's discussion with the ER resident and Attending the
decision was made to have her be CMO.
.
ROS: unable to obtain secondary to encephalopathy.Per husabnd,
had no complaints up to a few days prior to admission.
Past Medical History:
ONCOLOGIC HISTORY:
1980s melanoma that was excised from the right upper thigh,
sentinel lymph nodes ___ negative
___ transvaginal ultrasound showed a 4.7 x 4 x 4.4 cm
echogenic mass in the right external iliac chain, concerning for
malignant adenopathy, enlarged on ___
___, CT abdomen and pelvis reportedly showed two masses,
one in the right lower pelvis, abutting the inferior vena cava
and right common iliac vein measuring 3.6 cm in size; as well as
a large lobular mixed heterogeneous mass measuring 3-4 cm in
size
in the lower pelvis.
___, ultrasound-guided biopsy revealed cells that were
positive for S-100, MART-1, and HMB-45, most compatible with
melanoma.
___ PET CT scan showed multiple hypermetabolic masses in
the retroperitoneum, R iliac, and right pelvis also concerning
for soft tissue/nodal metastases from melanoma.
___ MRA of the pelvis showed an extensive enlarged
confluent adenopathy in the retroperitoneum
___, she underwent exploratory laparotomy with resection
of right pelvic mass and exposure of retroperitoneal paracaval
mass by Dr. ___. The surgery also involved resection of
the distal inferior vena cava and proximal right and left common
iliac vein with reconstruction
___ PET CT remaining sites of hypermetabolism at the
right
pericaval retroperitoneum with soft tissue mass measuring 2.8 cm
in diameter. The left periaortic 1.5 cm diameter nodule was
slightly decreased in size compared to previous. There were two
subcentimeter nodular foci along the right common iliac nodal
chain. There were no new suspicious pulmonary nodules.
___ MRI of the brain did not show any evidence of
metastatic disease.
___: 3 doses of ipilimumab 3 mg/kg (200 mg dose)
___: received ___ Target Now results for patient's tested
melanoma: BRAF mutant (V600E), c-Kit wild type; additional
microarray data available in patient's paper chart
___: Hold any further doses of ipilimumab due to concern for
pituitary hypophysitis.
___: Pituitary MRI: Partially empty sella turcica, unchanged
since ___. No evidence of pituitary abnormality. No
evidence of metastatic disease.
___: Torso CT: Multiple enlarged retroperitoneal lymph
nodes. Iliac vein stents in place. No evidence of metastasis
spreading beyond the noted lymphadenopathy, which per prior
oncology progress notes, appears stable to slightly smaller in
size.
PAST MEDICAL HISTORY:
1. Status post open heart surgery for patent ductus arteriosus
when she was ___ years old, done at ___,
stable; she is not followed by a cardiologist
2. History of left knee pain
3. Hypertension
4. Status post IVC artificial graft on ___, with
subsequent chronic warfarin use, stable.
5. Pituitary failure secondary to ipilimumab ___
Social History:
___
Family History:
Mother had ___, Father had CVA
Physical Exam:
GEN: NAD, somnlent but will mildly arouse to voice.
HEENT: conjunctivae clear, OP dry and without lesion
NECK: Supple, no JVD
CV: Reg rate and rhythm, no heaves.
CHEST: Resp unlabored, no accessory muscle use. no wheezes or
rhonchi.
ABD: Soft, NT, ND, no HSM
MSK: normal muscle tone and bulk
EXT: No c/c/e, normal perfusion
SKIN: No rash, warm skin
NEURO: aurosable to voice at times but very somnlent
PSYCH: comfortable
.
Pertinent Results:
___ 08:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 08:00PM URINE RBC-0 WBC-<1 BACTERIA-MOD YEAST-NONE
EPI-1
___ 08:00PM URINE HYALINE-24*
___ 08:00PM URINE MUCOUS-RARE
___ 06:17PM LACTATE-0.9
___ 06:00PM GLUCOSE-97 UREA N-42* CREAT-2.0* SODIUM-132*
POTASSIUM-3.3 CHLORIDE-91* TOTAL CO2-22 ANION GAP-22*
___ 06:00PM estGFR-Using this
___ 06:00PM ALT(SGPT)-78* AST(SGOT)-109* LD(LDH)-1350*
ALK PHOS-152* TOT BILI-1.2
___ 06:00PM LIPASE-24
___ 06:00PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.9
MAGNESIUM-2.4
___ 06:00PM WBC-19.7*# RBC-4.38 HGB-12.6 HCT-37.8 MCV-86
MCH-28.8 MCHC-33.4 RDW-14.1
___ 06:00PM NEUTS-88.9* LYMPHS-5.0* MONOS-5.5 EOS-0.2
BASOS-0.3
___ 06:00PM PLT COUNT-469*
___ 06:00PM ___ PTT-33.9 ___
.
CXR ___: No evidence of acute disease.
.
Brief Hospital Course:
.
___ yo woman with met melanoma s/p ipilimumab and currently on
vemurafenib with mixed response presented to the ED unresponsive
with fever and hypotension.
.
#MS changes: Pt was unresponsive on admission, however, the
morning after admission pt awoke and was back to her baseline.MS
changes likely due to infection/low blood pressure.
.
#Fever: Source unclear. CXR and u/a negative. Blood and urine
cultures remained sterile.
Pt completed empiric vancomycin and ___ hrs and was
switched to oral cipro and augmentin.Pt remained afebrile and
wbc trending down during hospital stay.
.
#Acute renal failure:Resolved with IVF.Likely pre-renal due to
hypotension/dehydration.
.
#Hypotension: Likely due infection and hypoadrenalism.Pt was
started on stress doses of hydrocortisone and
which was decreased to 50 mg TID and then back prednisone 5 mg.
HCTZ was discontinued and not restarted on discharge. Blood
pressure was normotensive throughout hospital stay.
.
#Pan-hypopit.As above-stress doses of hydrocortisone.
Outpt dose of levothyroxine was continued . TSH level wnl.
.
#H/O IVC artificial graft/chronic antocoagulation: INR
therapeutic at 2.9 on admission . INR was followed daily and
warfarin dosed based on INR. Lower dose of warfarin was need
while pt on ciprofloxacin.
.
Medications on Admission:
(per OMR)
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth daily
IPILIMUMAB [___] - (Prescribed by Other Provider) (On Hold
from ___ to unknown for hypophysitis) - 200 mg/40 mL (5
mg/mL) Solution - 3mg/kg IV every 3 weeks
LEVOTHYROXINE - 75 mcg Tablet - 1 tablet by mouth daily
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth every morning
VEMURAFENIB [___] - (On Hold from ___ to unknown
for
severe rash) - 240 mg Tablet - 5 Tablet(s) per day
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily as directed ; undergoing active
adjustment; currently ___ per day
.
Medications - OTC
CAMPHOR-MENTHOL [ANTI-ITCH] - 0.5 %-0.5 % Lotion - apply to
affected area twice daily as needed for rash
CETIRIZINE - 10 mg Tablet - 1 Tablet(s) by mouth daily as needed
for allergy symptoms, itchy skin ; may cause drowsiness
DIPHENHYDRAMINE HCL - 2 % Cream - apply to affected skin four
times a day as needed for itchy skin
.
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for coughing.
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
4. warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 ___:
dose needs to be adjusted based on INR. Follow-up INR on
___.
5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Fever
Acute renal failure
Adrenal insufficiency
Hypothyroidism
Melanoma
Chronic anticoagulation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___ , you presented to the emergency room with fever adn
very low blood pressure. You were treated with IV fluids , IV
antibiotics and stress doses of steroids.Blood and urine
cultures remained without growth. You were evaluaetd by
endocrinology adn transitioned back to your home dose of
prednisone.You were also transitioned to oral antibiotics.
Changes in medications:
1.Ciprofloxacin 500mg po bid x 3 days
2.Warfarin (coumadin) decreased to 3 mg daily 9 because of
ciprofloxacin) until ___ morning and adjusments to be doen by
coagulation clinic at ___. Ciprofloxacin can change.
3.Hydrochlorthiazide discontinued
4. If you are feeling weak and fatigued than usual you should
contact Dr ___ as you may need to increase your prednisone
dose.
Followup Instructions:
___
|
19972786-DS-20 | 19,972,786 | 24,256,499 | DS | 20 | 2199-12-10 00:00:00 | 2199-12-10 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx HTN, HLD, DMII who presented with the chief complaint of
continous nausea w/o vomiting for the past ___ days, unrelieved
by tums. He has not had associated chest pain, abdominal pain,
fevers, chills, diaphoresis. No dietary changes. His appetite
remains good and he's eating as he usually does; even endorses
feeling hungry during our interview.Patient also denies any
changes in his bowel habit-- his last BM was yesterday morning
and looked dark brown without any coating of blood. Endorses an
associated sensation of bloating. No recent changes in meds. Hx
of appendectomy.
At the ED, his initial vitals were 98.6 65 161/53 18 96% RA. CXR
w/o acute process and negative CT A/P with contast. EKG showed
~1mm ST elevation in V2. Cardiology was consulted and it was
thought that his EKG was largely unchanged. ETT was performed,
which showed ischemic EKG changes and poor exercise capacity.
Trops were negative x 2.
He was given ASA 325mg, Zofran, HCTZ, amlodipine, and metformin.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. ROS as above.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
HTN
DM type 2
Dyslipidemia
GERD
Peripheral neuropathy
h/o gout
Colonic polyps
Dizziness
Social History:
___
Family History:
Father and mother both passed away from an MI; mother was ___ and
father was ___.
Physical Exam:
VS: Wt=72.8 kg T=97.9 BP=146/57 HR=69 RR=16 O2 sat= 97 RA
General: well appearing gentleman who appears stated age; in no
apparent distress. Laughing and joking through entire interview.
HEENT: Sclerae are anicteric. Pupils are equal, round and
reactive to light and accommodation. Oropharynx is clear.
Neck: No JVP, no LAD
Chest: Clear to auscultation bilaterally, though decreased
breath sounds. No wheezes, rales or
rhonchi.
HEART: Regular rate and rhythm. ___ systolic murmur at the left
upper sternal border
ABDOMEN: Soft, nontender and nondistended. Normoactive bowel
sounds. No hepatosplenomegaly.
PULSES: 2+ radial and DP bilaterally
Pertinent Results:
ADMISSION LABS
___ 06:21PM BLOOD cTropnT-<0.01
___ 12:05AM BLOOD cTropnT-<0.01
___ 06:21PM BLOOD Lipase-97*
___ 06:21PM BLOOD ALT-18 AST-34 AlkPhos-65 TotBili-0.2
___ 06:21PM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-136
K-4.6 Cl-98 HCO3-25 AnGap-18
___ 06:21PM BLOOD Plt ___
___ 06:21PM BLOOD Neuts-55.2 ___ Monos-5.4 Eos-1.7
Baso-0.7
___ 06:21PM BLOOD WBC-5.6 RBC-3.88* Hgb-12.9* Hct-39.7*
MCV-102* MCH-33.2* MCHC-32.5 RDW-12.9 Plt ___
DISCHARGE LABS
___ 06:30AM BLOOD Calcium-10.0 Phos-3.5 Mg-1.9
___ 06:30AM BLOOD Glucose-100 UreaN-16 Creat-1.2 Na-135
K-4.5 Cl-99 HCO3-29 AnGap-12
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD WBC-4.6 RBC-4.02* Hgb-13.0* Hct-40.4
MCV-100* MCH-32.3* MCHC-32.2 RDW-13.7 Plt ___
STUDIES:
___ ETT
TOTAL EXERCISE TIME: 4.5 % MAX HRT RATE ACHIEVED: 86
ST DEPRESSION: ISCHEMIC PEAK INTENSITY: 1MM
ONSET: 4.5 MINUTES EX ___
RESOLUTION: 5 MINUTES REC 69 164/64 ___
INTERPRETATION: ___ history of hypertension, hyperlipidemia and
diabetes was referred to evaluate an atypical chest pain. The
patient completed 4 minutes and 34 seconds of a Gervino protocol
representing a poor exercise tolerance for his age;
approximately ___ METS. The exercise test was stopped due to
fatigue. No chest, back, neck, or arm discomforts were reported
during exercise. During recovery the patient reported the lower
abdominal discomfort that prompted his initial emergency
department evaluation. At peak exercise, 0.5-1mm horizontal
ST-segment depression was noted inferiorly and in the lateral
precordial leads. The rhythm was sinus with rare isolated ABPs
and VPBs. The hemodynamic response to exercise was appropriate.
IMPRESSION: Poor exercise tolerance in the setting of ischemic
ECG
changes and atypical symptoms. Appropriate hemodynamic response
to
exercise.
___ CXR
FINDINGS: PA and lateral chest radiographs. There is no focal
consolidation, pleural effusion, or pneumothorax. Subsegmental
areas of atelectasis in the right lung base can be seen on CT
Abdomen from same date. Eventration of the
right hemidiaphragm and tortuosity of the thoracic aorta are
unchanged from multiple priors. The heart size is top normal.
IMPRESSION: No acute cardiopulmonary process.
___ CT ABDOMEN/PELVIS WITH CONTRAST
CT ABDOMEN: The lung bases are clear. The heart is enlarged
and there are dense coronary artery calcifications and aortic
valve calcifications. The liver enhances homogeneously and there
is no focal liver lesion. The hepatic and portal veins are
patent. The gallbladder, pancreas, spleen, and adrenals are
normal. The kidneys enhance symmetrically and excrete contrast
without evidence of hydronephrosis or mass. No bowel
obstruction or bowel wall thickening. There is no portacaval,
mesenteric and retroperitoneal
lymphadenopathy. There is no free air or free fluid. There are
dense calcifications of the abdominal aorta and its major
branches.
CT PELVIS: The appendix is not visualized, but there are no
secondary signs of inflammation. The colon, rectum, urinary
bladder and prostate are normal. Soft tissue densities in the
bilateral inguinal canals are stable from prior CT and likely
represent undescended testes. There is no pelvic
lymphadenopathy or free fluid.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
worrisome for malignancy.
IMPRESSION:
No acute CT findings to explain patient's abdominal pain.
Brief Hospital Course:
___ gentleman with history of T2DM, hypertension and
hyperlipidemia who presented to ED for persistent nausea, which
resolved after receiving IV Zofran. given the posibility that
his nausea may have been an anginal equivalent, after detecting
a ___epression in V2, the patient underwent a stress test
that elicited ischemic changes in his inferolateral leads. His
overall problems during this hospitalization were managed as
follows:
#Nausea: there was initial concern for abdominal source v.
anginal equivalent. Pt had a negative CT, negative UA, and lack
of fevers ruling out infectious abdominal/urinary source.
Despite the coronary artery disease detected by his stress test,
his nausea did not seem to be an anginal equivalent given that
he denied experiencing this sx with exertion previously, and did
not even have recurrence during the stress test (it resolved
with zofran prior to ETT). Before discharge, patient has been
started on pantoprazole, since he endorsed a previous history of
ulcerative disease treated with maalox and symptoms of reflux
after eating large meals.
#Coronary artery disease: +ETT, with decreased exercise capacity
and ischemic changes. Patient opted to pursue optimized medical
therapy over cardiac catheterization. His 325 mg of aspirin was
changed to 81 mg, his 20 mg simvastatin was switched to 80 mg
atorvastatin, his amlodipine was discontinued and 25 mg
metoprolol succinate was started.
#Macrocytic anemia: Pt is asymptomatic (no SOB, CP,
palpitations, fatigue). Not on any medications that would cause
macrocytosis and he does not have known liver dz. This may have
developed ___ nutritional deficiency.
CHRONIC MEDICAL PROBLEMS
#Type 2 DM - last A1C this ___ is 6.3; patient continued to
take metformin.
#Hypertension - adequately controlled on home regimen. However,
given likely CAD with positive stress test, amlodipine was
discontinued for beta-blockade with metoprolol.
#Hyperlipidemia - Last lipid panel of Cholest Triglyc HDL
CHOL/HD LDLcalc 182 ___. Simvastatin 20 changed to
atorvastatin 80
TRANSITIONAL ISSUES
-check folate and thiamine
-monitor blood pressure control during next PCP visit
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Simethicone 120 mg PO QID:PRN gas
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Simethicone 120 mg PO QID:PRN gas
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
Nausea, resolved
HTN
HLD
T2DM (last A1C of 6.3)
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 provide you with care during your stay at
___. You came to the hospital
after you had several days of nausea, which we treated with a
medication called zofran; we also started a medication that will
reduce your stomach acid. To make sure there was no infectious
disease, you had imaging and blood work that was very
reassuring.
Since some patients will complain of nausea when they have heart
disease, you also had a stress test of your heart. This revealed
that you likely have some blockages of the arteries of your
heart. We talked about the possibility of either cardiac
catheterization (w/ possible stenting) to treat you or medical
optimization. You ultimately chose to be on medication only
treatment.
Please take your medications as prescribed and follow-up with
your primary care doctor and cardiologist.
We wish you the best,
Your team at ___
Followup Instructions:
___
|
19972786-DS-21 | 19,972,786 | 29,611,193 | DS | 21 | 2200-02-17 00:00:00 | 2200-02-18 14:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___
Chief Complaint:
1.) Abdominal Pain
2.) Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a hx of HTN, HLD, T2DM who presents
with acute onset of abdominal pain. He says the pain started
last night without any inciting factor. It is a ___, burning,
non-radiating pain in his left lower quadrant that is
intermittent. He is unsure of what inciting or alleviating
factors are - he does not believe it is related to eating
although he has been eating little due to the pain. He took
Maalox to no effect. He had a normal bowel movment this morning
with no bright red blood or dark stool. He has not taken any
medications for his symptoms and denies ever having this pain
before. His only other abdominal history includes an
appendectomy several years ago.
Additionally he endorses shortness of breath during exertion for
the last ___ days. Has cough productive of sputum. Denies leg
swelling, or chest pain. No f/c/n/v, headaches, dysphagia,
melena, diarrhea, constipation, BRBPR, joint pain, dysuria,
changes in his diet.
Of note, he was admitted ___ for nausea during which
time a workup included poor exercise tolerance in the setting of
ischemic EKG on ETT, neg CT abd pelvis. A cardiology consult at
that time did not attribute his nausea to angina. He was
discharged on pantoprazole, aspirin reduce to 81mg, 20mg
simvastatin increased to 80mg atorvastatin, and amlodipine
changed to 25mg metoprolol.
In the ED, initial vitals: T 98.5 HR 81 BP 164/85 RR 14 O2Sat
99% 2L NC
Vitals prior to transfer: HR 75 BP 153/70 RR 16 O2 98%RA
At time of admission, patient is resting comfortably and has no
pain. Is hungry and asking to eat a sandwich. Has no complaints.
Past Medical History:
HTN
DM type 2
Dyslipidemia
GERD
Peripheral neuropathy
h/o gout
Colonic polyps
Dizziness
Social History:
___
Family History:
Father and mother both passed away from an MI; mother was ___ and
father was ___.
Physical Exam:
ADMISSION PHYSICAL:
Vitals- 97.8 150/70 75 20 97% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear. Has dentures
Neck- supple, JVP elevated, no LAD, no thyromegaly
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG. Tachypneic when lying flat.
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly. Healed surgical scar in RLQ
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DRE - soft stool in rectal vault - no gross blood noticeable. No
palpable masses.
LABS: See below. Significant for ___ 126 ALT 93 AST 105 proBNP
4744 (no prior baseline value). Guiac negative.
DISCHARGE PHYSICAL:
Vitals: 98.3 136/63 68 18 95%RA
I/O: Since MN ___ 24HR 1200/1700
Wgt 70.5 kg
GENERAL - Laying in bed in NAD. Alert and interactive.
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, JVP not
elevated
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c, trace edema, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS AND IMAGING:
___ 08:50AM WBC-4.2 RBC-3.82* HGB-12.2* HCT-36.7* MCV-96
MCH-32.0 MCHC-33.3 RDW-14.3
___ 08:50AM NEUTS-73.8* LYMPHS-16.2* MONOS-6.7 EOS-2.7
BASOS-0.7
___ 08:50AM ALBUMIN-4.3
___ 08:50AM proBNP-4744*
___ 08:50AM ALT(SGPT)-93* AST(SGOT)-105* ALK PHOS-101 TOT
BILI-0.5
___ 08:50AM LIPASE-25
___ 08:50AM GLUCOSE-153* UREA N-14 CREAT-1.0 SODIUM-127*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-23 ANION GAP-17
___ 09:03AM LACTATE-1.8
___ 10:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:55PM cTropnT-<0.01
___ 01:55PM GLUCOSE-119* UREA N-12 CREAT-0.9 SODIUM-126*
POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-23 ANION GAP-15
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-4.3 RBC-3.99* Hgb-12.9* Hct-39.0*
MCV-98 MCH-32.2* MCHC-33.0 RDW-14.3 Plt ___
___ 07:55AM BLOOD Glucose-102* UreaN-14 Creat-1.1 ___
K-4.6 Cl-96 HCO3-27 AnGap-15
___ 07:55AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9
IMAGING:
___ ECHO (TTE): The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). Doppler
parameters are indeterminate for left ventricular diastolic
function. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad.
___ Chest Pa Lat: Moderate cardiomegaly with mild pulmonary
edema, small bilateral pleural effusions, and bibasilar
atelectasis.
___ CT Abd Pelvis: Small bilateral pleural effusions with mild
pulmonary edema, new from ___. New mild stranding and
fluid along the second portion of the duodenum and anterior
right pararenal space is non-specific but could represent
duodenitis. Pancreatitis is unlikely given the normal lipase
value. No small bowel obstruction or mesenteric ischemia.
Severe atherosclerosis.
Brief Hospital Course:
Mr. ___ is a ___ with a hx of HTN, HLD, T2DM who presented
with acute onset of abdominal pain of one day and shortness of
breath for ___ days. Upon admission his abdominal pain quickly
resolved with administration of a PPI and sucralfate - his pain
was most likely to indigestion and gas. His shortness of breath
was concerning for congestive heart failure given his medical
history as well as findings on chest x-ray concerning for
pulmonary edema and pleural effusions. He was evaluated while in
patient and was found to have LVH, mild atrial and mitral
regurgitation on ECHO.
#Congestive heart failure, preserved ejection fraction, new
diagnosis / acute exacerbation: Reported a ___ day history of
shortness of breath with cough productive of sputum. Has no
other signs, symptoms of acute process such as f/c/n/v or
elevated WBC. CXR is remarkable for bilateral pleural effusions
and pulmonary edema. Given his history of HTN it is most likely
that this shortness of breath is due to congestive heart
failure. An ECHO revealed that mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function, mild aortic regurgitation, and mild mitral
regurgitation. He was diuresed with IV furosemide, then
transitioned to a stable oral regimen.
#Electrolyte Abnormalities: Mr. ___ at admission was 126
and he was asymptomatic. His hyponatremia most likely due HCTZ
and hypervolemic hyponatremia due to CHF and CKD. We held his
hydrochlorothiazide which can worsen hyponatremia and intitiated
losartan instead. On Day 1 of his hospitalization, his K
continued to trend upwards so he was diuresed with the intention
of both addressing his hyperkalemia and hyponatremia. His
hyperkalemia resolved, and had improved hyponatremia.
#Abdominal pain: Acute onset abdominal pain with no other
associated symptoms such as nausea, vomiting, diarrhea, BRBPR,
or melena. Notable findings are elevated AST/ALT and potential
duodenitis on CT. It is unlikely that his pain is due to small
bowel obstruction, pancreatitis, AAA, or mesenteric ischemia.
Given duodenitis found on CT ordered H.Pylori stool antigen but
he was unable to produce a sample before discharge. Ultimately,
he was treated for gas and indigestion with double doses of his
home pantoprazole, sucralfate, and simethicone. Overall, he had
good oral intake and bowel movements without issue.
CHRONIC ISSUES
#HTN - Held HCTZ (see above) and initiated losartan. Also
continued him on his home metoprolol.
#T2DM - Held metformin while inpatient, maintained SSI.
#CKD - Cr is 0.9, baseline for patient.
#Hypercholesterolemia - Held home atorvastatin given elevated
LFTs, changed to pravastatin upon discharge.
#Gout - Continued home allopurinol.
TRANSITIONAL ISSUES
- Will potentially follow-up with cardiologist (Dr. ___
___ given CHF symptomology this hospitalization.
- Follow-up with PCP (Dr. ___
- Recommend outpatient H. pylori stool study given finding of
duodenitis on CT scan.
- Daily weights
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Aspirin 81 mg PO DAILY
8. Simethicone 166 mg PO QID:PRN gas
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Simethicone 166 mg PO QID:PRN gas
6. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. Pravastatin 40 mg PO DAILY
RX *pravastatin 40 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY:
- Congestive Heart Failure with preserved ejection fraction,
with acute exacerbation
SECONDARY:
- Abdominal pain / Duodenitis
- Abnormal liver function tests
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. ___,
Thank you for choosing ___ for your care. You were admitted
for abdominal pain of one day and shortness of breath that you
were experiencing for several days.
In terms of your abdominal pain, your labs and tests indicated
that you had a mild duodenitis (inflammation of a part of your
bowel). Your pain resolved quickly after admission and we
concluded given how you presented that it was most likely due to
indigestion and gas. We provided you with pantoprazole (a
medication you were already taking at home), sucralfate, and
simethicone. Your abdominal pain improved.
In terms of your shortness of breath, this is most likely due to
a condition called congestive heart failure. Your blood tests
and an ultrasound of your heart showed that you have mild
dysfunction of two valves in your heart and thickening of the
wall of your heart, which are contributing to congestive heart
failure. You will need close follow-up with a cardiologist to
address your symptoms of congestive heart failure and your ECHO
findings.
You should weigh yourself every day and if your weight increases
by more than 3lbs in one day, contact your PCP.
It was a pleasure to be a part of your care. We wish you the
very best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19972786-DS-22 | 19,972,786 | 27,486,130 | DS | 22 | 2200-05-16 00:00:00 | 2200-05-17 20:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization ___
History of Present Illness:
___ with pmhx of HTN, DM, HL and presents with 4 days of
exertional shortness of breath. Patient reports that he has also
had epigastric discomfort radiating from his abdomen up through
his chest with associated belching. He is presenting today
because he is having difficulty sleeping due to the
aforementioned symptoms and that they have not improved and SOB
is worse with lying down. The patient has been evaluated in the
past for chest pain most recently with a stress test that was
abnormal. Since that time has been followed by cardiology. He
saw them most recently 2 days ago where her these results were
discussed and the patient preferred not to have a cardiac
catheterization, however, his cardiologist indicated that this
may be an option of the road if he again had chest pain. She
denies any fever, chills, bowel or bladder changes.
In the ED initial vitals were: 97.4 65 165/78 16 99% ra
- Labs were significant for Na 131, trop <0.01
- Patient was given
On the floor, patient continued to have worsening SOB with lying
down as well as mild abdominal pain
Review of Systems:
(+) 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
DM type 2
Dyslipidemia
GERD
Peripheral neuropathy
h/o gout
Colonic polyps
Dizziness
Social History:
___
Family History:
Father and mother both passed away from an MI; mother was ___ and
father was ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals - T:98.2 BP:165/82 HR:75 RR:18 02 sat:96/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, mild JVD elevation to about
9cm
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG:mild bibasilar crackles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema b/l
NEURO: AOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
Vitals - 98.5 124/55-144/70 50-63 16 100% RA
Weight: 68.7 kg (69.5 kg ___
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: TAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema b/l. ___ with 2+ ___
NEURO: AOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 03:40AM BLOOD WBC-3.7* RBC-3.78* Hgb-12.5* Hct-36.5*
MCV-97 MCH-33.1* MCHC-34.2 RDW-15.1 Plt ___
___ 09:34AM BLOOD ___ PTT-33.2 ___
___ 03:40AM BLOOD Glucose-124* UreaN-23* Creat-1.1 Na-131*
K-4.3 Cl-97 HCO3-25 AnGap-13
___ 03:00PM BLOOD ALT-95* AST-79* AlkPhos-82 TotBili-0.7
___ 05:43PM BLOOD Calcium-9.9 Phos-3.5 Mg-1.8
CARDIAC LABS:
=============
___ 03:40AM BLOOD proBNP-9240*
___ 03:40AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-3 cTropnT-0.01
IMAGING/STUDIES:
================
___ Cardiac Cath:
Coronary angiography: right dominant
LMCA: 60% smooth distal left main
LAD: The LAD had an 80% stenosis in the mid portion with
post-stenotic aneurysmal dilation. The mid LAD was 100%
occluded
(filled by right to left collaterals). A large diagonal branch
arose just distal to the stenosis and was a medium-large vessel
without additional significant disease.
LCX: The LCX was a large vessel with a 60-70% stenosis in its
proximal portion. The LCX terminated in a large
posterolateral
branch.
RCA: The RCA was tortuous and had a 40% stenosis in the mid
segment. The distal RCA had a 80-90% stenosis prior to a large
PDA. The RCA gave prominent collaterals to the LAD - which
appeared to be a diffusely diseased vessel.
Interventional details
The patient presented with angina and an early positive stress
test for hypotension after 2.5 mins exercise. Given the three
vessel coronary artery disease with total occlusion of the LAD
and focal stenoses in the RCA and LCx - the patient will be
evaluated for CABG.
Assessment & Recommendations
1.Three vessel coronary artery disease
2.Consideration for CABG
___ CXR:
No acute cardiopulmonary process. Chronic changes of pleural
thickening at the bilateral lung bases and moderate
cardiomegaly.
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-3.7* RBC-4.01* Hgb-13.2* Hct-39.2*
MCV-98 MCH-32.8* MCHC-33.6 RDW-15.3 Plt ___
___ 06:00AM BLOOD ___ PTT-32.8 ___
___ 06:30AM BLOOD Glucose-107* UreaN-18 Creat-1.1 Na-132*
K-4.3 Cl-97 HCO3-26 AnGap-13
___ 06:30AM BLOOD ALT-63* AST-36 AlkPhos-71 TotBili-0.6
___ 06:30AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
___ 03:00PM BLOOD %HbA1c-6.4* eAG-137*
Brief Hospital Course:
___ with pmhx of HTN, DM, HL and presents with 4 days of
exertional shortness of breath, found to have multivessel
disease on cath as well as acute diastolic CHF exacerbation.
Patient was discharged with plan for return on ___ for CABG.
ACTIVE MEDICAL ISSUES:
# Unstable Angina: CAD previously stable on medical therapy.
Patient now presented with CP and cath showed mutivessel
disease. Troponins negative. His lesions were felt to be too
high risk and not amenable to stent placement. Patient was
evaluated for CABG while in-patient. Patient was scheduled to
return to the ___ Lobby at 6 AM on ___.
Patient was continued on aspirin, metoprolol and losartan. Home
atorvastatin was increased to 80mg daily from 40mg daily.
#acute diastolic CHF exacerbation: Patient presented with
worsening SOB and elevated BNP. Presentation most likely due to
CHF exacerbation, possibly secondary to ischemia. He was gently
diuresed with improvement in symptoms and discharged on home
lasix.
#HTN: continued metoprolol and losartan
#transaminitis: Patient presented with mildly elevated LFTs at
AST 79, ALT 63. They were felt to be possibly related to CHF
exacerbation and downtrended during hospitalization with
diuresis.
CHRONIC MEDICAL ISSUES:
#DM: held home metformin and maintained on sliding scale during
hospitalization
#HL: increased atorvastatin to 80mg daily
#GERD: continued ranitidine, pantoprazole
#Gout: continued allopurinol
TRANSITIONAL ISSUES:
-CABG plan: Patient instructed to return to ___
Lobby at 6 AM on ___ for CABG.
-home atorvastatin increased to 80mg daily
-discharged on furosemide 10 daily.
-discharge weight: 98.7 kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Simethicone 166 mg PO QID:PRN gas
3. Allopurinol ___ mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Atorvastatin 40 mg PO QPM
8. Furosemide 10 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Ranitidine 150 mg PO BID
6. Simethicone 166 mg PO QID:PRN gas
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Furosemide 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Unstable angina
Coronary Artery Disease
acute diastolic congestive heart failure
Secondary:
hypertension
diabetes
GERD
hyperlipidemia
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 ___ with chest pain and shortness of
breath. You were found to have obstructions in the vessels
around you heart that could not be fixed with stents. You were
evaluated by our surgeons who recommended bypass surgery, which
has been scheduled for ___. Please plan to arrive at the
___ Lobby at 6 AM on ___.
While you were in the hospital, you also had a little fluid
buildup in your lungs. This responded well to IV medication. You
should continue taking your home Lasix 10 mg daily.
We have increased the dose of your atorvastatin from 40 mg to 80
mg. You should continue to take your other medications as
prescribed and follow up with your doctors as directed. Please
weigh yourself daily and call your doctor if you gain more than
3 pounds.
It has been a pleasure taking care of you and we wish you all
the best,
Your ___ Care Team
Followup Instructions:
___
|
19972786-DS-26 | 19,972,786 | 25,671,888 | DS | 26 | 2201-02-16 00:00:00 | 2201-02-28 10:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Shortness of breath, nausea
Major Surgical or Invasive Procedure:
Right heart catheterization.
History of Present Illness:
Mr. ___ is a ___ yo gentleman with CAD s/p CABG, global
systolic dysfunction, HTN, HLD, CKD, DMII who presents with
shortness of breath and abdominal pain.
Patient has had 3 days of abdominal discomfort and nausea
improved with eating but associated cough w/ white sputum, SOB
and bilateral ___ swelling. No orthopnea, PND, CP, palpitations,
fever, emesis, diarrhea,sick contacts, ___ pain, N/V, or dysuria.
In the ED initial vitals were: ___, 90, 167/90, 16, 99% RA
EKG: None
Labs/studies notable for: BNP 13452, Na 129, Cr 1.3, WBC 3.7,
Hgb 10.8
Social History:
___
Family History:
Premature coronary artery disease- Father and mother both passed
away from an MI; mother was ___ and father was ___.
Physical Exam:
Admission:
GENERAL: Well appearing male in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple.
CARDIAC: RRR, normal S1, S2. Soft systolic murmur (II/VI) in
RLSB. No rubs/gallops. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No TTP/rebound/guarding.
EXTREMITIES: 2+ pedal edema. No clubbing or cyanosis. Moving
all extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Neuro: AOX3, CNII-XII intact
Discharge PHysical Exam:
VS: 98.1 123/63 57 18 100%RA
I/O: 300+/750 (spent much of yesterday off floor at RHC)
Wt 61.6
Dry weight: on last discharge weighed 66kg.
GENERAL: Thin, slightly wasted-looking male in NAD;
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP: 3cm above clavicle @ 30degrees
CARDIAC: RRR, normal S1, S2. systolic murmur (II/VI) in RLSB.
No rubs/gallops. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No TTP/rebound/guarding.
EXTREMITIES: No ___ today. No clubbing or cyanosis. Moving all
extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Neuro: AOX3
Pertinent Results:
Admission Labs:
============
___ 01:02PM GLUCOSE-140* UREA N-17 CREAT-1.1 SODIUM-129*
POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-26 ANION GAP-14
___ 01:02PM CALCIUM-9.5 PHOSPHATE-3.5 MAGNESIUM-1.7
___ 05:00AM LACTATE-1.1
___ 01:02PM cTropnT-0.01
___ 02:42AM cTropnT-<0.01
___ 04:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:50AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:50AM URINE HYALINE-1*
___ 04:50AM URINE MUCOUS-RARE
___ 02:42AM GLUCOSE-104* UREA N-19 CREAT-1.3* SODIUM-129*
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-25 ANION GAP-16
___ 02:42AM ALT(SGPT)-58* AST(SGOT)-60* ALK PHOS-122 TOT
BILI-0.4
___ 02:42AM LIPASE-33
___ 02:42AM ___
___ 02:42AM ALBUMIN-3.9
___ 02:42AM WBC-3.7* RBC-3.36* HGB-10.8* HCT-31.4* MCV-94
MCH-32.1* MCHC-34.4 RDW-13.2 RDWSD-45.6
___ 02:42AM NEUTS-55.7 ___ MONOS-9.7 EOS-3.2
BASOS-1.4* IM ___ AbsNeut-2.06 AbsLymp-1.10* AbsMono-0.36
AbsEos-0.12 AbsBaso-0.05
Discharge Labs:
============
___ 07:30AM BLOOD WBC-4.4 RBC-3.81* Hgb-12.0* Hct-35.5*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.2 RDWSD-44.6 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-105* UreaN-20 Creat-1.1 Na-132*
K-4.8 Cl-97 HCO3-26 AnGap-14
___:35AM BLOOD ALT-37 AST-38 AlkPhos-76 TotBili-0.6
___ 07:30AM BLOOD Calcium-10.2 Phos-3.5 Mg-2.0
Studies:
=======
CXR: ___
FINDINGS:
MILD TO MODERATE CARDIOMEGALY AND PULMONARY VASCULAR CONGESTION
ARE CHRONIC.
THERE IS NO GOOD EVIDENCE FOR PULMONARY EDEMA LEFT PLEURAL
THICKENING AND
ASSOCIATED LOWER LOBE ATELECTASIS ARE LONG-STANDING. SMALL
RIGHT PLEURAL
EFFUSION HAS RECURRED. NO PNEUMOTHORAX.
IMPRESSION:
1. PERSISTENT LEFT LOWER LOBE ATELECTASIS ASSOCIATED WITH
CHRONIC LEFT PLEURAL
SCARRING.
2. Pulmonary vascular congestion AND MILD TO MODERATE
CARDIOMEGALY OR CHRONIC.
ALTHOUGH THERE IS RECURRENT SMALL RIGHT PLEURAL EFFUSION THERE
IS NO PULMONARY
EDEMA.
Right Heart Catheterization ___:
High normal filling pressures, CI of 2.17, pulmonary HTN
See full report for details.
Brief Hospital Course:
Mr. ___ is a ___ yo gentleman with CAD s/p CABG, global
systolic dysfunction, HTN, HLD, CKD, DMII who presents with
shortness of breath, nausea and dyspepsia. Admitted for heart
failure.
#Acute on chronic systolic heart failure exacerbation
Most likely due to medication non-compliance
- Diuresed to euvolemia; right heart cath prior to admission
showed RA mean 3; Wedge 10; mean PA pressure mid ___. Discharged
on 20mg PO torsemide.
#Hyponatremia:
Somewhat hyponatremic at baseline; likely hypervolemic
hyponatremia in setting of heart failure; this improved with
diuresis.
#Indigestion and belching
Patient has had long-standing complaint of indigestion and
belching which improves with eating. Reports that he still has
good PO intake; no vomiting, diarrhea, or constipation.
Discomfort is attributed in part to abdominal congestion due to
CHF. Responds to famotidine and tums. Consider outpatient GI
work-up if symptoms persist even once euvolemic.
#Hypertension:
Patient hypertensive on admission, but has low pressures on home
antihypertensives (Hydralazine 25mg PO bid, Imdur 30 qday,
Amlodipine 2.5mg qday). Most likely a problem of medication
compliance.
#CAD: continue ASA 81mg, Atorvastatin 80, Metoprolol
# DM: written for insulin sliding scale, but had no elevated
blood sugars.
#Gout: Allopurinol ___ mg PO DAILY
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Metoprolol Succinate XL 25 mg PO DAILY
5. HydrALAzine 25 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Vitamin D 50,000 UNIT PO DAILY
9. Furosemide 10 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. HydrALAzine 25 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Vitamin D 50,000 UNIT PO DAILY
8. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
10. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic systolic heart failure
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital for heart failure. We gave you
IV lasix and your symptoms of cough and shortness of breath and
some of your nausea improved.
You were also treated for indigestion. We have prescribed
famotidine for your stomach symptoms. If you continue to have
stomach symptoms we recommend that you follow up with your
primary care provider or ___ gastroenterologist.
You were started on a new medications called torsemide. You will
take this instead of your Lasix (furosemide). All of your
medications are detailed in your discharge medication list. You
should review this carefully and take it with you to any follow
up appointments.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your dry weight (last weight here in the hospital)
is 61.6 kg (
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
19972786-DS-27 | 19,972,786 | 29,171,452 | DS | 27 | 2201-02-25 00:00:00 | 2201-02-28 10:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Nausea, Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac Cath.
History of Present Illness:
Mr. ___ is a ___ yo gentleman with CAD s/p CABG, global
systolic dysfunction, HTN, HLD, CKD, DMII who presents with
shortness of breath and abdominal pain. He was recently
admitted for CHF exacerbation with similar symptoms.
He was discharged ___ (4 days ago) and went home feeling ok,
though with persistent nausea and belching which was made better
by eating. He did not have any SOB until yesterday evening when
he was sitting, watching television, when he suddenly felt like
he could not breathe. He also has had some difficulty lying down
flat, though he denies this is due to shortness of breath.
Denies chest pain, palpitations, lower extremity edema,
lightheadedness, dizziness, fevers, sweats, chills, vomiting,
diarrhea, constipation (last BM yesterday), hematochezia,
difficulty urinating, joint pain, or rashes. He states that he
does take his medications though he cannot say what they are.
Per records his discharge weight was 61.6 kg, however he has not
been tracking his weight.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; post-op
Afib
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- LV global systolic dysfunction (___)
3. OTHER PAST MEDICAL HISTORY:
-HTN
-Type 2 DM
-Dyslipidemia
-GERD
-Peripheral neuropathy
-H/O gout
-Colonic polyps
Social History:
___
Family History:
Premature coronary artery disease- Father and mother both passed
away from an MI; mother was ___ and father was 75.
Physical Exam:
Admission Physical Exam:
===================
GENERAL: Well appearing male in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple.
CARDIAC: RRR, normal S1, S2. Soft systolic murmur (II/VI) in
RLSB. No rubs/gallops. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No TTP/rebound/guarding.
EXTREMITIES: 2+ pedal edema. No clubbing or cyanosis. Moving
all extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Neuro: AOX3, CNII-XII intact
Discharge Physical Exam:
===================
VS: 98.8 125/56 (99-143/50s) 50s-60s 18 100%RA
Weight 60.4 kg
I/O= 8hr: ___ 24hr: ___
GENERAL: WDWN in NAD. Oriented x2. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP at clavicle at 45 degrees
CARDIAC: RRR. III/VI systolic murmur loudest at apex, II/VI DM
loudest at LUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
Admission Labs:
============
___ 07:25PM GLUCOSE-178* UREA N-29* CREAT-1.5*
SODIUM-131* POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-26 ANION GAP-15
___ 07:25PM CALCIUM-10.2 PHOSPHATE-3.4 MAGNESIUM-1.8
___ 07:25PM PTT-92.8*
___ 05:34AM ___ PTT-29.3 ___
___ 05:20AM cTropnT-0.02*
___ 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:45AM D-DIMER-1300*
___ 12:56AM CK-MB-4
___ 12:56AM ALT(SGPT)-31 AST(SGOT)-40 ALK PHOS-112 TOT
BILI-0.4
___ 11:02PM cTropnT-0.02*
___ 11:02PM proBNP-8741*
___ 11:02PM WBC-4.8 RBC-4.02* HGB-12.8* HCT-37.9* MCV-94
MCH-31.8 MCHC-33.8 RDW-13.4 RDWSD-46.3
___ 11:02PM NEUTS-40.0 ___ MONOS-11.2 EOS-6.4
BASOS-1.7* AbsNeut-1.92 AbsLymp-1.96 AbsMono-0.54 AbsEos-0.31
AbsBaso-0.08
___ 11:02PM PLT COUNT-280
Discharge Labs:
=============
___ 07:30AM BLOOD WBC-4.6 RBC-3.64* Hgb-11.4* Hct-34.9*
MCV-96 MCH-31.3 MCHC-32.7 RDW-13.5 RDWSD-47.8* Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-102* UreaN-30* Creat-1.3* Na-134
K-5.1 Cl-97 HCO3-30 AnGap-12
___ 07:55AM BLOOD ALT-20 AST-31 AlkPhos-61
___ 07:30AM BLOOD Calcium-10.4* Phos-4.0 Mg-2.0 Iron-41*
___ 07:30AM BLOOD calTIBC-346 Ferritn-61 TRF-266
Studies:
Cardiac Catheterization (___)
The LMCA had tubular 40% stenosis. The only supply from the
LMCIA was an OM branch that has mild disease with 40-50%
stenosis and the SVG was seen to retrogradely fill from this
vessel back to the rams touchdown. The rams itself was a 0.5mm
vessel. The LAD filled via a LIMA and had mild disease the LIMA
itself was free of disease. The RCA was a tortuous vessel with
diffuse 40% stenosis proximally and 60% stenosis distally. The
SVG-RAMUS-OM was a diffusely diseased 2.0mm graft with long
diffused 70% disease touching down to the 0.5 mm Ramus and the
OM described previously that had mild disease. The SVG to LAD,
SVG to RCA were occluded.
Impression:
1. Moderate residual coronary disease
2. Occluded SVG RCA, SVG LAD.
3. SVG-RAMUS-OM not suitable for PCI.
Brief Hospital Course:
Mr. ___ is a ___ yo gentleman with CAD s/p CABG, global
systolic dysfunction (LVEF: 40-45%) repeat ECHO: LVEF 30%, HTN,
HLD, CKD, DMII who presents with shortness of breath and
abdominal pain. He was found to have a slightly increased
troponin as well as marked t-wave inversions in the
anterolateral leads; concern for ___.
#Troponinemia with t-wave inversions. Received loading dose of
___ in ED and heparin gtt, trops trended down. Repeated EKG
with improving T waves but still change from baseline. Coronary
angiography revealed disease of his SVG to RCA graft but good
flow to the RCA; no stentable lesion; medical management was
recommended. Continued daily ___.
#Dyspnea. Improved. History of CHF but does not appear to be
having an acute CHF exacerbation on physical exam. D-dimer was
elevated but CTA (final read) read as no PE. No tachycardia.
Appears euvolemic today. Continued home dose of torsemide and
spironolactone.
#Chronic systolic CHF (LVEF: 40-45% at last adimssion, most
recent LVEF is 30%) Not currently volume overloaded; BNP
elevated but lower than previous admission; was euvolemic to dry
on discharge 4 days prior to this admission (had RHCath on
previous admission). Cont metoprolol, torsemide, spironolactone,
losartan. Had previously stopped Imdur/Hydral due to
hypotension; Now restarting imdur 30 mg daily for after load
reduction and treatment of anginal symptoms.
#HTN
Has been hypertensive on past admissions and improved with home
medication regimen. BPs were in fact on the low side so we
discontinued Imdur/Hydral. Then restarted Imdur for
angina/afterload reduction. BP in good range on current
discharge regimen metoprolol, losartan, imdur. (See med list for
discharge dosing)
#Persistent dyspepsia
Nausea and belching that improves with eating. Concern that
this is anginal equivalent vs separate GI problem. GI work-up
recommended in past but not done. Seen by Gastroenterology
inpatient. EGD showed two antral nodules and an 8mm duodenal
mass. Biopsies were done and showed normal tissue in antrum and
chronic duodenitis. Hpylori testing was positive in early ___
and treated at that time; repeat Hpylori testing was pending at
discharge. Follow up with GI in ___ months is recommended.
Restarted pantoprazole (stopped famotidine);
#CAD: ___ 81mg, Atorvastatin 80
#CKD: monitor Cr; still stable at 1.3
#Hyponatremia: Hyponatremic at baseline and on previous
admissions due to obvious hypervolemia. Improved to 134 today.
#DM: Hemoglobin A1C in 6s since ___ on last admission
documented BG never over 140s; no fingersticks/ ISS required on
this admission. cont to monitor AM BG on Chemistries
# Gout: Allopurinol ___ mg PO DAILY
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. HydrALAzine 25 mg PO Frequency is Unknown
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Famotidine 20 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
9. Torsemide 10 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Torsemide 10 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Metoprolol Succinate XL 25 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Unstable Angina
Secondary: Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital for shortness of breath. We
found that you had EKG changes and other evidence that blood
flow to your heart was being blocked. We put you on a medication
that prevents blood from clotting and you improved. We did a
cardiac catheterization to determine which blood vessels to your
heart were blocked. No stents were placed and we have decided to
manage you with medicines.
You also have been having nausea, belching and belly pain that
improves when you eat. We consulted GI specialists to assess
your stomach problems and they recommended a test to look at
your esophagus and stomach called an EGD. The EGD showed
duodenitis.
We also put you on pantoprazole, a medication that can help with
stomach symptoms.
You were started on new medications including pantoprazole,
___ and losartan. It is very important that you continue to
take these. All of your medications are detailed in your
discharge medication list. You should review this carefully and
take it with you to any follow up appointments.
Because of your heart failure, please weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
The details of your follow up appointments are given below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
19972786-DS-28 | 19,972,786 | 20,400,012 | DS | 28 | 2201-05-04 00:00:00 | 2201-06-03 00:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is an ___ yo M with h/o CAD s/p CABG, sCHF (EF 30%),
HTN, HLD, CKD, DMII and peripheral neuropathy who presents with
recurrent, positional "dizziness".
Denies vertigo; dizziness has worsened over the past few days
and today he has felt unsteady on his feet as well. He was
recently admitted to the neurology service with similar
symptoms; at that time his MRI was negative for stroke and his
symptoms were felt likely due to a combination of orthostatis,
hypovolemic hyponatremia, and diabetic autonomic neuropathy.
Endorses nausea, but at his baseline; no vomiting, diarrhea.
Denies fevers/chills, URI-like symptoms.
In the ED, initial VS were 97.8 62 142/58 16 99% RA. Patient
evaluated by neurology for dizziness; neurology felt he was at
his baseline (naming difficulty, no cerebellar signs, +
peripheral neuropathy) and that dizziness was likely ___
orthostatic hypotesion; orthostatics were indeed positive. Labs
notable for bland UA, baseline anemia, normal chem10. CT Head
showed no acute process; chronic small vessel disease and
maxillary sinus disease. CXR showed pulmonary vascular
congestion and stable left pleural effusion. Patient was given 2
L IVF as well as Zofran, however persistently symptomatic, so
patient was admitted for further management.
On arrival to the floor, patient reports feeling better - able
to stand and walk from stretcher with only a little
unsteadiness.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; post-op
Afib
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- LV global systolic dysfunction (___)
3. OTHER PAST MEDICAL HISTORY:
-HTN
-Type 2 DM
-Dyslipidemia
-GERD
-Peripheral neuropathy
-H/O gout
-Colonic polyps
Social History:
___
Family History:
Premature coronary artery disease- Father and mother both passed
away from an MI; mother was ___ and father was ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 153/74 76 16 100% RA
139.7lbs (bed weight)
GENERAL: NAD
HEENT: PERRL, MMM
NECK: JVP at 2cm above clavicle at 45 degree
CARDIAC: RRR, S1/S2, II/VI systolic murmur loudest at apex,
II/VI DM loudest at LUSB
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
DISCHARGE
VS - 97.8 78 117/52 18 100%/RA
Weight: 61.3 kg standing
General: thin, well appearing, NAD
HEENT: anicteric sclera, PERRL, EOMI, dry OM, OP clear
Neck: supple, prominent arterial pulsations, no JVD, no LAD
CV: Regular rate, II/VI LUSB SEM, II/VI Apex SEM, no
rubs/gallops
Lungs: NLB, CTAB
Abdomen: soft, NT, ND, hypoactive BS
Ext: warm and well perfused, no cyanosis or edema
Neuro: A&O, CN II-XII intact, SILT, no weakness, ataxia, BLE
brisk reflexes
Pertinent Results:
ADMISSION
=========
___ 12:45PM WBC-4.2 RBC-3.47* HGB-10.8* HCT-33.2* MCV-96
MCH-31.1 MCHC-32.5 RDW-14.8 RDWSD-51.8*
___ 12:45PM NEUTS-57.7 ___ MONOS-7.4 EOS-1.7
BASOS-0.7 IM ___ AbsNeut-2.41 AbsLymp-1.35 AbsMono-0.31
AbsEos-0.07 AbsBaso-0.03
___ 12:45PM PLT COUNT-222
___ 12:45PM GLUCOSE-105* UREA N-19 CREAT-1.1 SODIUM-133
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
___ 12:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
PERTINENT
=========
LABS:
___ 06:00AM BLOOD WBC-4.2 RBC-3.79* Hgb-11.9* Hct-36.3*
MCV-96 MCH-31.4 MCHC-32.8 RDW-14.9 RDWSD-52.8* Plt ___
___ 06:00AM BLOOD Glucose-94 UreaN-21* Creat-1.1 Na-135
K-4.8 Cl-99 HCO3-27 AnGap-14
___ 06:00AM BLOOD Calcium-10.2 Phos-3.4 Mg-2.2
___ 06:50AM BLOOD ALT-17 AST-25 LD(LDH)-167 AlkPhos-71
TotBili-0.5
___ 06:50AM BLOOD proBNP-6844*
___ 06:50AM BLOOD VitB12-472 Folate-12.2
___ 06:50AM BLOOD %HbA1c-6.4* eAG-137*
___ 06:50AM BLOOD Cortsol-10.7
MICRO:
___ 12:45 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ ___:
1. No acute intracranial abnormality.
2. Extensive chronic small vessel ischemic disease.
3. Bilateral maxillary sinus disease, a component of which is
chronic on the left.
CXR ___: Mild pulmonary vascular engorgement and unchanged
small left pleural effusion. Continued bibasilar atelectasis.
Brief Hospital Course:
Mr. ___ is an ___ year old man with a history of CAD s/p 5v
CABG ___, ___ (EF 30%), CKD, DM2 who presents for second
admission for symptom of lightheadedness without vertigo. He was
found to have orthostatic vital signs. We believe this may be
due to autonomic neuropathy (history of diabetes, though fairly
well controlled) and medications (valsartan, metoprolol,
isosorbide, torsemide) contributing to impaired ability to
vasoconstrict adequately. His symptoms did not resolve with IVF,
suggesting he was not actually hypovolemic and supporting
autonomic dysfunction. Imdur was held on discharge and patient
was prescribed compression stockings. He was deemed to be safe
for discharge home.
# Orhtostatic Hypotension: likely ___ diabetic autonomic
neuropathy, though currently well controlled with A1c 6.4.
Neurology evaluated patient and though it was not likely an
alternative neurologic process; CT head notable only for chronic
cerebral vascular disease. Alternate etiologies include
medication related (on diuretic as well as ___ and arterial
dilators). Adrenal insufficiency considered but unlikely as
cortisol was 10.4 in early AM. B12/folate levels WNL. Patient
was ambulating with improved but not resolved symptoms s/p IVF.
Imdur was held and patient prescribed compression stockings on
discharge. Will F/U with neurology and cardiology.
# Chronic systolic CHF: LVEF is 30%, last ECHO ___. S/p 2L
IVF in ED. Last discharge dry weight 60.4 kg; appeared
relatively dry to euvolemic and near dry weight with BNP down
from last admission. Continued home metoprolol, spironolactone,
losartan, torsemide.
CHRONIC
#GERD: continued home pantoprazole
#CAD: s/p CABG: continued home ASA 81mg, Atorvastatin 80mg
#CKD: Cr at baseline of 1.0
#DM: Hemoglobin A1C in 6s since ___ on metformin at home: low
dose ISS while admitted
#Gout: continued home allopurinol ___
#Anemia: chronic, normocytic: stable
TRANSITIONAL
[]repeat EGD ___ per last GI note and ___ EGD
recommendations
[]consider stopping clopidogrel when deemed medically
appropriate (on since ___
[]follow up to see if patient has angina symptoms off of ISMN
[]follow up with neurology as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Torsemide 10 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Torsemide 10 mg PO DAILY
9. Vitamin D ___ UNIT PO 1X/WEEK (___)
10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
11. Compression stalkings
Compression stockings ___.
ICD10 ___.1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Orthostatic hypotension
#Probable diabetic autonomic neuropathy
SECONDARY DIAGNOSES:
#Coronary artery disease
#Chronic systolic congestive heart failure
#Type 2 diabetes
probable dehydration and medication effect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at the ___
___. You were admitted for feeling dizzy
with walking.
Your symptoms improved but did not resolve with intravenous
fluids. You were seen be neurologists who felt that you 1) did
not have any evidence of a stroke 2) your dizziness is likely
due to orthostatic hypotension (low blood pressure when changing
from sitting to standing). At home, you should get up from bed
and sitting very slowly. We stopped your isosorbide mononitrate
which can lower blood pressure as your blood pressures in the
hospital were reasonable 140s-150s. We are going to prescribe
compression stockings to prevent blood from pooling in your
legs.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow your new medication list.
Followup Instructions:
___
|
19972786-DS-32 | 19,972,786 | 23,470,157 | DS | 32 | 2204-09-03 00:00:00 | 2204-09-04 08:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / tizanidine
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx of HFrEF (EF 30%), CAD s/p CABG (LIMA-LAD, SVG-OM),
and HTN, CKD (1.2-1.3), mild dementia who presented to the ED
for
hip/back pain, found to have volume overload on exam, elevated
BNP, CXR with pulm edema, ___ c/w acute decompensated HFrEF.
Pt states that for the last several weeks he has noticed more
fluid. He went to his outpt cardiologist on ___ where he was
found to be volume overloaded. TTE showed EF 28% similar to
prior. Torsemide increased to 80 mg daily.
In the ED,
VS: 98.0 80 ___ 96% RA
EKG: SR, no ischemic changes
LABS:
- CBC: WBC 4.6, Hgb 9.6, plt 212
- Chem: Na 132, BUN 46, Cr 1.6
- Trop T: 0.04
- LFTs ALT 503, AST 357, Tb 0.5
- UA: Tr prot, otherwise unremarkable
- BNP 19000
IMAGING/STUDIES:
- CXR:
Mild pulmonary vascular congestion. Low lung volumes. Patchy
basilar opacities could be due to atelectasis, but infection or
aspiration is not excluded.
- CT A&P:
1. Acute fracture through the anterior inferior base of the L4
vertebral body.
2. Small amount of perihepatic and pelvic ascites. In the
presence of
gynecomastia, Findings may represent underlying liver disease.
Correlation with liver function tests is recommended.
3. No acute intraabdominal process identified.
4. No fracture, dislocation, or radiographic evidence of
steomyelitis or necrosis of the left hip.
- Pelvis XR:
No acute fracture or dislocation of the left hip or left femur.
Acute fracture of the anterior, inferior L4 vertebra was better
assessed on preceding CT.
CONSULTS:
- Spine consult: There is no spinal intervention for this and no
bracing needed. The patient can follow up in spine clinic with
Dr. ___.
MEDS:
11:29 PO Acetaminophen 1000 mg ___
___ 12:25 IV HYDROmorphone (Dilaudid) .25 mg ___
Partial Administration
___ 13:30 IV HYDROmorphone (Dilaudid) .25 mg ___
Partial Administration
___ 15:33 IV Furosemide 120 mg ___
___ 15:33 PO/NG OxyCODONE (Immediate Release) 2.5 mg
___
ED COURSE:
___ 16:45: VOID. ___ mL
On the floor, endorses the hx above. Denies dyspnea, orthopnea,
PND. Does endorse ___ Lt back/hip pain.
REVIEW OF SYSTEMS: Positive per HPI. Remaining 10 pt ROS
reviewed
and negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CAD s/p CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA;
- CHF, chronic systolic: Amyloid heart disease and ischemic
cardiomyopathy.
3. OTHER PAST MEDICAL HISTORY:
-HTN
-Type 2 DM
-Dyslipidemia
-GERD
-Peripheral neuropathy
-H/O gout
-Colonic polyps
Family History:
Premature coronary artery disease- Father and mother both passed
away from an MI; mother was ___ and father was ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: ___ ___ Temp: 97.4 PO BP: 155/69 L Lying HR: 92 RR: 18
O2 sat: 98% O2 delivery: RA
Wt: 147 lb
GENERAL: Confused in NAD.
HEENT: EOMI, PERRLA, MMM
NECK: Supple. JVP of 15 cm.
CARDIAC: RRR, no m/r/g
LUNGS: Crackles throughout, no wheezing
ABDOMEN: Soft, NT, ND
Back: Lt flank/hip pain with movement, associated tender
paraspinal muscle spasm
GU: No foley
EXTREMITIES: WWP, 2+ pitting edema b/l to knees.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: CN II-XII intact, MAE
DISCHARGE PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 736)
Temp: 98.2 (Tm 98.5), BP: 135/68 (97-142/53-68), HR: 74
(71-80), RR: 20 (___), O2 sat: 98% (97-100), O2 delivery: RA
Fluid Balance (last updated ___ @ 922)
Last 8 hours Total cumulative -90ml
IN: Total 360ml, PO Amt 360ml
OUT: Total 450ml, Urine Amt 450ml
Last 24 hours Total cumulative -318ml
IN: Total 1057ml, PO Amt 1057ml
OUT: Total 1375ml, Urine Amt 1375ml
GENERAL: alert and conversational, confused at baseline
HEENT: EOMI, MMM
NECK: JVP 8cm
CARDIAC: RRR, no m/r/g
LUNGS: Lungs clear
ABDOMEN: Soft, NT, ND
EXTREMITIES: WWP, no edema
NEURO: Moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
==============
___ 11:50AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:50AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 11:50AM URINE HYALINE-2*
___ 11:35AM GLUCOSE-133* UREA N-46* CREAT-1.6*
SODIUM-132* POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-24 ANION GAP-15
___ 11:35AM estGFR-Using this
___ 11:35AM ALT(SGPT)-503* AST(SGOT)-357* ALK PHOS-126
TOT BILI-0.5
___ 11:35AM LIPASE-23
___ 11:35AM cTropnT-0.04*
___ 11:35AM ALBUMIN-3.4*
___ 11:35AM WBC-4.6 RBC-3.07* HGB-9.6* HCT-28.6* MCV-93
MCH-31.3 MCHC-33.6 RDW-15.9* RDWSD-54.4*
___ 11:35AM WBC-4.6 RBC-3.07* HGB-9.6* HCT-28.6* MCV-93
MCH-31.3 MCHC-33.6 RDW-15.9* RDWSD-54.4*
___ 11:35AM NEUTS-73.3* LYMPHS-10.9* MONOS-12.6 EOS-2.6
BASOS-0.2 IM ___ AbsNeut-3.37 AbsLymp-0.50* AbsMono-0.58
AbsEos-0.12 AbsBaso-0.01
___ 11:35AM PLT COUNT-212
___ 11:35AM ___ PTT-28.5 ___
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-4.4 RBC-3.49* Hgb-10.9* Hct-33.6*
MCV-96 MCH-31.2 MCHC-32.4 RDW-16.4* RDWSD-55.6* Plt ___
___ 07:15AM BLOOD Glucose-118* UreaN-47* Creat-1.4* Na-139
K-4.6 Cl-95* HCO3-27 AnGap-17
___ 07:23AM BLOOD ALT-65* AST-48* AlkPhos-87 TotBili-0.8
IMAGING:
========
___ (PA & LAT)
IMPRESSION:
Mild pulmonary vascular congestion. Low lung volumes. Patchy
basilar opacities could be due to atelectasis, but infection or
aspiration is not excluded.
___ PELVIS & FEMUR
IMPRESSION:
No acute fracture or dislocation of the left hip or left femur.
Acute fracture of the anterior, inferior L4 vertebra was better
assessed on
preceding CT. Left knee chondrocalcinosis.
___ ABD & PELVIS W/O CON
IMPRESSION:
1. Acute fracture through the anterior, inferior base of the L4
vertebral
body.
2. Small amount of perihepatic and pelvic ascites. In the
presence of
gynecomastia, Findings may represent underlying liver disease.
Correlation
with liver function tests is recommended.
3. No fracture of the left hip identified.
MICROBIOLOGY:
=============
___ 11:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
SUMMARY:
___ w/ PMHx of HFrEF (EF 30%), CAD s/p CABG (LIMA-LAD, SVG-OM),
and HTN, CKD (1.2-1.3), mild dementia who presented to the ED
for hip/back pain, found to have L4 vertebral fracture.
Neurosurgery saw him and recommended conservative management. He
was also found to be volume overload on exam, elevated BNP, CXR
with pulm edema, ___ c/w acute decompensated HFrEF. He was
admitted to the CHF service and diuresed with IV lasix gtt @ 40.
He was transitioned to PO Torsemide and titrated to maintain
euvolemia. he was discharged at dry wt of 127 lbs with close
follow up with cardiology for continued management
TRANSITIONAL ISSUES:
==================
[] Post-Discharge Follow-up Labs Needed: Repeat chemistry ___
to ensure Cr and electroyltes stable on diuretic
[] F/u appts: ___ clinic, Cardiology, Neurosurgery
CHF:
[] Discharge weight: 127 lbs
[] Discharge diuretic: Torsemide 100
[] Discharge Cr: 1.4
[] Please weigh the patient every day. Should his weight
increase by ___ lbs above his dry wt, please give an extra dose
of Torsemide 100 mg and repeat chem
OTHER:
[] Follow up with spine for L4 vertebral fracture.
[] Patient evaluated by speech and swallow as inpatient who
suggested that patient be discharged on ground diet with thin
liquids. Recommend repeat in ___ weeks.
[] Patient with significant belching causing emotional distress
in the setting of constipation. Please ensure patient is having
___ BM per day. Patient requiring suppositories as inpatient.
# CODE: Full (presumed)
# CONTACT: ___ (grand-daughter) ___
CORONARIES: CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM,
dRCA), last LHC ___ with non-flow limiting stenosis of RCA
PUMP: Last TTE ___ EF 28% global HK
RHYTHM: SR
ACUTE ISSUES:
===============
# Acute on Chronic HFrEF:
# Ischemic/amyloid CMP
Hx of mixed iCMP and amyloid CMP. Presents with wt 147 up from
dry wt of 135, elevated JVP and edema on exam. proBNP now 20K,
CXR with congestion. Unclear precipitant of decompensation at
this time. Possibly represents natural progression of underlying
amyloid heart disease vs problems with med administration.
Started on lasix gtt to remove fluid requiring dose as high as
40cc. NHBK: No metop iso amyloid. Afterload: continued home
Isordil 20/Hydral 10 TID, losartan 12.5 mg. Repleted iron with 4
days of IV iron.
# L4 vertebral fracture:
New, found on CT. Spine consulted who rec non-op management.
Tylenol ___ q8h. Lidocaine patch x2. Low dose oxycodone as
needed. Pt was given TIZANIDINE, but became hypotensive and was
discontinued. Will need F/u w/ spine as outpt
#Choking
Patient noted to be choking while eating on several occasions
per nursing notes. Concerned that patient may be aspirating. S&S
evaluation including video swallow showed that despite food
intermittently entering the trachea, patient had good cough so
did not aspirate. Speech and swallow recommended that patient
continue on ground diet with thin liquids.
# CAD s/p CABG x5
# Elevated Troponin:
CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, dRCA), last
LHC ___ with non-flow limiting stenosis of RCA. Trop T 0.04
on admission, mild near his baseline. No significant ECG
changes. Suspect demand iso of CHF exacerbation. Continued home
DAPT and atorvastatin for ischemic CM. Patient was continued on
DAPT because per discussion with outpatient cardiologist,
patient has tolerated regimen thus far.
# ___ on CKD:
Cr 1.6 from baseline 1.3-1.4. Suspect cardiorenal. Cr at
discharge 1.6.
# Transaminitis:
Elevated in past with CHF exacerbations. Likely congestive
hepatopathy. LFTs on discharge had continued to downtrend.
CHRONIC ISSUES:
===============
# HTN: Continued Hydral + Imdur as above. Losartan as above
# Type 2 DM: Held home metformin. ISS in house
# GERD: Continued pantoprazole 40mg BID
# CODE: Full (presumed)
# CONTACT: ___ (grand-daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. HydrALAZINE 10 mg PO TID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Losartan Potassium 12.5 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
10. Torsemide 80 mg PO DAILY
11. Simethicone 40-80 mg PO TID abd pain/gas
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
Please hold for loose stools.
2. Senna 8.6 mg PO BID
3. Torsemide 100 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. HydrALAZINE 10 mg PO TID
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Losartan Potassium 12.5 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Simethicone 40-80 mg PO TID abd pain/gas
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Heart failure with reduced ejection fraction
L4 vertebral fracture
Acute kidney injury in the setting of chronic kidney disease
SECONDARY:
==========
Coronary artery disease
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. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a back fracture
- You had extra fluid in your body
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- Neurosurgery was consulted for your back. No intervention was
needed.
- We gave you medication to remove fluid from your body
- You were also seen by the speech and swallow team who
suggested you eat a ground diet to lower your risk of food
entering your lung.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs from your discharge weight of
127.2
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19972786-DS-34 | 19,972,786 | 21,739,538 | DS | 34 | 2205-02-21 00:00:00 | 2205-02-23 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / tizanidine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM BLOOD WBC-4.8 RBC-3.09* Hgb-10.0* Hct-31.0*
MCV-100* MCH-32.4* MCHC-32.3 RDW-15.9* RDWSD-57.6* Plt ___
___ 09:00PM BLOOD Neuts-78.0* Lymphs-13.8* Monos-5.7
Eos-1.3 Baso-0.6 Im ___ AbsNeut-3.72 AbsLymp-0.66*
AbsMono-0.27 AbsEos-0.06 AbsBaso-0.03
___ 07:04AM BLOOD ___ PTT-29.4 ___
___ 09:00PM BLOOD Glucose-164* UreaN-32* Creat-1.3* Na-142
K-3.7 Cl-99 HCO3-30 AnGap-13
___ 09:00PM BLOOD Calcium-10.1 Phos-2.4* Mg-2.0
PERTINENT LABS:
===============
___ 07:04AM BLOOD ALT-93* AST-37 LD(LDH)-241 AlkPhos-98
TotBili-1.0
___ 09:00PM BLOOD CK-MB-3 cTropnT-0.08* ___
___ 03:10AM BLOOD CK-MB-3 cTropnT-0.08*
___ 06:15AM BLOOD cTropnT-0.06*
DISCHARGE LABS:
===============
___ 07:20AM BLOOD WBC-5.0 RBC-3.46* Hgb-11.1* Hct-34.2*
MCV-99* MCH-32.1* MCHC-32.5 RDW-15.9* RDWSD-57.1* Plt ___
___ 07:20AM BLOOD Glucose-109* UreaN-49* Creat-1.4* Na-138
K-4.3 Cl-90* HCO3-33* AnGap-15
___ 07:20AM BLOOD Calcium-10.3 Phos-2.7 Mg-2.3
IMAGING:
========
NONE
Brief Hospital Course:
Mr. ___ is an ___ year old male with past medical history
significant for CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM,
dRCA; cath ___ w/severe stenosis of SVG-RCA not amenable to
PCI), HFrEF ___ (infarct-mediated iso fixed perfusion
defects, and TTR amyloid cardiomyopathy), HTN, DM2, HLD, CKD
stage 3, GERD, gout, and dementia (MMS ___ in ___ who
presents with two weeks of increasing shortness of breath and is
being admitted to ___ service for HF exacerbation. He was volume
overloaded and diuresed well with IV Lasix boluses. His SOB
improved and he was discharged on Torsemide 100 BID.
====================
TRANSITIONAL ISSUES:
====================
Discharge Cr: 1.4
Discharge Weight: 113.98lb
Discharge diuretic: Torsemide 100mg BID, metolazone 5mg
daily:PRN for weight gain greater than 3 lbs
[ ] We increased his home diuretic dosing from Torsemide 80mg
QAM and 60mg QPM to 100mg BID
[ ] Patient should be weighed daily. If his weight increases by
3 lbs, he should receive po metolazone 5mg and KCl 40 mEq.
[ ] We discussed his condition with his granddaughter, who is
his HCP, and they made the decision to enroll in hospice upon
discharge. In my discussions with the patient he does not seem
to grasp the severity of his condition or be able to engage in
conversations about overall prognosis due to this limited
understanding.
===============
ACTIVE ISSUES:
===============
# Acute on chronic decompensated heart failure
# HFrEF 28% (infarct-mediated iso fixed perfusion defects, and
TTR amyloid cardiomyopathy; global biventricular dysfunction)
# Moderate TR:
The patient presented with evidence of heart failure
exacerbation after recent HF admission. Potential triggers
include recent URI/pneumonia given cough, although afebrile and
no white count. Reports med and diet compliance. PE unlikely
given history, however, recently hospitalized patient w/o
anticoagulation. ACS less likely based on troponins and EKG.
Most likely this represents progression of his heart failure. We
discussed with his HCP/granddaughter who reports that they have
started palliative care discussions with doctors at his nursing
home about goals of care. We diuresed him with IV Lasix boluses,
and his SOB symptoms improved, although he continued to complain
of belching, likely due to abdominal congestion from his volume
overload. He was transitioned to Torsemide 100mg BID prior to
discharge, which is increased from his home dose of Torsemide
80AM, 60PM. He is also being discharged on metolazone 5mg
daily:PRN for weight gain greater than 3 lbs which should be
taken with potassium chloride 40 mEq. We continued him on his
home hydralazine 10mg TID and isosorbide mononitrate ER 30mg
BID.
# CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, dRCA; cath
___
w/severe stenosis of SVG-RCA not amenable to PCI)
He was continued on his home aspirin 81, Plavix 75, atorvastatin
80, and Imdur 30mg BID
#CKD
His Cr was stable during the admission at his baseline of
1.3-1.6.
# Macrocytic anemia:
His Hgb was stable at his baseline of ___.
================
CHRONIC ISSUES:
================
# Gout:
He was continued on home allopurinol ___ daily.
# HLD:
He was continued on home atorvastatin 80mg qhs.
# DM2:
His home metformin was held and he was given sliding scale
insulin.
# GERD:
He was continued on his home PO pantoprazole 40 daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
6. Calcium Carbonate 500 mg PO QID:PRN indigestion
7. Clopidogrel 75 mg PO DAILY
8. HydrALAZINE 10 mg PO TID
9. Torsemide 80 mg PO QAM
10. Torsemide 60 mg PO QPM
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
12. Benzonatate 100 mg PO TID:PRN Cough
13. Pantoprazole 40 mg PO Q24H
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Simethicone 80 mg PO QID:PRN gas
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
17. GuaiFENesin ___ mL PO Q6H:PRN Cough
18. Isosorbide Dinitrate 30 mg PO BID
Discharge Medications:
1. MetOLazone 5 mg PO DAILY:PRN weight gain of 3lbs in one day
2. Potassium Chloride 40 mEq PO DAILY:PRN when taking
metolazone
Hold for K >
3. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Benzonatate 100 mg PO TID:PRN Cough
9. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
10. Calcium Carbonate 500 mg PO QID:PRN indigestion
11. Clopidogrel 75 mg PO DAILY
12. GuaiFENesin ___ mL PO Q6H:PRN Cough
13. HydrALAZINE 10 mg PO TID
14. Isosorbide Dinitrate 30 mg PO BID
15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. Simethicone 80 mg PO QID:PRN gas
Hyperkalemia precludes the use of ___. Beta
blockers not prescribed due to intolerance in the setting of
biopsy confirmed cardiac amyloidosis.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-acute on chronic systolic heart failure
-chronic kidney disease
-type 2 diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were feeling short of breath because you had fluid in your
lungs.
- This was caused by a condition called heart failure, where
your heart does not pump hard enough and fluid backs up into
your lungs.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given medications to help get the fluid out.
- Your breathing got better and were ready to leave the
hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is
113.98lb. Call your doctor if your weight goes up or down more
than 3 pounds (increases to a weight of 117lb) in one day or 5
lb in one week.
- Call you doctor if you notice any of the "danger signs" below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19973083-DS-5 | 19,973,083 | 20,741,363 | DS | 5 | 2123-10-20 00:00:00 | 2123-10-21 07:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Aortic valve replacement with a 25 mm Onyx mechanical valve
on ___ (Dr ___
Transesophageal ECHO ___
History of Present Illness:
Ms. ___ is a ___ yo woman with a history of aortic
insufficiency and congestive heart failure status post aortic
valve replacement with On-X valve on ___. She was discharged
home on POD 6 on Coumadin for mechanical valve/ atrial
___ syndrome. Cardiac surgery
office received call ___ from patient complaining of
intermittent SOB. Patient reports she felt fine when she woke
this am and became acutely short of breath about 2300 ___. She
had a bedside echo by cardiology in the ED which showed no
pericardial effusion and severe MR, which was unchanged from an
echo 1 week prior. In the ED she had worsening dyspnea and
hypoxia ___ on NRB and was placed on bipap with
significant improvement in symptoms. She was given Lasix with
brisk response. She is transferred to ___ for further care.
Past Medical History:
Anemia
___ Syndrome
Aortic Insufficiency
Breast Mass, left
Cerebrovascular Accident
Congestive Heart Failure, acute diastolic
Hypertension
Lupus
Nocturnal Polyuria
Non-specific reaction to PPD without tuberculosis
Pre-diabetes
Surgical History:
Cesarean-section, ___
Hysterectomy, ___
Social History:
___
Family History:
Mother- HTN
Father- HTN
** no premature coronary artery disease
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
Temp 98.6 137/96 HR 76 16 92% NRB
Height: 65" Weight:
General: Awake, alert in moderate distress, tachypnic, leaning
forward, ___ word dyspnea
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []-not examined due to patient discomfort
Neck: Supple [x] Full ROM [x]
Chest: Lungs-crackles ___ way up posteriorly, scattered wheezes,
sputum productive white/creamy
Heart: RRR [x] + mech click unable to assess for murmur due to
patient positioning
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema L>R
Varicosities: None [x]
Neuro: Grossly intact [x]
sternal incision clean, dry, sternum stable
Pulses:
DP Right:+ Left:+
___ Right:+ Left:+
==========================
DISCHARGE PHYSICAL EXAM
==========================
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 with JVP not elevated above the clavicle at 90
degrees.
CARDIAC: RRR, normal S1, prominent S2. ___ click heard
diffusely.
___ holosystolic murmur hear best at apex No rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. WWP
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Midline
sternotomy with dressing CDI.
Pertinent Results:
======================
ADMISSION LAB RESULTS
======================
___ 02:19AM BLOOD WBC-7.1 RBC-3.92 Hgb-8.2* Hct-28.5*
MCV-73* MCH-20.9* MCHC-28.8* RDW-18.6* RDWSD-47.3* Plt ___
___ 02:19AM BLOOD Neuts-69.7 Lymphs-13.6* Monos-14.3*
Eos-1.6 Baso-0.4 Im ___ AbsNeut-4.91 AbsLymp-0.96*
AbsMono-1.01* AbsEos-0.11 AbsBaso-0.03
___ 02:19AM BLOOD Neuts-69.7 Lymphs-13.6* Monos-14.3*
Eos-1.6 Baso-0.4 Im ___ AbsNeut-4.91 AbsLymp-0.96*
AbsMono-1.01* AbsEos-0.11 AbsBaso-0.03
___ 02:19AM BLOOD ___ PTT-52.7* ___
___ 02:19AM BLOOD Glucose-112* UreaN-50* Creat-2.2* Na-137
K-5.1 Cl-101 HCO3-22 AnGap-14
___ 02:19AM BLOOD proBNP-5530*
___ 02:19AM BLOOD cTropnT-0.03*
___ 02:19AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2
___ 02:25AM BLOOD ___ pO2-36* pCO2-42 pH-7.42
calTCO2-28 Base XS-2
___ 02:25AM BLOOD Lactate-2.1*
======================
DISCHARGE LAB RESULTS
======================
___ 07:15AM BLOOD WBC-3.5* RBC-3.93 Hgb-8.2* Hct-28.1*
MCV-72* MCH-20.9* MCHC-29.2* RDW-17.9* RDWSD-45.3 Plt ___
___ 07:10AM BLOOD ___ PTT-51.3* ___
___ 07:10AM BLOOD Glucose-103* UreaN-52* Creat-2.1* Na-145
K-4.3 Cl-102 HCO3-26 AnGap-17
___ 07:10AM BLOOD Glucose-103* UreaN-52* Creat-2.1* Na-145
K-4.3 Cl-102 HCO3-26 AnGap-17
___ 07:10AM BLOOD ALT-27 AST-24 AlkPhos-134* TotBili-0.2
___ 07:10AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0
=======================
IMAGING AND REPORTS
=======================
Transthoracic Echocardiogram ___
There is mild symmetric left ventricular hypertrophy with a
normal cavity size. There is normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection fraction is 55%.
There is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Diastolic parameters are
indeterminate. Normal right ventricular cavity size with
moderate global free wall hypokinesis. There is post-thoracotomy
interventricular septal motion. A mechanical aortic valve
prosthesis is present. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is moderate to severe [3+] mitral regurgitation.
The pulmonic valve leaflets are normal. The tricuspid
valve leaflets appear structurally normal. There is moderate to
severe [3+] tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. In the setting of at least
moderate to severe tricuspid
regurgitation, the pulmonary artery systolic pressure may be
UNDERestimated. There is a small to moderate loculated
pericardial effusion. There is normal respiratory variation in
transmitral or transtricuspid inflow, suggesting absence of
tamponade physiology. Bilateral pleural effusions are present.
IMPRESSION: Focused study. Mild symmetric left ventricular
hypertrophy with preserved left ventricular systolic function.
Moderately hypokinetic right ventricle. Well-seated, mechanical
aortic valve (gradients not assessed). Moderate to severe mitral
and tricuspid regurgitation. Moderate
pulmonary hypertension. Small to moderate (from 0.8 up to 1.4
cm) focal pericardial effusion anterior to the right atrium
without echocardiographic evidence of tamponade. Bilateral
pleural effusions.
Transthoracic Echocardiogram ___
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. 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. The visually estimated left ventricular ejection
fraction is >=60%. Due to severity of mitral regurgitation,
intrinsic left ventricular systolic function is likely lower.
Left ventricular cardiac index is normal (>2.5 L/min/m2). There
is no resting left ventricular outflow tract gradient. Normal
right ventricular cavity size with mild global free wall
hypokinesis. Tricuspid annular plane systolic excursion (TAPSE)
is depressed. There is post-thoracotomy interventricular septal
motion. The aortic sinus diameter is normal for gender. A
bileaflet mechanical aortic
valve prosthesis is present. The prosthesis is well seated with
normal disc motion and transvalvular gradient. The effective
orifice area index is moderately reduced (0.65-0.85 cm2/m2).
There is trace (normal for
prosthesis) aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is moderate to severe [3+] mitral regurgitation. The tricuspid
valve leaflets appear
structurally normal. There is an eccentric, interatrial sepal
directed jet of mild to moderate [___] tricuspid regurgitation.
There is mild pulmonary artery systolic hypertension. There is a
small pericardial effusion anterior to the right atriuim (clip
31). A left pleural effusion is present.
IMPRESSION: Well seated, normal functioning bileaflet mechanical
AVR with normal gradient and trace aortic regurgitation.
Moderate to severe mitral regurgitation with normal valve
morphology. Mild pulmonary artery systolic hypertension.
Mild-moderate tricuspid regurgitation.
TRANSESOPHAGEAL ECHO ___
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. Theleft atrial appendage
ejection velocity is normal. No spontaneous echo contrast or
thrombus is seen in thebody of the right atrium/right atrial
appendage. The right atrial appendage ejection velocity is
normal. There isno evidence for an atrial septal defect by
2D/color Doppler. Overall left ventricular systolic function is
normal.Due to severity of mitral regurgitation, intrinsic left
ventricular systolic function is likely lower. The
rightventricle has depressed free wall motion. Intrinsic right
ventricular systolic function is likely lower due to theseverity
of tricuspid regurgitation. There are simple atheroma in the
descending aorta to 40cm from theincisors. A bileaflet
mechanical aortic valve prosthesis is present. The prosthesis is
well seated with normaldisc motion and transvalvular gradient.
No masses or vegetations are seen on the aortic valve. No
abscess isseen. There is no aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral
valveprolapse. No masses or vegetations are seen on the mitral
valve. No abscess is seen.There is a central jet ofmoderate to
severe mitral regurgitation [3+].The tricuspid valve leaflets
appear structurally normal. Nomass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild to moderate
___ regurgitation. There is moderate pulmonary
artery systolic hypertension. There is a trivial
pericardialeffusion.
IMPRESSION: Moderate to severe functional mitral regurgitation.
Well seated mechanical bileafletOn-X aortic valve with normal
disc motion and transvalvular gradients. Grossly normal
leftventricular systolic function with depressed right
ventricular systolic function. Mild to moderatetricuspid
regurgitation. At least moderate pulmonary artery systolic
hypertension.
Brief Hospital Course:
___ yo female with a past medical history of CVA,
antiphospholipid syndrome on warfarin, and AI s/p AVR ON-X on
___ who upon discharge has been experiencing recurrent
progressive SOB requiring inpatient diuresis (___) now
with progressive SOB. TTE on admission showed 3+ MR, EF 54%. She
was admitted to the cardiac surgery service where she was
diuresed with steady improvement in her symptoms and volume
status on exam. Once euvolemic a TTE continued to demonstrate
moderate to severe MR; TEE ___ performed showing 3+ MR with ___
central jet of MR. ___ was maintained on 40mg of torsemide.
=====================
Transitional issues:
=====================
[ ] ___ to draw labs on ___ for appointment with Dr. ___
___ on ___. This will include BMP and INR. The INR will
be followed up by her primary care physician, ___.
[ ] Discharge creatinine: 2.1
[ ] Discharge weight: 150 pounds
[ ] Discharge diuretic: 40mg of torsemide
[ ] Patient is completing a reload of amiodarone for persistent
atrial fibrillation (despite being on amiodarone
postoperatively). She will continue on 200 bid until ___. Then,
she should be on 200 mg daily.
[ ] Please consider referral to nephrology for establishment of
care given likely new CKD
# CORONARIES: No artherosclerosis
# PUMP: LVEF >60% (visual estimate)
# RHYTHM: NSR with short lasting pAfib
ACUTE PROBLEMS:
===============
#Valvular heart disease
#Severe MR
Ms. ___ has been experiencing recurrent exacerabations of
her valvular heart disease. She initially underwent aortic valve
replacement in on ___. Her aortic insufficiency was thought
to be a consequence of remote endocarditis. Post operatively,
she was found to have new moderate mitral regurgitation. On
subsequent TTE, the regurgitation was worsening. She was
discharged on oral diuretics, but became dyspneic at home. On
this admission, her TTE showed 3+ MR, EF 54%. This was on ___.
She responded well to aggressive diuresis. Echo on ___, with
Ms. ___ at near ___, demonstrated moderate to severe
MR increasing the concern for a primary valvulopathy (SLE) or
structural cause of her MR possibly secondary to the aortic
valve replacement. TEE ___ continued to demonstrate 3+ MR with ___
central jet of MR, no prolapse, no valvular lesions. This did
not reveal an etiology for her MR. ___ weight
remained stable on PO diuretics and it was felt that it was safe
to discharge her home on an oral regimen of torsemide 40 mg
daily. with close follow up. D/c Weight 150.57 lbs
#AOCKI
Looking at creatinine in BI system. It appears that in early
___ Ms. ___ had a baseline creatinine of 1.0. Following
her AVR, creatinine rose to 3.9. This raises concern for
perioperative kidney injury/ATN. It does not appear that Ms.
___ renal function has fully recovered since that time.
It appears that her new baseline creatinine is 1.6. Given
chronicity of 1 month, does not meet criteria for CKD. She was
aggressively diuresed this admission, with creatinine peaking to
2.2. She remained stable on PO torsemide. Discharge creatinine
was 2.1. Patient should see a nephrologist after discharge.
#pAfib
Ms. ___ first experience afib perioperatively. A fib this
hospitalization, 1 month out from procedure, was paroxysmal. She
continued to experience paroxysmal afib while on amiodarone 200
mg. Amiodarone was reloaded by increase to 200 mg BID for two
weeks ___ - ___ and then to amiodarone 200 mg QD. With
amiodarone increased, Ms. ___ rate returned to ___ with
first degree AV block. Warfarin was continued with a goal INR of
2.5 - 3.5 (confirmed with cardiac surgery: higher goal given
history of CVA, pAFIB, and AVR). Her next INR check will be two
days after discharge, ___ and her labs will be sent to
PCP for dose adjustments.
#SLE
#Anti phospholipid syndrome
APLS diagnosed in ___. Records not available to investigate
further work up or reason for testing. No work up mentioned in
available records since that time. New onset valvular heart
disease requiring AVR along with moderate to sever MR at
___ are concerning for SLE valvulopathy. SLE valvulopathy
is more commonly seen in individuals with high antiphospholipid
titers. Denied any signs/symptoms of Lupus, denies prior flares,
and does not know when she was diagnosed. Given low diagnostic
accuracy of antibody titers for SLE valvular disease, which does
not correlate with SLE flares, and provided other plausible
structural causes of MR, further testing was deferred this
hospitalization.
#Pre-diabetes
A1c 5.8 ___. BSG was within normal range this
hospitalization. Continued to monitor.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. HydrALAZINE 25 mg PO Q6H
6. Metoprolol Tartrate 75 mg PO BID
7. Potassium Chloride 20 mEq PO DAILY
8. Furosemide 20 mg PO DAILY
9. Ranitidine 150 mg PO DAILY
10. ___ MD to order daily dose PO DAILY16 Mechanical AVR
___. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. CARVedilol 6.25 mg PO BID
2. Torsemide 40 mg PO DAILY
3. Valsartan 40 mg PO BID
4. Amiodarone 200 mg PO BID
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Warfarin 3 mg PO DAILY16 Duration: 1 Dose
Target INR: 2.5 - 3.5
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Aspirin EC 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Ranitidine 150 mg PO DAILY
11.Outpatient Lab Work
Nonrheumatic aortic (valve) insufficiency. ICD 10: I35.1
INR, BMP to be drawn on ___
Fax results to Dr. ___: ___ and Dr. ___:
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart failure exacerbation
PMH:
Aortic Insufficiency, s/p Aortic valve replacement with a 25 mm
Onyx
mechanical valve on ___ by Dr ___
___
Lupus
___ syndrome
History of CVA
Anemia
prediabetes
mobile left breast mass in ___
non-specific reaction to PPD without tuberculosis
nocturnal polyuria
diastolic heart failure
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
___ trace Edema
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19973133-DS-12 | 19,973,133 | 20,578,132 | DS | 12 | 2189-04-06 00:00:00 | 2189-04-07 19:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar
Solution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl
sutures / steri strips
Attending: ___
___ Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with hx of COPD, HTN, HLD, hypothyroidism presents with 2
weeks of URI symptoms and 2 days of fever, found to have
influenza A and anemia.
The patient reports developing non-productive cough, rhinorrhea,
and malaise about 2 weeks prior, after she received her second
influenza shot. She says a cold has been going around her
family--her husband and son have also had similar symptoms.
However, 2 days ago she developed fevers to 102, chills,
weakness and myalgias with decreased PO intake. She also reports
increased shortness of breath with exertion, not at rest. Says
it feels like her COPD flaring up. She denies any chest pain,
palpitations, nausea, vomiting, abdominal pain, sore throat, ear
ache, dysuria.
She also reports black stools for about 10 days since starting
oral ferrous sulfate. Has been having loose stools for about 2
weeks, soft not watery, about 2x/day. Denies any
lightheadedness/dizziness. No prior GI bleed. Reports hx of iron
deficiency anemia. Had colonoscopy ___ years prior.
In the ED, initial vitals: 98.6 88 125/78 16 97% RA.
Labs were significant for hct 30.4->25.9, creatinine 1.3->1.1,
positive influenza A. CXR showed no acute cardiopulmonary
process. She was given 2L IVF, albuterol and ipratropium nebs,
1g tylenol, and home levothyroxine, citalopram, aspirin and
protonix. Rectal exam showed guaiac positive brown stool. She
was admitted for influenza, anemia. Vitals prior to transfer:
97.8 79 120/55 20 96% RA.
Currently, the patient feels fatigued. Some abdominal/chest pain
from coughing.
Past Medical History:
- Chronic iron deficiency anemia without known source of
bleeding.
- Hypertension.
- Hypothyroidism.
- Osteoarthritis.
- Hyperlipidemia.
- GERD.
- COPD/asthma
- Skin cancers.
- Severe back pain due to sarcoid sacroiliac dysfunction, now
much improved after injection.
-___ ___ neuropathy
- Cataracts
- Nephrolithiasis s/p lithotripsy x3 (calcium stones)
- s/p Appendectomy
- Positive PPD
- s/p Bladder suspension
- s/p TAH
- s/p spinal fusion ___
-cervical rib resection ___
-no DM
Social History:
___
Family History:
mother - ___ disease, DM, breast cancer, valvular heart
disease, pernicious anemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.0 123/53 84 18 97% RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 98.3, 126/73, 96, 18, 92% RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
================
___ 02:00PM BLOOD WBC-6.2 RBC-4.32 Hgb-9.7* Hct-30.4*
MCV-70* MCH-22.4* MCHC-31.9 RDW-19.4* Plt ___
___ 02:00PM BLOOD Neuts-75.0* ___ Monos-5.3 Eos-0.6
Baso-0.3
___ 02:00PM BLOOD Glucose-91 UreaN-17 Creat-1.3* Na-137
K-5.2* Cl-99 HCO3-25 AnGap-18
___ 02:00PM BLOOD ALT-26 AST-51* AlkPhos-79 TotBili-0.3
___ 02:00PM BLOOD Albumin-4.2
OTHER LABS:
============
___ 03:33PM BLOOD Ret Aut-1.5
___ 03:33PM BLOOD LD(LDH)-190 TotBili-0.2
___ 03:33PM BLOOD calTIBC-390 ___ Ferritn-27 TRF-300
___ 03:33PM BLOOD Iron-16*
___ 06:06AM BLOOD Glucose-124* UreaN-5* Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-29 AnGap-11
DISCHARGE LABS:
================
___ 05:30AM BLOOD WBC-7.5 RBC-3.82* Hgb-8.3* Hct-29.2*
MCV-76* MCH-21.6* MCHC-28.3*# RDW-21.0* Plt ___
MICRO:
=======
___ BLOOD CULTURE x2 -- NGTD, FINAL RESULT PENDING
___ STOOL C DIFFICILE ASSAY -- Positive for toxigenic C.
difficile
IMAGING:
========
___ CHEST (PA & LAT)
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ F with hx of COPD, HTN, HLD, hypothyroidism presents with 2
weeks of URI symptoms and 2 days of fever, found to have
influenza A and anemia.
# Influenza A: Patient with fever, chills, weakness, and cough
on presentation, and tested positive for influenza A. Likely
upper respiratory infection 2 weeks ago with superimposed
influenza for 2 days with fevers. Although patient likely 48
hours after onset of influenza, treated with tamiflu given
comorbidities (COPD) as she is at risk for decompensation. She
was also treated supportively with cough medications, zofran,
and tylenol. She improved and by discharge was feeling better.
# Anemia: Patient with hct in the upper ___ during admission,
with stable blood counts. Slightly lower than recent baseline of
low ___. Pt c/o dark stools, but difficult to interpret in
setting of recent iron use. Stool in ED was brown and guaiac
positive. Iron studies reveal low iron and ferritin, consistent
with iron deficiency. Last colonoscopy and EGD done in ___.
Hemolysis w/u negative. She has a history of iron deficiency
anemia and was previously evaluated by hematology; last saw them
___. Possibly due to slow GIB vs. iron deficiency from
malabsorption or poor intake. No hx of prior GIBs. She was given
IV iron infusions and restarted on oral ferrous sulfate. She
will need colonoscopy and EGD for further evaluation.
# Diarrhea: Patient reporting mild amount of small volume
diarrhea, mostly mucus and nonbloody beginning a couple of days
into her hospital course. She remained afebrile with the onset
of the diarrhea and was without abdominal pain. She tested
positive for C difficile and was started on treatment with PO
metronidazole 500mg TID for a 14 day course to end ___. This
is her first episode of c diff.
# COPD: Patient with non-O2 dependent COPD, with worsening
shortness of breath. No evidence of COPD exacerbation. She was
given standing duonebs, albuterol prn, advair and cough
medications. She improved clinically by the day of discharge.
# ___: Resolved. Creatinine on admission 1.3, then improved to
baseline. Likely pre-renal in setting of acute infection and
poor PO intake.
# HTN: Initially held amlodipine and lisinopril given acute
infection, however, were restarted by discharge.
# Depression: Continued citalopram
# Hypothyroidism: Continued levothyroxine
# Chronic pain: Held vicodin as non-formulary, instead gave
oxycodone prn
# GERD: continued protonix
TRANSITIONAL ISSUES:
====================
- Will need colonoscopy and EGD for further evaluation of iron
deficiency anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Alendronate Sodium 70 mg PO QMON
3. Amlodipine 5 mg PO BID
4. Benzonatate 100 mg PO TID:PRN cough
5. budesonide-formoterol 160-4.5 mcg/actuation 2 puffs BID
6. Citalopram 20 mg PO QHS
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
8. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Tiotropium Bromide 1 CAP IH DAILY
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN cough
3. Citalopram 20 mg PO QHS
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
9. Alendronate Sodium 70 mg PO QMON
10. Amlodipine 5 mg PO BID
11. budesonide-formoterol 160-4.5 mcg/actuation 2 PUFFS BID
12. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
13. Lisinopril 20 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Dextromethorphan Polistirex ___ mg PO Q12H
RX *dextromethorphan polistirex ___ mg/5 mL 5 mL by mouth every
twelve (12) hours Refills:*0
16. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
DO NOT use alcohol while taking this medication. Concurrent
alcohol use will cause severe GI upset
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*40 Tablet Refills:*0
17. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth once a day
Disp #*1 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza A infection
Iron deficiency anemia
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay. You were
admitted for fever and shortness of breath, and were found to
have the flu. You were started on tamiflu and were given
supportive medications, such as cough medications and tylenol.
You improved and by discharge were feeling better. In addition,
you were found to have iron deficiency anemia. Your blood counts
remained stable during your stay and you were given a few doses
if IV iron infusions. Please follow up with your PCP after
discharge; you will likely need a colonoscopy and possibly upper
endoscopy for further evaluation.
You were also found to have an intestinal infection called
Clostridium difficile (or C diff). We treated you with an
antibiotic called metronidazole. Please take this medication as
prescribed. It is very important that you DO NOT use alcohol
while taking this medication as it can cause very severe GI
upset (nausea, vomiting etc). Please take all of the pills and
do not skip doses or shorten your antibiotic course without
speaking to your doctor.
Your follow up appointments are listed below. Please take all of
your medications a prescribed.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
19973133-DS-14 | 19,973,133 | 20,505,308 | DS | 14 | 2192-08-28 00:00:00 | 2192-08-29 20:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar
Solution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl
sutures / steri strips
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Right femoral neck fracture s/p right hip hemiarthroplasty on
___
History of Present Illness:
___ female history of severe COPD (on 3 L home O2),
hypertension, aortic stenosis, HFpEF, pulmonary hypertension,
dyslipidemia who presents with right hip pain status post
mechanical fall. The patient was ambulating in her home without
a walker when she got tangled in her oxygen tubing and tripped
and fell directly onto her right side. Noticed immediate pain
and deformity. Was unable to bear any weight on the right side.
She presented to the hospital for further evaluation. Denies
any
numbness tingling or pain elsewhere.
Past Medical History:
- Chronic iron deficiency anemia without known source of
bleeding.
- Hypertension.
- Hypothyroidism.
- Osteoarthritis.
- Hyperlipidemia.
- GERD.
- COPD/asthma
- Skin cancers.
- Severe back pain due to sarcoid sacroiliac dysfunction, now
much improved after injection.
-___ ___ neuropathy
- Cataracts
- Nephrolithiasis s/p lithotripsy x3 (calcium stones)
- s/p Appendectomy
- Positive PPD
- s/p Bladder suspension
- s/p TAH
- s/p spinal fusion ___
-cervical rib resection ___
-no DM
Social History:
___
Family History:
mother - ___ disease, DM, breast cancer, valvular heart
disease, pernicious anemia
Physical Exam:
ADMISSION EXAM
==============
General: Well-appearing female in no acute distress.
Right lower extremity:
Leg shortened and externally rotated
Unable to tolerate log roll or axial compression
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
DISCHARGE EXAM
==============
VITALS: Stable, satting mid-90's on 3L NC
GENERAL: Resting comfortably in bed in no acute distress.
HEENT: Anicteric.
CV: Regular rate and rhythm. Grade ___ systolic murmur.
heard loudest at left sternal border.
PULM: Reduced breath sounds at lung bases. No wheezing or rales.
ABD: +Bowel sounds, soft, non-tender, non-distended.
SKIN: Dressed wound right hip. Bruising over nasal bridge.
PSYCH: A&O x3, moving all limbs with purpose
Pertinent Results:
ADMISSION LABS
==============
___ 10:00PM BLOOD WBC-9.5 RBC-4.38 Hgb-14.2 Hct-41.8 MCV-95
MCH-32.4* MCHC-34.0 RDW-13.2 RDWSD-47.0* Plt ___
___ 10:00PM BLOOD Neuts-78.7* Lymphs-12.1* Monos-5.6
Eos-2.1 Baso-0.7 Im ___ AbsNeut-7.50* AbsLymp-1.15*
AbsMono-0.53 AbsEos-0.20 AbsBaso-0.07
___ 10:00PM BLOOD Plt ___
___ 10:00PM BLOOD Glucose-123* UreaN-14 Creat-1.3* Na-136
K-5.8* Cl-92* HCO3-28 AnGap-16
___ 10:00PM BLOOD estGFR-Using this
DISCHARGE LABS
==============
___ 03:36AM BLOOD WBC-11.7* RBC-2.93* Hgb-9.4* Hct-28.7*
MCV-98 MCH-32.1* MCHC-32.8 RDW-12.9 RDWSD-46.5* Plt ___
___ 03:36AM BLOOD Plt ___
___ 03:36AM BLOOD Glucose-116* UreaN-23* Creat-1.1 Na-134*
K-4.2 Cl-93* HCO3-30 AnGap-11
___ 03:36AM BLOOD cTropnT-<0.01
___ 03:36AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
NOTABLE LABS
============
___ 10:00PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
NOTABLE IMAGING
===============
___ FEMUR XR
IMPRESSION:
Limited study due to underpenetration. Right femoral neck
fracture, likely basicervical, with impaction. Right femoral
head articulates with the acetabulum.
___ PELVIC XR
Limited study due to underpenetration. Right femoral neck
fracture, likely basicervical, with impaction. Right femoral
head articulates with the acetabulum.
___ CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Small bilateral pleural effusions.
3. Moderate to severe pulmonary emphysema.
4. Biapical pleuroparenchymal scarring and calcifications are
unchanged and likely sequela of prior infection.
___ TTE
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic stenosis. Mild mitral
regurgitation. Moderate pulmonary hypertension.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
Brief Hospital Course:
HOSPITAL COURSE
===============
___ is an ___ female with a past medical history significant
for severe COPD (on 3 L home O2), hypertension, aortic stenosis,
HFpEF, pulmonary hypertension, and dyslipidemia who presented to
the ___ ED after a fall, found to have right femoral neck
fracture s/p right hip hemiarthroplasty on ___, transferred to
medicine due to hypoxia and delirium.
ACUTE ISSUES
============
# HYPOXIA / HFpEF / COPD
Patient developed increasing O2 requirements following her right
hip hemiarthroplasty, improved w/ IV Lasix, CXR with mild
pulmonary vascular congestion without overt pulmonary edema. CTA
showing severe emphysema but no PE. On ___, back on baseline 3L
O2. Discharged on Lasix 60mg PO QD (was on ___ alternating
doses at home).
# FEMORAL NECK FRACTURE
Patient sustained a femoral neck fracture following a mechanical
fall at her home. s/p right hip hemiarthoplasty on ___.
Patient's surgical site is healing well and the surgery was
uncomplicated.
- Activity: WBAT & ROMAT RLE
- Anticoagulation: heparin 5000 U sc tid
- Pain Control: tylenol ___ TID, Oxycodone 5mg PO q 4 hours
while awake, Oxycodone 2.5mg PO q 6 hours PRN, Lidocaine Patch
# DELIRIUM
The patient has evidence of delirium evolving in in the setting
of a high risk patient with multiple triggers. She was noted
overnight to have some signs and features of sun-downing.
Resumed home Alprazolam 0.25mg QHS. Analgesia as detailed above.
Stable at discharge.
# EtOH USE DISORDER
Significant alcohol use along with chronic prescription opioid
use, likely major contributor to recent falls. Started on MVI,
thiamine, folate. Should continue to encourage alcohol
cessation.
CHRONIC ISSUES
==============
# HFpEF
No current signs of volume overload on exam. Intermittently
hypoxic. No frank pulmonary edema on CXR or exam. TTE done ___
with LVEF of 76%. On lasix 60mg/80mg alternating daily doses at
home. No signs of acute decompensation at this time.
# HTN
- Continued home amLODIPine 5 mg PO DAILY
- Held home Lisinopril 20 mg PO DAILY given recent procedure,
normotension
# COPD
# Pulmonary Hypertension (WHO class II/III): On 3L NC O2 at
baseline.
- Continued home Tiotropium Bromide 1 CAP IH DAILY
- Continued home Symbicort inhalation DAILY
- Continued home Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
# GERD
- Continued home Pantoprazole 40 mg PO Q24H
# HYPOTHYROIDISM
- Continued home Levothyroxine Sodium 50 mcg PO DAILY
# DEPRESSION/ ANXIETY
- Continued home Citalopram 30 mg PO QHS
- Continued home ALPRAZolam 0.25 mg PO DAILY:PRN severe anxiety
TRANSITIONAL ISSUES
===================
[] Medication changes
- Lasix changed from alternating ___ every other day to 60mg
PO DAILY
- Started subq heparin to be continued at least 4 weeks post-op
- Stopped HYDROcodone-Acetaminophen, replaced with oxycodone and
APAP
- Stopped Lisinopril 20 mg PO DAILY as not hypertensive
- Started on folate, multivitamin, thiamine given alcohol use
[] Please call ___ to schedule orthopedics follow-up
with ___ within ___ weeks
[] Please call ___ to make appointment with patient's
PCP/gerontologist ___ at time of discharge.
[] Patient with significant alcohol use; this along with chronic
prescription opioid use has likely been large contributor to
recent falls and trauma. Would continue to strongly encourage
alcohol cessation
[] Please titrate down oxycodone amount as possible once
patient's post-surgical pain resolves
[] Obtain daily weights and monitor respiratory status, if
significant weight increase or increase oxygen requirements
(baseline 3 liters) would consider increasing Lasix dose
# CODE: FULL
# CONTACT:
- Name of health care proxy: ___
- Relationship:daughter
- Phone ___, Cell phone: ___
42 minutes was spent seeing, examining and
supervising/coordinating the discharge of Ms. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO DAILY
2. GuaiFENesin ER 600 mg PO Q12H
3. Tiotropium Bromide 1 CAP IH DAILY
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
5. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
6. ALPRAZolam 0.25 mg PO DAILY:PRN severe anxiety
7. amLODIPine 5 mg PO DAILY
8. Citalopram 30 mg PO QHS
9. Fexofenadine 180 mg PO DAILY
10. Furosemide 60 mg PO EVERY OTHER DAY
11. Furosemide 80 mg PO EVERY OTHER DAY
12. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Lisinopril 20 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. FoLIC Acid 1 mg PO DAILY
3. Heparin 5000 UNIT SC TID
4. Lidocaine 5% Patch 1 PTCH TD QAM pain
5. Lidocaine 5% Patch 2 PTCH TD QPM
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H
do not give overnight, do not wake up to give
8. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
9. Thiamine 100 mg PO DAILY
10. ALPRAZolam 0.25 mg PO QHS severe anxiety
11. Furosemide 60 mg PO DAILY
12. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
13. amLODIPine 5 mg PO DAILY
14. Citalopram 30 mg PO QHS
15. Docusate Sodium 100 mg PO DAILY
16. Fexofenadine 180 mg PO DAILY
17. GuaiFENesin ER 600 mg PO Q12H
18. Levothyroxine Sodium 50 mcg PO DAILY
19. Pantoprazole 40 mg PO Q24H
20. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
21. Tiotropium Bromide 1 CAP IH DAILY
22. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until found to be hypertensive
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- Right femoral neck fracture s/p right hip hemiarthroplasty on
___
Secondary diagnoses
- Heart failure with preserved EF
- COPD
- Alcohol use disorder
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 after you fell and broke your
hip. You underwent surgery to repair your hip.
You developed some breathing difficulties and required higher
levels of oxygen for a while, but this improved and you were
back to your home O2 requirement.
You have had multiple falls recently, and your alcohol use is
likely a strong contributor to this. We STRONGLY encourage you
to cut down or stop your alcohol intake to prevent further
serious health problems.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
19973133-DS-17 | 19,973,133 | 23,458,544 | DS | 17 | 2193-08-17 00:00:00 | 2193-08-19 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar
Solution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl
sutures / steri strips
Attending: ___.
Chief Complaint:
Weakness, recent fall
Major Surgical or Invasive Procedure:
EGD/colonoscopy
History of Present Illness:
Ms. ___ is a ___ yo F with hx of COPD on 3 L O2 at
baseline, HTN, HFpEF, HLD, hypothyroidism, back pain, who
presents to the ED following a fall and continued UTI symptoms
that was previously treated at urgent care on a course of 10
days
cefpodoxime.
Per history obtained in the ED, she states was diagnosed with a
UTI 10 days ago and treated with cefpodoxime x10 days. She was
on
her last dose of cefpodoxime but presented to the ED with
continued dysuria, increased urinary frequency, and right flank
pain. She feels that her symptoms have not resolved and she
feels
less well and more fatigued. She also has new incontinence.
She also reports a fall forward 4 days ago onto her knees and
then her side with headstrke on the wall. She denies LOC and no
residual headache.
She denied fevers, chest pain, SOB, syncope, LOC or dizziness.
In the ED, initial vitals were:
159/80, HR 95, 97.7, 100% on 3L NC, pain ___
Exam was notable for:
- soft, nontender abdomen, stool brown but guaiac positive,
normal rectal tone
Labs were notable for:
- WBC 7.8, Hb 5.5, HCT 21, plt 335
- repeat WBC 8.0, Hb 7.4, HCT 27, Plt 354
- repeat WBC 6.8, Hb 7.1, HCT 25.7, Plt 318
- ALT 9, AST 22, Tbili 0.2, Alb 4.3, AP 64
- Na 135, K 4.7 Cr 1.2, BG 107
Na 139, K 4.6, Cr 0.9, BG 101
- UA with straw colored urine, neg bood, neg nitrite, trace
leuks, RBC <1, WBC 1, bact none, yeast none, epi 0
- lactate 0.6
Studies were notable for:
- CT abd/pelvis -- findings concerning for right rectus sheath
hematoma measuring 2.3 x 5.7 x 6.7 cm, nonobstructing 4 mm left
upper pole renal calculi, diverticulosis without evidence of
diverticulitis
- no active extravasation on imaging and ___ deferred
intervention
- CXR with no evidence of pulmonary edema or pneumonia
- EKG: sinus rhythm, ?left atrial enlargement
The patient was given:
- morphine sulfate 4 mg, morphine 2 mg x2
- LR 1 L
- citalopram 20 mg
- levothyroxine 50 mcg
- 1 neb ipratroprium-albuterol
Consults:
- ___ -- right rectus hematoma post fall, Hb 10 --> 5 over 3
months, no extravasation, no ___ intervention planned for now
- SW for patient's husband who cannot go home alone -- patient
and husband live at ___
- ___ allowing husband to remain at bedside with
patient
overnight
- SW to coordinate with ___ staff
On arrival to the floor, she says she has been feeling lousy and
tired for the past ~10 days. She states that she fell about
10ish
days ago by tripping up on some wires while getting off the
couch. She says she fell to her knees, hit her right side on the
couch, and smacked her head against the wall. She denies any
headaches, lightheadedness, dizziness, or loss of consciousness
after the fall. It was a bit unclear if this fall happened 10
days ago or just 4 days ago because she thinks she was feeling
lousy before the fall which prompted her to present to urgent
care.
On ___, she presented to urgent care with right sided back pain
and urinary frequency and was treated with cefpodoxime for 10
days. She nearly finished her course except for 1 pill. She did
not feel that the treatment helped with her symptoms at all.
She says the pain on her right side feels like someone kicked
her
and rates it as ___. She is not sure if the pain started
gradually or all of a sudden. She has been taking motrin and
aleve every day for >1 month and sometimes up to 6 pills a day.
She also used voltaren gel which does not help. She also
endorses
leg weakness and increase in urinary frequency.
She is having normal bowel movements (last BM yesterday). She
endorses chronic cough and she wears 3 L O2 at home but 2 L when
she goes out because there isn't enough oxygen. She feels short
of breath when she is out running errands.
She also endorses weakness in her legs that has been getting
worse over the last month. She says she was seeing ___ and doing
really well. She walks with a cane when outside but otherwise
walks without any support.
Otherwise, she denies headache, lightheadedness, dizziness, sore
throat, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, numbness or tingling.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
-Prior diagnoses: Depression, anxiety
-Hospitalizations: Denies
-Partial hospitalizations: Denies
-Psychiatrist: Denies
-Therapist: Denies
-Medication trials: Celexa, Prozac
-___ trials: Denies
-Suicide attempts: Denies
-Self-injurious behavior: Denies
-Harm to others: Denies
-Trauma: Denies
-Access to weapons: Denies
.
PAST MEDICAL HISTORY:
- Chronic iron deficiency anemia
- Hypertension.
- Hypothyroidism.
- Osteoarthritis.
- Hyperlipidemia.
- GERD.
- COPD/asthma
- Skin cancer.
- sarcoid sacroiliac dysfunction,
- ___ ___ neuropathy
- Cataracts
- Nephrolithiasis s/p lithotripsy x3 (calcium stones)
- s/p Appendectomy
- s/p Bladder suspension
- s/p TAH
- s/p spinal fusion ___
.
Social History:
___
Family History:
Mother -- valvular heart disease, breast cancer
Father -- leukemia
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 147/76, HR 94, 97% on 3 L NC, 97.9
GENERAL: Alert and interactive. In no acute distress. Wearing NC
O2.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
Conjunctiva pale.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic
ejection murmur, heard ___ at RUSB.
LUNGS: Clear to auscultation bilaterally but some minimal
expiratory wheezes on anterior exam only. No increased work of
breathing.
BACK: No CVA tenderness bilaterally. Well healed scars in
thoracic and lumbar area.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Possibly with central umbilical
hernia that is soft. Tenderness to palpation on right side/front
of flank (but no CVA tenderness), no skin changes or erythema.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Otherwise grossly intact.
DISCHARGE PHYSICAL EXAM:
===================
PHYSICAL EXAM:
VS: 128/66, HR 95, RR 18, 100% on 3L
GENERAL: NAD, lying in bed.
HEENT: Anicteric sclerae. Pale conjunctiva. MMM.
NECK: No JVD. No cervical/clavicular LAD.
CV: RRR. S1/S2. Systolic ejection murmur at RUSB.
PULM: Clear to auscultation bilaterally.
ABD: BS+, soft, ND, mildly tender to palpation in RLQ/right back
EXTR: WWP, no edema, clubbing, jaundice
Pertinent Results:
ADMISSION LABS:
===========
___ 07:52PM BLOOD WBC-7.8 RBC-2.80* Hgb-5.5* Hct-21.1*
MCV-75* MCH-19.6* MCHC-26.1* RDW-16.5* RDWSD-45.2 Plt ___
___ 07:52PM BLOOD Glucose-107* UreaN-32* Creat-1.2* Na-135
K-4.7 Cl-97 HCO3-24 AnGap-14
___ 07:52PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.8 Mg-2.1
Interim labs:
___ 04:36AM BLOOD calTIBC-536* VitB12-349 Folate->20
Ferritn-13 TRF-412*
REPORTS:
=======
___ CXR
Apical scarring is noted bilaterally. No evidence of focal
consolidation,
pleural effusion or pneumothorax. Minimal bibasal atelectasis.
No pulmonary
edema. Cardiac and hilar silhouettes are normal. Prominent
aortic arch
calcifications are noted.
___ CT abd/pelvis
1. Findings concerning for a right rectus sheath hematoma
measuring 2.3 x 5.7
x 6.7 cm.
2. Nonobstructing 4 mm left upper pole renal calculi
3. Diverticulosis without evidence of diverticulitis.
___: colonoscopy
- normal mucosa in whole colon
- diverticulosis of descending colon and sigmoid colon
- colon was tortuous, requiring use of rescue colonoscope to
transverse sigmoid
- grade 2 internal hemorrhoids
___ EGD
- normal mucosa of whole esophagus
- esophageal hiatal hernia
- polyps (3 mm to 5 mm) in antrum and fundus (biopsy)
- erosions in fundus in hiatal hernia
- normal mucosa in whole examined duodenum
- erythema in antrum
DISCHARGE LABS:
===========
___ 06:20AM BLOOD WBC-7.3 RBC-3.18* Hgb-7.2* Hct-25.3*
MCV-80* MCH-22.6* MCHC-28.5* RDW-19.5* RDWSD-55.6* Plt ___
___ 06:20AM BLOOD Glucose-103* UreaN-13 Creat-1.1 Na-145
K-3.5 Cl-102 HCO3-23 AnGap-20*
Brief Hospital Course:
SUMMARY
=============================================================
Mrs. ___ is an ___ woman with COPD on 3L O2, HFpEF, HTN,
HLD, and hypothyroidism who presents with fatigue and R torso
pain after a fall ___ days ago and recent UTI, found to have a R
rectal sheath hematoma and guaiac positive stools, c/f GI bleed.
She received 2 units PRBC due to low Hb (down to 5.5 in the ED).
However, her Hb remained low at 7.3 on ___. Pt originally
wanted to leave AMA due to concern for ongoing care of husband
with ___ at the ___ living facility, but the team
convinced her to stay in the hospital for further evaluation
given the risk of decompensation despite transfusion. GI was
consulted, EGD was performed on ___ which revealed the presence
of non bleeding erosions in fundus of hiatal hernia suggestive
of ___ lesions. Pt was discharged in stable condition, w/
Hb 7.2.
TRANSITIONAL ISSUES:
=
=
=
================================================================
PCP:
[] Please get repeat CBC at PCP ___ appointment
[] Patient had a stable right rectus sheath hematoma. Please
evaluate location to make sure there is no concerning findings.
[] Per patient, she tripped which precipitated her fall. Please
consider home safety evaluation for fall risk.
[] Please ensure that patient has started omeprazole 20mg BID
and stopped taking pantoprazole. She should continue 20 mg BID
for ___ weeks and then transition to daily 20 mg.
[] Consider starting ferrous sulfate every other day (has been
shown to be better than daily iron)
New meds: pantoprazole
Stopped meds: amlodipine, lisinopril
Changed meds: None
ACTIVE ISSUES:
=
=
=
================================================================
#Acute on chronic anemia, fatigue:
Etiology of acute anemia ___ GI bleed vs. rectus sheath hematoma
(less likely given it is stable w/o signs of extravasation per
___, w/ underlying chronic iron deficiency anemia. In working
up, GI was consulted and EGD was performed which found the
presence of non bleeding erosions in fundus of hiatal hernia
suggestive of ___ lesions for which she is to be managed
with omeprazole twice a day. Pt is also caretaker for her
husband with ___, and presentation may have an element of
caretaker fatigue.
# Right rectus sheath hematoma
2.3 x 5.7 x 6.7 cm hematoma from recent fall, possibly
exacerbated by chronic cough from COPD and HTN. Women and older
patients are also at higher risk due to small rectus abdominis
muscle mass and therefore less likely to be able to tamponade
the rectus sheath hematoma. Pt not on systemic anticoagulation,
and coags normal. ___ consulted and did not see any active
extravasation.
# Urinary frequency
Recent presumed UTI treated with cefpodoxime x 10d. Patient
still reports increased frequency and new incontinency, but UA
negative with only trace leuk esterase. Possible etiologies also
include urinary tract atrophy (common in postmenopausal women).
# Fall
multifactorial with multiple comorbidities: weakness with recent
acute on chronic anemia, hypothyroidism, possible UTI, and COPD
wearing oxygen and could have tripped on wires (per patient
report). Pt also has history of chronic alcohol use, which could
be contributing to weakness in legs. Continued home
levothyroxine, folate and thiamine.
# Pain
Per review of old records, patient was on Vicodin and Xanax in
the past (refer to ___ gerontology note) though there was
concern for over use. Patient has hx of chronic back pain and
receives nerve blocks for shoulder pain. She is seen in chronic
pain clinic.
# ___
Patient presented with ___ that resolved prior to discharge,
likely in the setting of dehydration given poor PO intake and
increased urinary frequency with recent UTI
CHRONIC/STABLE ISSUES
=====================
# Chronic hypoxic respiratory failure -- COPD on home O2 3L:
continued O2 3L with goal O2 >88%, albuterol 1 puff PO q4 hr PRN
for wheeze, sybmicort 2 puffs BID, and tiotropium 1 puff daily
# HTN: held home amlodipine 5 mg daily and lisinopril 2.5 daily
in case of hypotension with GI bleed
# Hypothyroidism: continued home 50 mcg tablet daily
# HFpEF:continued home Lasix 60 mg daily
# Depression: continued mirtazapine 7.5 mg qhs and citalopram 30
mg qhs
# Allergies: continued fexofenadine 180 mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
3. amLODIPine 5 mg PO DAILY
4. Citalopram 30 mg PO QHS
5. Docusate Sodium 100 mg PO DAILY
6. Fexofenadine 180 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
9. Mirtazapine 7.5 mg PO QHS
10. Lidocaine 5% Patch 2 PTCH TD QPM
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. FoLIC Acid 1 mg PO DAILY
15. Furosemide 60 mg PO DAILY
16. Thiamine 100 mg PO DAILY
17. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild
18. GuaiFENesin ER 600 mg PO Q12H
19. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID:PRN
Discharge Medications:
1. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*1
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
4. amLODIPine 5 mg PO DAILY
5. Citalopram 30 mg PO QHS
6. Docusate Sodium 100 mg PO DAILY
7. Fexofenadine 180 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 60 mg PO DAILY
10. GuaiFENesin ER 600 mg PO Q12H
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lidocaine 5% Patch 2 PTCH TD QPM
13. Lisinopril 2.5 mg PO DAILY
14. Mirtazapine 7.5 mg PO QHS
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID:PRN Wheezing
17. Thiamine 100 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=============================
Acute on chronic anemia
Right rectus sheath hematoma
SECONDARY:
=============================
Urinary frequency
Fall
___
COPD
HTN
Hypothyroidism
HFpEF
Depression
Allergies
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 here at ___
___!
WHY WAS I IN THE HOSPITAL?
================================
- You were admitted to the ___ due to a fall, followed by a
low red blood count, concerning for a bleed.
WHAT HAPPENED IN THE HOSPITAL?
================================
- We performed a series of blood tests and imaging studies to
evaluate for sites of bleeding.
- You received blood transfusion in the hospital due to your
decreasing red blood count.
- You were evaluated by the GI doctor and ****they performed a
procedure to check for sites of active bleeding in your stomach
and intestines***
- You were also started on a medication called pantoprazole to
alleviate the symptoms.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
================================
- You should follow up with your doctors at the ___
appointment below.
- If your symptoms worsen acutely (such as dizziness, bright red
blood in your stool), you should see a doctor in the emergency
department immediately.
We wish you all the ___!
Your ___ care team
Followup Instructions:
___
|
19973133-DS-18 | 19,973,133 | 25,361,247 | DS | 18 | 2193-08-23 00:00:00 | 2193-08-24 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar
Solution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl
sutures / steri strips
Attending: ___.
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Capsule Endoscopy
History of Present Illness:
Ms. ___ is a ___ female with medical history
notable for COPD on ___ L O2, HFpEF, recent admission for anemia
and rectus sheath hematoma, hypertension, hyperlipidemia,
hypothyroidism who presents for evaluation of dark stools.
Of note, she was recently hospitalized from ___ to ___. She
initially presented after a fall, was found to have a rectal
sheath hematoma, as well as anemia with guaiac positive stools
requiring 2 units PRBCs. During admission, she had an EGD on
___
demonstrating nonbleeding erosions consistent with Camerons
lesions and a colonoscopy with diverticulosis and internal
hemorrhoids. She was discharged home on oral PPI.
She reports feeling well after discharge and then woke up in the
morning on ___ feeling unwell and lightheaded. She thought
that she was just feeling the effects of being in bed in the
hospital for 5 days. She made herself homemade waffles and bacon
and then went to go to clean the litter box when she broke out
in
a sweat and had to use the bathroom urgently. She had a large
black stool that is consistent with her prior episodes of
bleeding. She denies any nausea or vomiting. She has only had
one
stool in total today. She still feels unsteady on her feet but
denies dizziness when laying down.
On arrival to ED, initial vitals were stable: T 97.4, heart rate
94, BP 123/66, respiratory rate 18 satting 96% on 2 L nasal
cannula. ED exam notable for diffuse tenderness to palpation
worse in the left upper quadrant. Rectal exam demonstrating
melena with positive guaiac.
Initial ED labs notable for H/H 8.5/30.9 from 7.2/25.3 at
discharge. BMP with serum creatinine 1.3, from baseline 0.9-1.1;
otherwise CBC, chemistries, LFTs, coags, urinalysis
unremarkable.
Repeat CBC 6 hours later 7.8/27.9
In the ED she was started on IV PPI twice daily and received
some
of her home medications.
On arrival to the floor she endorses the above and reports back
pain which is chronic. She otherwise has no acute concerns.
ROS: 10 point review of systems otherwise negative
Past Medical History:
PAST PSYCHIATRIC HISTORY:
-Prior diagnoses: Depression, anxiety
-Hospitalizations: Denies
-Partial hospitalizations: Denies
-Psychiatrist: Denies
-Therapist: Denies
-Medication trials: Celexa, Prozac
-___ trials: Denies
-Suicide attempts: Denies
-Self-injurious behavior: Denies
-Harm to others: Denies
-Trauma: Denies
-Access to weapons: Denies
.
PAST MEDICAL HISTORY:
- Chronic iron deficiency anemia
- Hypertension.
- Hypothyroidism.
- Osteoarthritis.
- Hyperlipidemia.
- GERD.
- COPD/asthma
- Skin cancer.
- sarcoid sacroiliac dysfunction,
- ___ ___ neuropathy
- Cataracts
- Nephrolithiasis s/p lithotripsy x3 (calcium stones)
- s/p Appendectomy
- s/p Bladder suspension
- s/p TAH
- s/p spinal fusion ___
.
Social History:
___
Family History:
Mother -- valvular heart disease, breast cancer
Father -- leukemia
Physical ___:
ADMISSION PHYSICAL EXAM
=====================
VS: 97.9 F, 154 / 75, HR 89, RR 18, 972l
GENERAL: Alert and interactive. In no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
Conjunctiva pale.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic
ejection murmur, heard best at ___.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Round mass-like structure
palpated to the right of the umbilicus
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Fluid filled blister approx 2cm in length on the
anterior chest
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Otherwise grossly intact.
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.4 PO 140 / 67 90 18 96% on 2L
GENERAL: Alert and interactive. In no acute distress.
HEENT: EOMI. Sclera anicteric and without injection. MMM.
Conjunctiva pale.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic
ejection murmur, heard best at RUSB.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Easily reducible hernia
palpated
to right of umbilicus
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: WWP.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Otherwise grossly intact.
Pertinent Results:
ADMISSION LABS
=============
___ 03:04PM WBC-8.9 RBC-3.81* HGB-8.5* HCT-30.9* MCV-81*
MCH-22.3* MCHC-27.5* RDW-20.1* RDWSD-58.9*
___ 03:04PM NEUTS-78.5* LYMPHS-9.7* MONOS-9.2 EOS-0.9*
BASOS-1.1* IM ___ AbsNeut-7.00* AbsLymp-0.86* AbsMono-0.82*
AbsEos-0.08 AbsBaso-0.10*
___ 03:04PM PLT COUNT-418*
___ 03:04PM ___ PTT-23.9* ___
___ 03:04PM ALBUMIN-4.3 IRON-204*
___ 03:04PM ALT(SGPT)-10 AST(SGOT)-26 ALK PHOS-74 TOT
BILI-0.2
___ 03:04PM GLUCOSE-97 UREA N-18 CREAT-1.3* SODIUM-143
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17
DISCHARGE LABS
=============
___ 08:10AM BLOOD WBC-7.2 RBC-3.62* Hgb-8.2* Hct-29.3*
MCV-81* MCH-22.7* MCHC-28.0* RDW-19.7* RDWSD-57.9* Plt ___
___ 08:10AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-145
K-4.2 Cl-104 HCO3-27 AnGap-14
___ 08:10AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8
IMAGING
=======
___: Capsule Endoscopy Report Summary/Impression:
1. Mild patchy gastric erythema in keeping with known gastritis
2. One punctate non-bleeding angioectasia in proximal jejunum of
unlikely clinical importance.
3. Isolated region of mild non-specific erythema in proximal
ileum of unlikely clinical importance.
4. Three small to medium-sized non-bleeding angioectasias in the
colon. No stigmata of recent bleeding.
5. Known non-bleeding colonic diverticulosis.
6. No active bleeding in the small bowel.
7. No melenic stool in the observed colon.
Brief Hospital Course:
___ female with medical history notable for COPD on ___
L
O2, HFpEF, recent admission for anemia and rectus sheath
hematoma, hypertension, hyperlipidemia, hypothyroidism who
presents with one episode of melena.
=============
ACUTE ISSUES:
=============
# Acute on chronic anemia
# Melena
EGD during last admission with medium sized hiatal hernia and
___ erosions, also with several polyps in the antrum and
fundus that were biopsied. Req'd 2uPRBCs. Current bleeding may
be
secondary either of these or post-biopsy bleeding from polyps
(though this would be a late presentation). She also had a
colonoscopy that showed diverticulosis and internal hemorrhoids.
GI was consulted and felt the bleeding was likely due to known
___ erosions but recommended capsule endoscopy given
biopsies taken on endoscopy. Results demonstrated mild patchy
erythema consistent with known gastritis. One punctate
non-bleeding angioectasias in proximal jejunum, unlikely
clinical importance. No stigmata of recent bleeding of three
small-medium angioectasias. Non-bleeding colonic diverticulosis,
no active bleeding in small bowel, no melenic stool in observed
colon. Patient placed on BID PPI and started on Carafate four
times daily per GI. On discharge was continued on BID PPI and
Carafate BID with GI f/u in one-two months per GI. Patient will
also need CBC in one week and one month.
# ___. Patient presenting with Cr 1.3, up from a baseline of
around 1.0. Likely in the setting of bleeding. Home diuretics
and lisinopril were held and she received 50cc LR for fluid
resuscitation. Home Lasix and Lisinopril restarted prior to
discharge.
CHRONIC/STABLE ISSUES:
======================
# COPD on home ___
- Continued O2 3L with goal O2 >88%
- albuterol 1 puff PO q4 hr PRN for wheeze
- sybmicort nonformulary, treated with advair instead
- tiotropium 1 puff daily
# HTN
Held home amlodipine 5 mg and lisinopril 2.5 in the setting of
bleeding. Restarted upon discharge.
# Hypothyroidism
- continued home 50 mcg levothyroxine daily
# HFpEF
- Held home Lasix 60 mg daily in the setting of bleeding,
restarted on discharge.
# Depression
- Continued mirtazapine 7.5 mg qhs and citalopram 30 mg qhs
# Allergies
- Continued fexofenadine 180 mg daily
CORE MEASURES:
==============
# CODE: Full code, limited trial of resuscitation for 24 hours
# CONTACT: ___) -- ___
TRANSITIONAL ISSUES:
=================
[] f/u with PCP for repeat CBC in one week and another in one
month per GI.
[] f/u with gastroenterology in ___ months.
[] Medications: Pt instructed to take omeprazole BID and
Carafate BID until GI f/u, Iron supplementation until f/u with
PCP. Pt instructed to take Senna and uptitrate to Miralax if
needed as well as to call PCP office if no bowel movement by
___.
New Medications
Carafate twice daily
Senna once to twice daily
Changed Medications
Please take your omeprazole twice per day rather than once per
day
Stopped Medications
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Citalopram 30 mg PO QHS
5. Docusate Sodium 100 mg PO DAILY
6. Fexofenadine 180 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 60 mg PO DAILY
9. GuaiFENesin ER 600 mg PO Q12H
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Mirtazapine 7.5 mg PO QHS
13. Thiamine 100 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Lidocaine 5% Patch 2 PTCH TD QPM
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
17. Pantoprazole 40 mg PO Q12H
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Citalopram 30 mg PO QHS
5. Docusate Sodium 100 mg PO DAILY
6. Fexofenadine 180 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 60 mg PO DAILY
9. GuaiFENesin ER 600 mg PO Q12H
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Mirtazapine 7.5 mg PO QHS
13. Thiamine 100 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Lidocaine 5% Patch 2 PTCH TD QPM
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
17. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 ml by mouth
once a day Disp #*30 Tablet Refills:*0
2. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
5. amLODIPine 5 mg PO DAILY
6. Citalopram 30 mg PO QHS
7. Docusate Sodium 100 mg PO DAILY
8. Fexofenadine 180 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 60 mg PO DAILY
11. GuaiFENesin ER 600 mg PO Q12H
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Lidocaine 5% Patch 2 PTCH TD QPM
14. Lisinopril 2.5 mg PO DAILY
15. Mirtazapine 7.5 mg PO QHS
16. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
18. Thiamine 100 mg PO DAILY
19. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Upper GI Bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___
___!
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital out of concern for bleeding
from your stomach or intestines after passing stool with blood
in it.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We completed laboratory tests to evaluate for bleeding and
monitored you to ensure you were stable.
- We consulted our gastroenterology team who used a small
capsule to evaluate for any bleeding in your stomach and
intestines which did not show any signs of overt bleeding.
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. I was unable to make
these appointments for you as it is a ___.
- Please make a followup appointment to see Dr ___
this week or early next week by calling her office at
___ to get a repeat CBC. You will also need another
followup CBC in one month.
- Please make an appointment in the ___ clinic at
___ to make an appointment in one month.
Medications:
- Please take your omeprazole twice per day rather than once
per day.
- Please take iron supplementation until you follow up with
your PCP, ___
- ___ start taking Senna once per day to help with your
bowel movements. You may also try Miralax to help move your
bowels if the Senna does not work. If you do not have a bowel
movement by ___ please call your PCP's office.
New Medications
Carafate twice daily
Senna once to twice daily
Changed Medications
Please take your omeprazole twice per day rather than once per
day
Stopped Medications
None
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19973404-DS-14 | 19,973,404 | 27,326,628 | DS | 14 | 2163-11-27 00:00:00 | 2163-11-27 16:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of type I
diabetes c/b gastroparesis, nephropathy, retinopathy who
presents with 5 days of abdominal pain and diarrhea. Her
symptoms began after eating a large meal at ___ which she
knows she isn't supposed to eat. And thereafter she began her
symptoms. Regarding her diarrhea, she's had about 10 watery
bowel movements a day. She reports no associated hematochezia,
melena, and denies other inciting triggers such as recent
antibiotic usage, recent travel, camping, exposure to sick
contacts, young children. No recent GI illness among her
family/friends. Her abdominal pain is left and right upper
quadrant sharp, radiating from left to right, about 30 minutes
after a meal. Some mild nausea and vomitting but not as
prominent. Pain feels similar to gastroparesis but lack of
vomitting and diarrhea is unusual.
.
Initial VS in the ED: ___ 133/86 12 100% r/a. Patient was
given 2L NS and morphine 5mg IV x 2. She was admitted for pain
control.
.
On the floor, the patient complains of persistent abdominal pain
and diarrhea.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied constipation. No recent
change in bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
1) Ventriculomegaly, not felt to have increased ICP
2) Bipolar Disorder
3) Diabetes Type I followed at ___ with retinopathy,
nephropathy/proteinuria, and gastroparesis
4) Glaucoma
5) Hepatitis B per notes
6) S/p cholecystectomy ___
7) S/p uterine polyp removal ___ and uterine laser
.
Social History:
___
Family History:
She has a family history significant for asthma in her father.
Her father is also a type-2 diabetic and has cardiac disease.
She has a sister who is a type 2 diabetic and is schizophrenic
and died of a heart attack in ___.
Physical Exam:
Vitals: 97.9 120/70 98 18 100%RA ___ 194 57kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild RUQ and LUQ tenderness, 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:
ADMISSION:
___ 12:59PM BLOOD WBC-8.1# RBC-4.14* Hgb-12.9 Hct-36.9
MCV-89 MCH-31.2 MCHC-35.0 RDW-12.2 Plt ___
___ 12:59PM BLOOD Neuts-76.3* Lymphs-13.8* Monos-4.2
Eos-5.6* Baso-0.2
___ 12:59PM BLOOD ___ PTT-27.9 ___
___ 12:59PM BLOOD Glucose-250* UreaN-14 Creat-0.6 Na-130*
K-4.2 Cl-99 HCO3-21* AnGap-14
___ 12:59PM BLOOD ALT-21 AST-17 AlkPhos-55 TotBili-0.3
___ 08:10AM BLOOD Calcium-7.4* Phos-3.3# Mg-1.4*
___ 12:59PM BLOOD TSH-1.7
___ 12:59PM BLOOD Carbamz-12.8*
___ 09:15PM BLOOD Carbamz-8.7
___ 12:59PM BLOOD Glucose-229* Lactate-0.9 K-4.3
DISCHARGE:
___ 07:05AM BLOOD WBC-5.6 RBC-3.72* Hgb-11.8* Hct-33.0*
MCV-89 MCH-31.8 MCHC-35.9* RDW-12.3 Plt ___
___ 07:05AM BLOOD Glucose-68* UreaN-5* Creat-0.6 Na-141
K-3.8 Cl-105 HCO3-30 AnGap-10
___ 07:05AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8
REPORTS:
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2:04 ___
1. Dilated, fluid-filled stomach, which may be related to the
patient's known history of gastroparesis.
2. Scattered fluid-filled small bowel loops can be seen with
gastroenteritis, though this is a nonspecific finding and must
be correlated with the patient's n.p.o. status.
3. Prominence of the common bile duct, little changed from prior
studies, and likely reflecting prior cholecystectomy.
Brief Hospital Course:
Assessment and Plan:
___ year old woman with a history of type I diabetes c/b
gastroparesis, nephropathy, retinopathy who presents with 5 days
of abdominal pain and diarrhea thought to be secondary to a
gastroparesis flare.
.
# Abdominal pain and diarrhea: Clinical picture and CT abdomen
showing retained fluid in the stomach is highly suggestive of
gastroparesis. Normal LFTs and lipase made hepatitis and
pancreatitis unlikely. Concominant gastroenteritis possible
given diarrhea but patient without any other viral prodrome such
as fever, body aches, etc other than abdominal pain and
diarrhea. Diabetic enteropathy is a possibility but unlikely as
this usually presents with incontinence which she lacked.
Medications possible but most doses stable. TSH wnl here and TtG
wnl in ___. Diarrhea resolved upon admission making infectious
diarrhea highly unlikely. The patient significantly improved
with fluids, reglan (only 5mg to mitigate the risk of tardive
dyskinesia given her concominant seroquel, risks were discussed
with the patient). The patient tolerated a regular diabetic diet
the day prior as well as the day of discharge with minimal pain,
no diarrhea or vomitting. Patient was instructed to adhere to
small frequent meals, as meal size indiscretions were behind the
likely trigger for this flare. She expressed an understanding of
the plan moving forward.
.
# Type I diabetes: Patient very savvy and last A1C 6.3, but
control is actually in reality worse because she is brittle with
lots of highs and lots of lows. Lantus 19 units HS was
continued, she unfortunately developed AM hypoglycemia to the
___ with sx. Per the patient, this happens frequently as an
outpatient because her gastroparesis makes aborption of food and
carb counting unpredictable. ___ was consulted who
recommended cutting down to 16 of lantus and cutting back
significantly her sliding scale. Upon discharge, the patient was
lowered further to even 14 units lantus HS given her persistent
hypoglycemia (although improving by admission). Her outpatient
___ Dr. ___ was contacted to check in on
the patient ___ to assess her glucose control. The patient
was also instructed to only take her insulin upon successful
completion of a meal in order to make carb counting more
predictable. The patient will set up a sooner follow up with her
___ doctors and ___ be in touch with Dr. ___.
.
# Seizure disorder: Continued carbamazapine 800mg PO QAM and
1000mg PO QPM (discussed with pharmacy as her confirmed dosage).
Her carbamazapine level (the second one was correctly timed as
12 hours after her dose) was in the therapeutic range.
.
# Bipolar: Continued seroquel 200mg PO QAM, 400mg PO QPM
(discussed with pharmacy). ___ rec attempted 3 times with 3
different pharmacies without success, per inpatient pharm, these
are correct dosages
.
# Prophylaxis: Subcutaneous heparin, bowel regimen
.
# Code: presumed full
TRANSITIONAL ISSUES:
Sugar checks by Dr. ___ next week.
Medications on Admission:
Confirmed:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*0*
2. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Carbamazepine 200 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Carbamazepine 200 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for abdominal pain.
Disp:*15 Tablet(s)* Refills:*0*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
12. Lantus 19 units qhs
13. Novolog sliding scale
Discharge Medications:
1. carbamazepine 200 mg Tablet Sig: Four (4) Tablet PO QAM (once
a day (in the morning)).
2. carbamazepine 200 mg Tablet Sig: Five (5) Tablet PO QPM (once
a day (in the evening)).
3. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. quetiapine 200 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*12 Tablet(s)* Refills:*0*
6. insulin glargine 100 unit/mL Cartridge Sig: Fourteen (14)
UNITS Subcutaneous at bedtime.
7. Novolog 100 unit/mL Solution Sig: One (1) Subcutaneous once
a day: Per home carb-counting scale.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic gastroparesis
Type 1 diabetes poorly controlled (ie brittle)
Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for gastroparesis causing abdominal pain,
vomitting, and some diarrhea. Your symptoms resolved with
fluids, reglan, and other supportive measures. Your stay was
complicated by hypoglycemia, which is a chronic issue for you.
In discussion with ___ consultants, we have decided on a
modified regimen for you for the next few days while your
gastroparesis resolves. We will communicate this with Dr.
___ will also check in with you next week. Remember,
the key to controlling your gastroparesis is small frequent
meals.
We have made the following changes to your medications:
DECREASE your lantus to 14 units every night until you speak
with Dr. ___ week
CONTINUE your original carb counting insulin scale but take the
insulin after meals to ensure good absorption while you
gastroparesis is resolving
START metoclopromide 5mg by mouth 30 minutes before each meal
for the next 3 days
Please call Dr. ___ if you develop any further low
blood sugars. Please contact your PCP for any other concerning
symptoms.
Followup Instructions:
___
|
19973404-DS-17 | 19,973,404 | 23,868,350 | DS | 17 | 2166-01-02 00:00:00 | 2166-01-02 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vomiting and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o Female with past medical history including Hep B, bipolar
disorder, seizure disorder, IDDM and gastroparesis developed
severe nausea, vomiting, and abdominal pain at 11pm last night
(___). She reports that she has had episodes of
gastroparesis in the past, and that this episode is distinct by
the rapid onset of abdominal pain after vomiting but is
otherwise similar to past episodes of gastroparesis. Notably
she denies bloody or bilious vomiting, only food, secretions,
and then dry heaving. She was complaining of constipation
however had a large non bloody bm prior to coming to the ED.
She had been on a "light fast" of a diet consisting of
vegetables and chicken prior to eating a ___ hamburger
for dinner yesterday evening. Feels well otherwise. S/p Botox
injection of pylorus in ___, has not had any episodes of
gastroparesis since that time. Last BM was yesterday evening;
she denies conspitation at present.
In the ED, initial vitals: 97.6 133/78 96 16 98%RA. Labs
were notable for glucose of 236 and magnesium of 1.5 but were
otherwise unremarkable. She received metoclopramide,
hydromorphone, lorazepam, and ondansetron in the ED. Vitals
prior to transfer: 98.7 124/85 100 14 98%RA
On the floor the patient endorsed ___ abdominal pain, severe
nausea and she continued to vomit nonbilious nonbloody emesis.
Vitals were 97.8 135/71 10 16 100%RA FSBG 184.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena. No numbness or weakness,
no focal deficits.
Past Medical History:
BIPOLAR DISORDER
DIABETES MELLITUS - insulin dependent. Pt reports proteinuria,
nephropathy, and retinopathy in addition to gastroparesis.
GLAUCOMA
RIGHT BUNDLE BRANCH BLOCK
SEIZURE DISORDER - currently treated with Carbamazepine to which
Pt attributes vertigo/dizziness, self-changed evening dose to
800mg from 1000mg yesterday (___)
ALCOHOL ABUSE
ASTHMA
HEPATITIS B
HEP C
GASTROPARESIS - s/p Botox injection in ___
Past Surgical History:
CHOLECYSTECTOMY ___
FROZEN SHOULDER ___
UTERINE POLYPS
PRIOR CESAREAN SECTION
G3P1 MIS2
BILATERAL TUBAL LIGATION
Social History:
___
Family History:
Extensive family history of Diabetes Mellitus with both parents
still living. Heart disease in father. ___ family history
of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.8 135/71 10 16 100%RA FSBG 184
General- Alert, oriented, no acute distress. Sitting on bed
consuming ice chips.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, Systolic murmur. No rubs/gallops.
Abdomen- soft, nondistended. Diffusely tender, worst at
umbilicus. Diminished bowel sounds. No rebound tenderness, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 grossly intact, motor function grossly normal
DISCHARGE EXAM
Vitals (7:15am) 97.6 114/71 80 18 100%RA
General- Alert, oriented, no acute distress.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilateratlly.
CV- Regular rate and rhythm, normal S1 + S2, grade II systolic
flow murmur, rubs, gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- moving all extremities, motor function grossly normal
Pertinent Results:
Admission labs:
___ 09:35AM GLUCOSE-236* UREA N-13 CREAT-0.5 SODIUM-142
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-20
___ 09:35AM estGFR-Using this
___ 09:35AM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-62 TOT
BILI-0.4
___ 09:35AM LIPASE-12
___ 09:35AM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-3.3
MAGNESIUM-1.5*
___ 09:35AM WBC-7.7# RBC-4.07* HGB-12.8 HCT-38.1 MCV-94
MCH-31.5 MCHC-33.7 RDW-11.8
___ 09:35AM NEUTS-89.8* LYMPHS-6.6* MONOS-2.4 EOS-1.0
BASOS-0.2
___ 09:35AM PLT COUNT-187
___ 09:15AM ALT(SGPT)-19
KUB ___:
Normal bowel gas pattern without obstruction.
Discharge labs:
___ 06:45AM BLOOD WBC-10.0 RBC-3.66* Hgb-11.5* Hct-34.2*
MCV-94 MCH-31.5 MCHC-33.7 RDW-11.8 Plt ___
___ 06:45AM BLOOD Glucose-163* UreaN-15 Creat-0.6 Na-137
K-3.8 Cl-103 HCO3-16* AnGap-22*
Brief Hospital Course:
___ F with PMH of seizure disorder, bipolar disorder,hepatitis
B, IDDM and history of gastroparesis s/p pyloric Botox injection
presents with acute onset nausea, vomiting, and abdominal pain
several hours after consuming her first fatty meal in several
weeks.
#Nausea and Vomiting: Pt has a history of gastroparesis and
reports that this episode is nearly identical to gastroparesis
episodes in the past. While she has not suffered severe nausea
and vomiting since the pyloric Botox injection in ___, her
abrupt change in diet (fatty meal after a period of "light
fasting") may have contributed to the present episode. KUB
demonstrated normal bowel gas pattern which was reassuring that
she did not have ileus or obstruction leading to nausea and
vomiting. She was initially made NPO and then advanced to sips.
She had several episodes of nonbloody, nonbilious emesis.
After administration of metoclopromide and toradal, she felt her
symptoms were improved and diet was advanced to full liquids in
the AM. This was well tolerated and she was advanced to regular
diabetic diet. She has continued to take her home domperidone
during this admission. She was discharged on her home regimen.
Of note the patient self tapered her carbamazepine. We
recommeded she share this change with her providers.
Additionally as carbamazepine and seroquel may be contributing
to decreased gastric motility would consider tapering this
medications as an outpatient if appropriate.
#Diabetes mellitus - The patient was continued on sliding scale
and fixed dose insulin. Her fixed dose was reduced overnight to
9 units Glargine due to reduced PO intake and returned to ___ Glargibe on ___ after she began to eat again.
#Exposure - Due to needlestick exposure in ED, patient was
ordered for HCV viral load, Hep C Ab, HIV
Chronic issues:
#BIPOLAR DISORDER - continued home quetiapine.
#GLAUCOMA - continued home latanoprost
#RIGHT BUNDLE BRANCH BLOCK - EKG unchanged
#SEIZURE DISORDER - continued home carbamazepine at 800mg BID.
The patient had been prescribed for 800mg QAM and 1000mg QPM but
had self-decreased to 800mg QPM due to vertigo/dizziness.
#HEPATITIS B - continued Viread 300mg daily
Transitional Issues
- Would consider taper of seroquel and carbamezepine if able
- Bicarb low on date of discharge, patient appears well would
recommend repeat electrolytes at follow-up
- Patient was full code throughout this admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Valerate 0.1% Cream 1 Appl TP APPLY TWICE A DAY
FOR UP TO TWO WEEKS AT A TIME
2. Carbamazepine 800 mg PO BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Lisinopril 10 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Glargine 18 Units Bedtime
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
9. DiCYCLOmine 20 mg PO QID
10. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
11. QUEtiapine Fumarate 300 mg PO BID
Discharge Medications:
1. Carbamazepine 800 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Glargine 18 Units Bedtime
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 10 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
8. Domperidone 10 mg PO QID
9. QUEtiapine Fumarate 300 mg PO BID
10. Betamethasone Valerate 0.1% Cream 1 Appl TP APPLY TWICE A
DAY FOR UP TO TWO WEEKS AT A TIME
11. DiCYCLOmine 20 mg PO QID
12. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID
continue your current sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: gastroparesis
Secondary: diabetes mellitus
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 because of nausea, vomiting,
and abdominal pain. The physicians who took care of you
believed that this was another episode of gastroparesis which
was triggered by eating a fatty meal after eating a low fat diet
for several weeks. Your pain and nausea were treated, and you
were restarted on food which you have been able to eat without
nausea, vomiting, or pain. You will need to follow-up with your
primary care doctor as well as your gastroenterologist.
Followup Instructions:
___
|
19973404-DS-18 | 19,973,404 | 22,452,588 | DS | 18 | 2166-01-08 00:00:00 | 2166-01-08 14:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of chronic Hep B, bipolar disorder, seizure
disorder, IDDM and gastroparesis presents with nausea associated
with ABD pain. She has had generalized malaise since d/c from
hospital (was here ___ and treated for gastroparesis with
improvement). She states that she was still nauseas at the time
of discharge but that she said she felt fine in order to avoid
getting another IV placed. She went directly to bed when she
went home and has only eaten a waffle and ham sandwich due to
severe nausea. Has been able to tolerate liquid intake despite
nausea. She developed abdominal pain after being home one day,
and did attempt PO zofran per her outpatient gastroenterologist
Dr. ___. She denies any emesis since discharge. Has
not had a bowel movement in 5 days and is beginning to feel
bloated. Also insists she has not passed gas in 5 days.
In the ED intial vitals were: 99.0 96 157/78 20 99% RA
There, she was unable to take p.o. Zofran and Compazine did not
help her. Also got morphine x2 without relief. Labs were notable
for Hct of 36.9 which is at her baseline. She also had FSBG of
72 and then 79 for which she was given sips of orange juice with
improvement to the , EKG demonstrated RBB which is old, with
question of mild ST depressions in V4 and V5 leads. QTc of 425,
compared to 457 on ___.
Vitals prior to transfer:98.2 121/67 77 16 98%RA pain ___
On the floor she continues to endorse nausea and abomdinal pain,
though it is improved since presentation to the ED. She feels
thirsty and has ___ abdominal pain. No vomiting. She has
continued to take her home domperidone while waiting for a bed
in the ED. Has some headache. Denies chest pain, shortness of
breath.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No diarrhea. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
BIPOLAR DISORDER
DIABETES MELLITUS - insulin dependent. Pt reports proteinuria,
nephropathy, and retinopathy in addition to gastroparesis.
GLAUCOMA
RIGHT BUNDLE BRANCH BLOCK
SEIZURE DISORDER - currently treated with Carbamazepine to which
Pt attributes vertigo/dizziness, self-changed evening dose to
800mg from 1000mg yesterday (___)
ALCOHOL ABUSE
ASTHMA
HEPATITIS B
HEP C
GASTROPARESIS - on domperidone, s/p Botox injection in ___
.
Past Surgical History:
CHOLECYSTECTOMY ___
FROZEN SHOULDER ___
UTERINE POLYPS
PRIOR CESAREAN SECTION
G3P1
BILATERAL TUBAL LIGATION
Social History:
___
Family History:
Extensive family history of Diabetes Mellitus with both parents
still living. Heart disease in father. ___ family history
of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.9 122/75 82 18 97%RA ___ pain FSBG 48
General- Alert, oriented, no acute distress.
HEENT- Sclera anicteric, MMM with some white coating on tongue,
oropharynx clear
Neck- supple
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, Grade 3 Systolic flow murmur. No
rubs/gallops.
Abdomen- soft, nondistended. Periumbical TTP. Bowel sounds
present. No rebound tenderness, no organomegaly. ___ sign
negative.
Ext- warm, well perfused, palpable pulses, no clubbing, cyanosis
or edema
Neuro- Moving all extremities, motor function grossly normal
.
DISCHARGE PHYSICAL EXAM:
Vitals- 98.1 120/75 78 18 99%RA ___ pain
FSBG 59 at 4:45am, 150 at 5:40am
General- Alert, oriented, no acute distress.
HEENT- Sclera anicteric, moist MM, oropharynx clear
Neck- supple
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, Grade 3 Systolic flow murmur. No
rubs/gallops.
Abdomen- soft, nondistended. No TTP. No rebound tenderness, no
organomegaly.
Ext- warm, well perfused, palpable pulses, no clubbing, cyanosis
or edema
Neuro- Moving all extremities, motor function grossly normal
Pertinent Results:
Admission labs:
___ 09:20PM BLOOD WBC-6.2 RBC-3.89* Hgb-12.3 Hct-34.9*
MCV-90 MCH-31.7 MCHC-35.3* RDW-12.3 Plt ___
___ 09:20PM BLOOD Neuts-62.7 ___ Monos-8.1 Eos-3.0
Baso-0.4
___ 09:20PM BLOOD Plt ___
___ 09:20PM BLOOD Glucose-256* UreaN-8 Creat-0.5 Na-134
K-3.6 Cl-94* HCO3-24 AnGap-20
___ 09:20PM BLOOD ALT-28 AST-27 AlkPhos-55 TotBili-0.3
___ 10:15PM BLOOD CK(CPK)-52
___ 09:20PM BLOOD Lipase-18
___ 10:15PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:20PM BLOOD cTropnT-<0.01
___ 09:20PM BLOOD Albumin-4.0 Calcium-8.3* Phos-3.6 Mg-1.7
.
Discharge labs:
___ 05:15AM BLOOD Glucose-90 UreaN-4* Creat-0.5 Na-143
K-4.3 Cl-105 HCO3-30 AnGap-12
___ 05:15AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.8
.
Imaging:
___ KUB:
IMPRESSION: Frontal upright and supine views of the abdomen
show no pathologic distention of large or small bowel. There is
formed stool in the transverse and left colon, and no free
subdiaphragmatic gas. Vascular clips denote prior right upper
quadrant surgery.
Brief Hospital Course:
___ h/o chronic Hep B, bipolar disorder, seizure disorder, IDDM
and gastroparesis p/w N/V associated with abd pain consistent
with gastroparesis flare.
.
#Nausea, Abdominal pain / Gastroparesis Flare: This patient's
presentation is most c/w unresolved gastroparesis from last
admission. Her carbamazepine and Seroquel may be contributing to
decreased gastric motility, and we would encourage her outpt
psychiatrist to consider tapering this medications as an
outpatient if appropriate. Additionally, her KUB was not
concerning for obstruction/flatus but showed much stool, making
it likely that constipation was also contributing to nausea.
Although her presenting symptoms were unlikely to have been
cardiac in nature, due to an isolated ST depressionin V4 in ED,
we ruled out cardiac etioloty with trop/repeat EKG/tele. She was
initially placed on sips with IVF and IV metoclopromide
standing, IV Zofran prn, IV Toradol and Tylenol for pain prn, as
well as her home domperidone. Her bowel regimen was also
increased to include senna, bisacodyl PR, and Miralax. Her
symptoms improved and her diet was slowly advanced to clears and
then a regular diabetic diet. She was able to tolerate each
advancement. GI was consulted on ___ for ? of repeat
Botox injection via EGD but they indicated that any endoscopic
procedure should be completed as an outpatient. At discharge,
she had eaten a full breakfast and denied any nausea, vomiting,
or abdominal pain. She reported many bowel movements during her
admission with simultaneous improvement in her abdominal pain.
She was discharged on her home domperidone.
.
#Hypoglycemia/Diabetes Mellitus- Patient has a history of Type I
diabetes and has become hypoglycemic during this admission
requiring close monitoring. In ED FSBG was 72 and 79, treated
with sips of orange juice. Pt FSBG down to 48 on her first
overnight on the floor. The initial hypoglycemic events were
likely due to receiving full 18 unit Lantus dose evening of ___
in setting of persistent reduced oral intake. We reduced her ___
Lantus dose to 9 given her poor oral intake. ___ Diabetes
was consulted on ___ and suggested adjusting her Lantus dose to
14 while maintaining her home sliding/scale + carb correction.
She received ___ NS at rate of 50cc/hour while she had poor
PO intake. This was discontinued the evening of ___ after she
tolerated a small evening meal and clear liquids. Early morning
___, she had another FSB to 59 which improved to 150 after
apple juice. This was most likely due to a small dinner, and we
anticipate that the hypoglycemic episodes will cease given that
she is able to eat full meals starting today. She was discharged
on her home insulin regimen, glargine 18 units qhs plus insulin
SS and carb counting. She was not hypoglycemic on discharge.
.
CHRONIC ISSUES:
#BIPOLAR DISORDER - continued home quetiapine.
#GLAUCOMA - continued home latanoprost
#RIGHT BUNDLE BRANCH BLOCK - aside from one isolated ST
depression on her ED EKG, this patient's EKG was unchanged
during admission.
#SEIZURE DISORDER - continued home carbamazepine
#HEPATITIS B - continued Viread 300mg daily
Transitional issues:
- This patient will need to follow-up with her outpatient
gastroenterologist to discuss how to prevent gastroparesis
flares in the future. This may involve altering her diet or
receiving another pyloric Botox injection
- She will require outpatient follow-up with her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine 800 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Glargine 18 Units Bedtime
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 10 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
8. Domperidone 10 mg PO QID
9. QUEtiapine Fumarate 300 mg PO BID
10. Betamethasone Valerate 0.1% Cream 1 Appl TP APPLY TWICE A
DAY FOR UP TO TWO WEEKS AT A TIME
11. DiCYCLOmine 20 mg PO QID
12. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID
13. Ondansetron Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Betamethasone Valerate 0.1% Cream 1 Appl TP APPLY TWICE A DAY
FOR UP TO TWO WEEKS AT A TIME
2. DiCYCLOmine 20 mg PO QID
3. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID
4. Carbamazepine 800 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Domperidone 10 mg PO QID
7. Glargine 18 Units Bedtime
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. Lisinopril 10 mg PO DAILY
10. QUEtiapine Fumarate 300 mg PO BID
11. Simvastatin 40 mg PO DAILY
12. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
gastroparesis, hypoglycemia, insulin-dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care while you were
admitted to the ___. As you
know you were admitted because you were having continued
symptoms of your gastroparesis. You were treated with a
restricted diet and medications, in particular medicine that
made you feel less naseous and that would help you move your
bowels. You should follow up with your gastroenterologist and
primary care doctor after you leave the hospital.
Followup Instructions:
___
|
19973404-DS-19 | 19,973,404 | 29,788,438 | DS | 19 | 2167-09-12 00:00:00 | 2167-09-13 12:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
EGD with botox injections
History of Present Illness:
=======================================================
MEDICINE NIGHTFLOAT ADMISISON NOTE
Date of admission: ___
=======================================================
___.
CC:nausea/vomiting and epigastric pain
HISTORY OF PRESENT ILLNESS:
___ year old woman with a history of type I diabetes c/b
gastroparesis/nephropathy/retinopathy, bipolar, who presents
with vomiting and nausea and abdominal pain
Ms ___ reports that this morning she awoke with ___
abdominal pain that was associated with non-bloody, mildly
bilious vomiting. She reports that her symptoms were exactly the
same as her previous gastroparesis episodes. Her last flare was
one year ago and required hospitalization for IV pain meds and
anti-emetics.
In the ED, initial vs were: 18:45 10 97.6 101 151/84 20 99% RA
Exam notable for: pt awake and alert, speaking in full clear
sentences, pleasant and cooperative, abd was soft tender
throughout, +bs.
Labs were remarkable for: UA with 1000 glucose, Chem panel with
glucose of 300 and white blood cell count of 12.4.
Patient was given: 1000ml NS, reglan, Ativan, dilaudid with
improvement of symptoms. She is admitted for further pain and
nausea control. Vitals on transfer were: sleeping 98.2 101
127/64 18 97% RA
On arrival to the floor, she is feeling much better and
abdominal pain is now ___. Nausea is improving and she would
like to try drinking gingerale. She has a history of
gastroparesis and says this feels "exactly the same". Denies
fever, chills, sweats, HA, rhinnorhea, cough, melena, BRBPR, CP,
SOB. Endorses recent episode of hyperglycemia.
She reports that she has obtained good control of her
gastroparesis with Domperidone 10 mg PO QID, which she has to
obtain in ___ and which is not FDA approved in the ___. She
reports that she has difficulty with the expense and has
recently cut back on how often she takes it over the past week.
She is concerned that it was decreasing this med that lead to
this flare.
Review of sytems:
(+) Per HPI
PAST MEDICAL HISTORY:
1) Ventriculomegaly, not felt to have increased ICP
2) Bipolar Disorder
3) Diabetes Type I followed at ___ with retinopathy,
nephropathy/proteinuria, and gastroparesis
4) Glaucoma
5) Hepatitis B per notes
6) S/p cholecystectomy ___
7) S/p uterine polyp removal ___ and uterine laser
MEDICATIONS AT HOME:
The Preadmission Medication list is accurate and complete
1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID
2. Carbamazepine 800 mg PO BID
3. Domperidone 10 mg PO QID
4. Lisinopril 10 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
7. Glargine 18 Units Bedtime
8. QUEtiapine Fumarate 200 mg PO BID
9. Fexofenadine 180 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
ALLERGIES: NKDA
SOCIAL HISTORY: ___
FAMILY HISTORY:
She has a family history significant for asthma in her father.
Her father is also a type-2 diabetic and has cardiac disease.
She has a sister who is a type 2 diabetic and is schizophrenic
and died of a heart attack in ___.
PHYSICAL EXAM:
Vitals: 97.9 121/54 107 18 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate, normal rhythm, normal S1S2. Has II/VI
crescendo SEM at LUSB and holosytolic murmur at apex.
Abdomen: soft, mild tenderness over epigastric region,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes appreciated
Neuro: CN ___ grossly intact, ___ strength in all extremities,
no peripheral sensory deficits.
ACCESS: #20 ___
LABS:
=========================
137 97 11
---------------< 305 AGap=24
4.2 20 0.6
Ca: 9.7 Mg: 1.7 P: 4.1
94
12.4 \ 12.7 / 223
/ 36.9 \
N:92.8 L:4.1 M:2.3 E:0.1 Bas:0.3 ___: 0.4
MICRO:None pending
STUDIES:
============================
+ EGD (___): Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach (injection)
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
ASSESSMENT AND PLAN:
___ year old woman with a history of type I diabetes c/b
gastroparesis, nephropathy, retinopathy, bipolar,
cholecystectomy, C-section who presents with vomiting and nausea
and abdominal pain.
#Gastroparesis: Current nausea and epigastic pain most likely
secondary to gastroparesis given history of recurrent
gastroparesis. Pt notes this feels exactly like similar episodes
and she has been diagnosed in past by gastric emptying study.
Pancreatitis or liver pathology less likely given negative in
past but will check
- check LFTs, lipase
- Zofran, Ativan, Hydromorphone overnight
- Sips with plan to ADAT a clear diet
- Consider GI consult in AM
- In AM, attending will need to write note in chart authorizing
use of domperidone.
# Mild Leukocytosis: Patient with WBC of 12.4. Suspect this is
stress reaction for recurrent vomiting. She denies fevers,
chills, dysuria or cough.
- continue to monitor.
CHRONIC ISSUES:
====================
# DM Type 1: Patient is very well educated regarding management
and current dosing. Humalog sliding scale calorie based.
- Continue with 18U qhs lantus and Humalog sliding scale
# Nephropathy: Continue lisinopril
# Bipolar: stable. Not currently promoting any manic or
depressed mood. Continue with seroquel.
# Hepatitis B: continue tenofovir.
CORE MEASURES:
====================
# FEN: No IVF, replete electrolytes, regular diet
# PPX: Subcutaneous heparin, senna/colace, pain meds
# ACCESS: peripherals
# CODE: Full
# CONTACT: Husband ___
# DISPO: CC7, pending above
Past Medical History:
BIPOLAR DISORDER
DIABETES MELLITUS - insulin dependent. Pt reports proteinuria,
nephropathy, and retinopathy in addition to gastroparesis.
GLAUCOMA
RIGHT BUNDLE BRANCH BLOCK
SEIZURE DISORDER - currently treated with Carbamazepine to which
Pt attributes vertigo/dizziness, self-changed evening dose to
800mg from 1000mg yesterday (___)
ALCOHOL ABUSE
ASTHMA
HEPATITIS B
HEP C
GASTROPARESIS - on domperidone, s/p Botox injection in ___
.
Past Surgical History:
CHOLECYSTECTOMY ___
FROZEN SHOULDER ___
UTERINE POLYPS
PRIOR CESAREAN SECTION
G3P1
BILATERAL TUBAL LIGATION
Social History:
___
Family History:
Extensive family history of Diabetes Mellitus with both parents
still living. Heart disease in father. ___ family history
of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 121/54 107 18 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate, normal rhythm, normal S1S2. Has II/VI
crescendo SEM at LUSB and holosytolic murmur at apex.
Abdomen: soft, mild tenderness over epigastric region,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes appreciated
Neuro: CN ___ grossly intact, ___ strength in all extremities,
no peripheral sensory deficits.
DISCHARGE PHYSICAL EXAM:
Vitals: afebrile, BP baseline here in 130's/70's (currently
111/65)HR: , 100% RA
General: Alert, oriented, in no acute distress
HEENT: mmm, no vertical nystagmus noted.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm, normal S1 + S2, no murmurs noted.
Abdomen: soft, non-distended, tender in RLQ, no rebound
Ext: Warm, well perfused
Skin: No rash.
Neuro: moving all extremities, distal sensation intact.
Pertinent Results:
ADMISSION LABS:
___ 08:51PM WBC-12.4*# RBC-3.93 HGB-12.7 HCT-36.9 MCV-94
MCH-32.3* MCHC-34.4 RDW-11.9 RDWSD-41.1
___ 08:51PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.3* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-11.47*# AbsLymp-0.51* AbsMono-0.29
AbsEos-0.01* AbsBaso-0.04
___ 08:51PM GLUCOSE-305* UREA N-11 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-24*
___ 08:51PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-75 TOT
BILI-0.4
___ 08:51PM LIPASE-18
___ 08:51PM CALCIUM-9.7 PHOSPHATE-4.1 MAGNESIUM-1.7
___ 08:56PM URINE MUCOUS-RARE
___ 08:56PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
___ 08:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:56PM URINE COLOR-Straw APPEAR-Clear SP ___
DISCHARGE LABS:
___ 05:49AM BLOOD WBC-5.5 RBC-3.52* Hgb-11.2 Hct-34.8
MCV-99* MCH-31.8 MCHC-32.2 RDW-12.4 RDWSD-44.4 Plt ___
___ 05:49AM BLOOD Plt ___
___ 05:49AM BLOOD Glucose-142* UreaN-3* Creat-0.5 Na-135
K-4.0 Cl-98 HCO3-23 AnGap-18
___ 05:49AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7
___ 06:29AM BLOOD VitB12-1559*
PERTINENT IMAGING:
___ ABDOMEN XR (SUPINE ONLY): Nonobstructive bowel gas
pattern.
___ CTA HEAD W&W/O C & RECONS: final read pending, study
sent for possible stroke and was unrevealing.
___ MR HEAD W/O CONTRAST: There is no acute infarct or
intracranial hemorrhage.
___ TTE: The left atrium is normal in size. No
thrombus/mass is seen in the body of the left atrium. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are mildly thickened. No mass
or vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
___ CT HEAD W/O CONTRAST: No evidence of acute intracranial
hemorrhage or large vascular territorial infarction.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of type I
diabetes c/b gastroparesis, nephropathy, retinopathy, bipolar,
cholecystectomy, C-section who presents with vomiting and nausea
and abdominal pain. Vomiting, nausea and abdominal pain occured
in the setting of trying to cut back on domiperidone dose from
QID to BID due to cost of medication. Patient had no signs of
infection and her lipase was normal. Domiperidone was restarted
and patient was advanced to regular diabetic diet. Patient
continued to have nausea and vomiting which was felt in part to
be due to her elevated blood sugars. ___ was consulted who
titrated her inpatient insulin regimen with subsequent
improvement in her blood sugars. By the time of discharge,
patient noted resolution of her nausea, vomiting, and abdominal
pain and was tolerating po intake well. Since the patient
reported having an insufficient amount of domperidone available
before the arrival of her next shipment of domperidone from ___,
she was prescribed Ativan to take in the meantime. She had an
EGD with botox injection which she tolerated well with
improvement of symptoms.
Patient was noted to develop new vertical nystagmus during her
hospital stay. A code stroke was called, however no evidence of
stroke was noted on CT/CTA/MRI and TTE was performed
demonstrating no defects including PFO. Neurology was consulted
but ultimately etiology of nystagmus remained unclear and
nystagmus improved by day of discharge.
ACTIVE ISSUES
=============
#Gastroparesis: Thought to be triggered by patient attempting to
decrease domperidone dose frequency to save on cost. Domperidone
restarted at old regimen. However, patient initially with
persistent nausea and vomiting despite restarting domiperidone
that was thought to be related to concomitant poor blood sugar
control. S/p EGD with botox injections in pylorus. She was seen
by nutrition with recommendations for a gastroparesis diet and
she ultimately able to tolerate small meals and liquids. She
discharged with Ativan for nausea and an anxiety component of
her gastroparesis with instructions to take the Ativan 30
minutes prior to meals.
#Vertical Nystagmus: Code stroke called ___ in absence of other
symptoms with negative imaging for posterior stroke
(CT/CTA/MRI), TTE also neg for PFO. Neurology re-consulted given
acute change of nystagmus with vertigo and gait instability c/f
central process. Per Neuro, vertical nystagmus similiar from
prior assessment. Unlikely pontine stroke or seziure. Consider
carbamazepime toxicity; nystagmus worsened by low magnesium.
Repeat CTH negative. She was treated with Meclizine and
magnesium repleted with improvement in her symptoms and was
set-up with follow-up with Neurology.
# DM Type 1: Managed per ___ recommendations, discharged on
her home 18 units of Lantus.
CHRONIC ISSUES:
====================
# Nephropathy: Lisinopril 10 mg PO/NG DAILY
# Bipolar: stable. Not currently promoting any manic or
depressed mood. Restarted on Lithium Carbonate 900 mg PO QHS per
her home medications. Continued with QUEtiapine Fumarate 200 mg
PO/NG BID, CarBAMazepine 800 mg PO/NG BID
# Hepatitis B: continued tenofovir.
# Hyperlipidemia: held Simvastatin 40 mg PO/NG DAILY while
inpatient, restarted as outpatient.
# GERD: Fexofenadine 180 mg PO DAILY
Transitional Issues:
=====================
#) Magnesium: Patient started on oral magnesium due to low Mg
and because she is on multiple QTc prolonging medications.
Please follow up and titrate as clinically warranted.
#) QTc: Patient on multiple QTc prolonging medications including
domperidone and quetiapine. Please repeat EKG at next
appointment and repeat as clinically warranted.
#) Domiperidone: Patient tried to cut back due to cost. Planning
to go back to QID dosing. Consider trialing taper to TID if
clinically warranted to help with cost. At time of discharge,
patient reported having insufficient amount of domperidone to
make it until arrival of next shipment. Consequently was
discharged on Zofran and advised to change back to domperidone
once the next shipment arrived.
#) Type 1 DM: Reports difficulty controlling BS due to
gastroparesis and resultant difficulty in predicing required
insulin dose. Reports hypoglycemia at home to ___ and
hyperglycemia to 200s. Please follow up.
# Diabetes: She should follow up in ___ as
well. To schedule please contact (___) and/or ask for
___ or leave a voice message for her.
#) Nystagmus: Worked up by neurology with no evidence of stroke.
Follow up in neurology outpatient clinic if this persists and is
symptomatic.
#) Code status: Full
#) CONTACT: ___ (Husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID
2. Carbamazepine 800 mg PO BID
3. Domperidone 10 mg PO QID
4. Lisinopril 10 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
7. Glargine 18 Units Bedtime
8. QUEtiapine Fumarate 200 mg PO BID
9. Fexofenadine 180 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
12. Lithium Carbonate 900 mg PO QHS
13. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Medications:
1. Carbamazepine 800 mg PO BID
2. Domperidone 10 mg PO QID
3. Fexofenadine 180 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. QUEtiapine Fumarate 200 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID
12. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Lithium Carbonate 900 mg PO QHS
14. Psyllium Powder 1 PKT PO TID:PRN constipation
15. Glargine 18 Units Bedtime
16. Meclizine 12.5 mg PO Q6H:PRN vertigo
RX *meclizine 12.5 mg 1 tablet(s) by mouth every six (6) hours
Disp #*45 Tablet Refills:*0
17. Lorazepam 0.5 mg PO QAC
RX *lorazepam 0.5 mg 1 tablet(s) by mouth before meals Disp #*21
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
==================
1. Gastroparesis
2. Type 1 Diabetes Mellitus
3. Nystagmus
Secondary diagnoses:
=====================
1. Nephropathy
2. Bipolar disorder
3. Hepatitis B
4. Hyperlipidemia
5. Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you during your admission to ___
___. You were admitted due to
nausea/vomiting and epigastric pain. This was felt to be due to
your gastroparesis. We restarted your domiperidone at its
prescribed dose of four times per a day. Unfortunately, you
continued to have nausea and vomiting on this regimen. This was
thought to be due to your high blood sugars. We changed your
insulin regimen while you were in the hospital and your blood
sugars then improved. You also saw your gastroenterologist and
you had a procedure to inject botox into your stomach.
You also had developed some eye movements while you were in the
hospital that were concerning for a stroke. The neurology team
evaluated you and performed a number of imaging tests that did
not show any evidence of a stroke. It is unclear what caused
these eye movements. Please follow up with neurology for
continued management. You may take meclizine for your symptoms
of vertigo.
You should continue your domiperidone at your prescribed dose of
four times a day. You stated that you did not have a sufficient
quantity of domperidone to take until you received your next
shipment. Thus, we have prescribed you some Ativan to take in
the meantime. You should restart your dopmeridone at your usual
dose once you get more domperidone.
You should follow up with your GI doctor, a neurologist and your
PCP. You should follow up with ___ clinic. You
should follow up with Neurology if your eye symptoms continue.
We wish you a speedy recovery!
- Your ___ Care Team
Followup Instructions:
___
|
19973404-DS-20 | 19,973,404 | 22,873,532 | DS | 20 | 2167-09-17 00:00:00 | 2167-09-17 17:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a history of type I diabetes c/b
gastroparesis/nephropathy/retinopathy, bipolar, who presents
with recurrent vomiting and nausea and abdominal pain. Pt was
discharged 3 days ago for the same issues, recieved an EGD with
botox injection. She was doing well, tolerating food until today
at 9:30, when her symptoms suddenly returned. She had acute
onset abdominal pain, diarrhea, and nausea/NBNB vomiting. She
denies hematochezia or hematemesis. Denied fever, sick contacts
or eating out.
EKG: SR 98, RBBB QTc 491, no ST changes, similar to prior
In the ED, initial vitals were: 97.4 109 126/69 16 100% RA
- Labs were significant for WBC 18.7, H/H 14.8/43.8, BUN/Cr
___, blood glucose 338, negative u/a, normal lactate.
- CT abd/pelvis showed small bowel inflammation c/w enteritis.
- The patient was given 3L NS in ED, as well 1mg IV dilaudid
x3, 4 mg Zofran IV x3, 6U insulin and 400 mg IV cipro and 500mg
IV flagyl.
Vitals prior to transfer were: 98.5 ___ 18 98% RA
Upon arrival to the floor, VS were 97.8, 125/65, HR 106, RR 14,
97% RA. Patient reported her nausea/vomiting had resolved with
the IV dilaudid and Zofran. Continued to endorse mild abdominal
pain.
Past Medical History:
BIPOLAR DISORDER
DIABETES MELLITUS - insulin dependent. Pt reports proteinuria,
nephropathy, and retinopathy in addition to gastroparesis.
GLAUCOMA
RIGHT BUNDLE BRANCH BLOCK
SEIZURE DISORDER - currently treated with Carbamazepine to which
Pt attributes vertigo/dizziness, self-changed evening dose to
800mg from 1000mg yesterday (___)
ALCOHOL ABUSE
ASTHMA
HEPATITIS B
HEP C
GASTROPARESIS - on domperidone, s/p Botox injection in ___
.
Past Surgical History:
CHOLECYSTECTOMY ___
FROZEN SHOULDER ___
UTERINE POLYPS
PRIOR CESAREAN SECTION
G3P1
BILATERAL TUBAL LIGATION
Social History:
___
Family History:
Extensive family history of Diabetes Mellitus with both parents
still living. Heart disease in father. ___ family history
of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.8, 125/65, HR 106, RR 14, 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mild mid-epigastric/RUQ ttp, non-distended,
bowel sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities, speech fluent,
gait deferred.
DISCHARGE PHYSICAL EXAM:
Vital Signs: T: 98.1 BP: 108/59 HR: 83 RR: 18 Sp02: 98 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Normal S1,S2, regular rate, no m/r/g.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions
Neuro: CN II-XII intact, no vertical nystagmus noted, distal
sensation intact.
Pertinent Results:
ADMISSION LABS:
___ 03:15PM BLOOD WBC-18.7*# RBC-4.61# Hgb-14.8# Hct-43.8#
MCV-95 MCH-32.1* MCHC-33.8 RDW-12.1 RDWSD-42.1 Plt ___
___ 03:15PM BLOOD Neuts-91.7* Lymphs-2.1* Monos-5.4
Eos-0.1* Baso-0.3 Im ___ AbsNeut-17.11* AbsLymp-0.40*
AbsMono-1.00* AbsEos-0.01* AbsBaso-0.05
___ 03:15PM BLOOD Plt ___
___ 03:15PM BLOOD Glucose-338* UreaN-12 Creat-0.7 Na-135
K-4.5 Cl-95* HCO3-22 AnGap-23*
___ 03:15PM BLOOD ALT-34 AST-39 AlkPhos-68 TotBili-0.5
___ 03:15PM BLOOD Lipase-25
___ 03:15PM BLOOD Albumin-4.1 Calcium-10.2 Mg-1.6
___ 03:15PM BLOOD Lactate-1.8
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.1* Hct-30.7*
MCV-95 MCH-31.2 MCHC-32.9 RDW-12.1 RDWSD-41.6 Plt ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-140 K-3.4
Cl-103 HCO3-27 AnGap-13
___ 06:55AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.5*
PERTINENT IMAGING:
___ CT ABD/PELVIS W/ CONTRAST
IMPRESSION:
1. Multiple focal regions of small bowel wall thickening with
surrounding
inflammatory changes, raise concern for enteritis.
2. Mild descending colonic wall thickening and edema. While
these findings may be secondary to underdistention, the
associated adjacent inflammatory changes and mesenteric fluid
suggest colitis. Findings may be secondary to infectious,
ischemic, or inflammatory causes.
3. Moderate axial hiatal hernia. 4. 2.2 cm left adnexal cyst
may be physiologic if patient is premenopausal.
If patient is postmenopausal, recommend follow-up pelvic
ultrasound for
further assessment.
MICROBIOLOGY:
Blood Culture- pending
Stool Culture- pending
Brief Hospital Course:
___ year old woman with a history of type I diabetes c/b
gastroparesis recently admitted for nausea/vomiting in the
setting of self-discontinuation of domperidone represents with
acute onset sharp abdominal pain with diarrhea/nausea/vomiting.
Clinical picture most concerning for gastroenteritis. She
improved with hydration and was able to eat and drink normally
on the day after admission. Stool cultures were sent but were
pending at the time of discharge.
ACTIVE ISSUES:
==============
# Gastroenteritis: Nausea and diarrhea on day of admission. Was
started on IV abx in Emergency Department. She was afebrile and
hemodynamically stable. CT Abdomen/Pelvis showed
enteritis/colitis. Most likely this is viral gastroenteritis,
however bacterial could not be ruled out. C Diff was unlikely
given no recent antibiotics. She improved with hydration and
was able to eat without issue. Stool cultures were sent and are
pending at discharge.
#Gastroparesis: Gastroparesis was resolving as an outpatient
and aside from some vomiting with her initial presentation, she
was able to tolerate small meals on a low fiber, low fat diet.
Controlled with Domperidone and Lorazepam 0.5 prior to meals for
nausea.
# DM Type 1: Recent high sugar to 480's as outpatient in the
setting of eating canned fruit. Blood sugar was well controlled
as an inpatient with home regimen of 18 ___ and sliding
scale.
CHRONIC ISSUES:
===============
# Nephropathy: Lisinopril 10 mg PO/NG DAILY continued
# Bipolar: stable. Not currently promoting any manic or
depressed mood. Continued on Lithium Carbonate 900 mg PO QHS,
QUEtiapine Fumarate 200 mg PO/NG BID, Lorazepam and
CarBAMazepine 800 mg PO/NG BID
# Hepatitis B: continue tenofovir.
# Hyperlipidemia: hold Simvastatin 40 mg PO/NG DAILY
Transitional Issues:
=====================
[] consider alternative magnesium repletion as mg oxide is not
well tolerated.
[] f/u stool Yersinia, EHEC, Campylobacter, Shigella
[] Recommendation from CT Abdomen/Pelvis: 2.2 cm left adnexal
cyst may be physiologic if patient is premenopausal. If patient
is postmenopausal, recommend follow-up pelvic ultrasound for
further assessment.
(From most recent d/c on ___
#) QTc: Patient on multiple QTc prolonging medications including
domperidone and quetiapine. Please repeat EKG at next
appointment and repeat as clinically warranted.
#) Domiperidone: Patient tried to cut back due to cost. Planning
to go back to QID dosing. Consider trialing taper to TID if
clinically warranted to help with cost. At time of discharge,
patient reported having insufficient amount of domperidone to
make it until arrival of next shipment. Consequently was
discharged on Zofran and advised to change back to domperidone
once the next shipment arrived.
#) Type 1 DM: Reports difficulty controlling BS due to
gastroparesis and resultant difficulty in predicting required
insulin dose. Reports hypoglycemia at home to ___ and
hyperglycemia to 200s. Please follow up.
# Diabetes: She should follow up in ___ as
well. To schedule please contact (___) and/or ask for
___ or leave a voice message for her.
#) Nystagmus: Worked up by neurology with no evidence of stroke.
Follow up in neurology outpatient clinic if this persists and is
symptomatic.
CODE STATUS: Full Code
CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine 800 mg PO BID
2. Domperidone 10 mg PO QID
3. Fexofenadine 180 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. QUEtiapine Fumarate 200 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
11. Lithium Carbonate 900 mg PO QHS
12. Psyllium Powder 1 PKT PO TID:PRN constipation
13. Meclizine 12.5 mg PO Q6H:PRN vertigo
14. Lorazepam 0.5 mg PO QAC
15. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbamazepine 800 mg PO BID
3. Domperidone 10 mg PO QID
4. Fexofenadine 180 mg PO DAILY
5. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 10 mg PO DAILY
7. Lithium Carbonate 900 mg PO QHS
8. Lorazepam 0.5 mg PO QAC
9. Meclizine 12.5 mg PO Q6H:PRN vertigo
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. QUEtiapine Fumarate 200 mg PO BID
12. Simvastatin 40 mg PO DAILY
13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Psyllium Powder 1 PKT PO TID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Gastroenteritis
Secondary Diagnoses:
Gastroparesis
Diabetes Type I
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You came in after you had severe abdominal pain with diarrhea
and vomiting. In the Emergency Department, you were found to
have a high white blood cell count concerning for possible
infection. Your symptoms are likely due to gastroenteritis.
This is likely viral and will get better on its own without
antibiotics.
You should follow-up with your PCP. It was as pleasure taking
care of you.
-Your ___ Team
Followup Instructions:
___
|
19973404-DS-25 | 19,973,404 | 25,995,277 | DS | 25 | 2170-07-19 00:00:00 | 2170-07-19 20:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
abdominal pain, n/v
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of DM c/b gastroparesis, bipolar d/o, seizure d/o, Hep B
who presents with abdominal pain, n/v, admitted for presumed
gastroparesis flare. Patient recently seen by GI/gastroparesis
specialist. Outpatient gastric emptying study ordered and
patient
instructed to hold domperidone for 5 days prior to exam. Test
was
scheduled for ___ however on ___ patient developed severe and
acute abdominal pain. She was advised by her GI physician to
present to ER for evaluation. Patient states the pain was ___,
located in epigastric area, sharp and at times cramping,
associated with NBNB emesis, currently down to ___ with
dilaudid. Her last BM was yesterday, feels more constipated due
to using Zofran. Denies f/c, states pain is consistent with her
usual gastroparesis flares, has been unable to tolerate much
food
without pain or n/v. Denies CP, SOB, light-headedness and
dizziness. Also notes glucose at home has been more labile since
stopping domperidone which she attributes in part to
inconsistent
PO intake. Has had several hypoglycemic episodes at home as well
as in ED.
In the ED, patient's vitals were as follows: T 97.5, HR 86, BP
148/92, RR 16, SpO2 98% on RA. CMP wnl, CBC wnl. She had a RUQUS
which did not show any acute abnormalities. She was given 0.5 mg
IV dilaudid x 2, Zofran 4 mg x2, LR 1L x 2. Patient had an
episode of hypoglycemia in ED to ___ requiring IV dextrose. She
was admitted to medicine for further work up and monitoring.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Diabetes Mellitus: insulin dependent. Pt reports proteinuria,
nephropathy, and retinopathy in addition to gastroparesis.
- Gastroparesis - on domperidone, s/p Botox injections
- Bipolar Disorder
- Seizure Disorder - currently treated with Carbamazepine
- EtOH Use Disorder
- Right Bundle Branch Block
- Asthma
- Hepatitis B
- Hepatitis C
- Glaucoma
- G3P1
Past Surgical History:
- Cholecystectomy ___
- Frozen shoulder ___
- Uterine Polyps
- Cesarean Section
- Bilateral tubal ligation
Social History:
___
Family History:
Extensive family history of Diabetes Mellitus with both parents
still living. Heart disease in father. ___ family history
of cancer.
Physical Exam:
GENERAL: Alert and in no apparent distress
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, slightly TTP in epigastric
area.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
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
Pertinent Results:
___ 02:03PM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-140
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10
___ 02:03PM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-82 TOT
BILI-<0.2
___ 02:03PM WBC-5.8 RBC-4.09 HGB-13.0 HCT-37.4 MCV-91
MCH-31.8 MCHC-34.8 RDW-11.9 RDWSD-39.4
RUQ US ___
FINDINGS:
Limited views of the pancreas appear unremarkable. Distal CBD
measures up to
1 cm, unchanged from prior. Gallbladder is surgically absent.
Minimal
prominence of the intrahepatic biliary tree is unchanged from
prior. The
liver is normal in appearance and echotexture. No ascites.
Main
portal vein
is patent with hepatopetal flow. Right kidney measures 9.6 cm
and appears
normal without hydronephrosis or worrisome lesion. Left kidney
measures 9.7
cm and is normal in grayscale appearance without worrisome
lesion. The spleen
is normal in size at 9.5 cm in length.
IMPRESSION:
Status post cholecystectomy. Stable prominence of the biliary
tree.
FINDINGS: Residual tracer activity in the stomach is as
follows:
At 45 mins 97% of the ingested activity remains in the stomach
At 2 hours 83% of the ingested activity remains in the stomach
At 3 hours 65% of the ingested activity remains in the stomach
At 4 hours 33% of the ingested activity remains in the stomach
The majority of the residual tracer activity remains in the
gastric fundus
throughout the study. The gastric emptying curve demonstrates a
plateau over
the first 45 minutes then gradually slopes more steeply
downward.
IMPRESSION: Markedly delayed gastric emptying.
Brief Hospital Course:
Ms. ___ is a ___ female with the
past medical history of DM c/b gastroparesis, bipolar d/o,
seizure d/o, Hep B who presents with abdominal pain, n/v,
admitted for presumed gastroparesis flare.
ACUTE/ACTIVE PROBLEMS:
#Abdominal pain
#Nausea/vomiting
#Gastroparesis flare - occurred in setting of discontinuation of
domperidone in preparation for gastric emptying study. Have
instructed patient that narcotics should be used sparingly as
this may also affect gastric emptying study.
-NM gastric emptying study ___ showed Markedly delayed gastric
emptying. I discussed with Dr. ___. The pt will likely
need pyloroplasty. His office will call her to refer her to a
surgeon for this procedure.
-Pt can resume her domperidone at discharge.
#DM1 c/b hypoglycemia and hyperglycemia - labile BS with one
documented hypoglycemic episode in ED and several at home per
patient. Likely in setting of inconsistent PO intake from
gastroparesis
-___ consult appreciated.
-Per ___ recs, pt advised to take Lantus 10U in AM and 16U in
___ along
with current sliding scale and carb counting (1U per every 18g
carbohydrates)
CHRONIC/STABLE PROBLEMS:
#Hep B - continue viread
#Bipolar d/o - continue asenapine
#Seizure d/o - continue carbamazepine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ASENapine 5 mg SL QHS
2. Aspirin 81 mg PO DAILY
3. CarBAMazepine 800 mg PO BID
4. Lisinopril 15 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
8. domperidone maleate Study Med 10 mg PO QACHS
9. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID
10. linaCLOtide 72 mcg oral DAILY
11. Multivitamins 1 TAB PO DAILY
12. Simvastatin 40 mg PO QPM
13. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Glargine 10 Units Breakfast
Glargine 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. ASENapine 5 mg SL QHS
3. Aspirin 81 mg PO DAILY
4. CarBAMazepine 800 mg PO BID
5. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID
6. Cetirizine 10 mg PO DAILY
7. domperidone maleate Study Med 10 mg PO QACHS
8. linaCLOtide 72 mcg oral DAILY
9. Lisinopril 15 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Simvastatin 40 mg PO QPM
14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Type 1 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented with a flare up of gastroparesis which caused
nausea, vomiting and abdominal pain. You underwent a gastric
emptying study which showed that you have marked delayed
emptying. You will be contacted by the Gastrointestinal follow
upw with regards to appropriate follow up. You were also seen by
___ specialists and your insulin was
adjusted.
Lantus 10U in the morning, 16U in the evening
Sliding scale with meals as directed.
Carbohydrate counting (1U for every 18g of carbs).
Followup Instructions:
___
|
19973404-DS-29 | 19,973,404 | 27,142,177 | DS | 29 | 2171-09-13 00:00:00 | 2171-09-13 20:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 03:55PM BLOOD WBC-5.8 RBC-3.92 Hgb-12.1 Hct-36.7 MCV-94
MCH-30.9 MCHC-33.0 RDW-12.1 RDWSD-41.7 Plt ___
___ 03:55PM BLOOD Plt ___
___ 09:22PM BLOOD D-Dimer-462
___ 03:55PM BLOOD Glucose-75 UreaN-16 Creat-0.5 Na-139
K-4.2 Cl-103 HCO3-26 AnGap-10
___ 03:55PM BLOOD ALT-10 AST-18 AlkPhos-91 TotBili-<0.2
___ 03:55PM BLOOD Lipase-15
___ 03:55PM BLOOD cTropnT-<0.01
___ 04:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6
___ 03:55PM BLOOD Albumin-4.3
LAB RESULTS ON DISCHARGE:
=========================
___ 04:30AM BLOOD WBC-3.9* RBC-3.42* Hgb-10.6* Hct-31.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-12.1 RDWSD-41.3 Plt ___
___ 04:30AM BLOOD Glucose-186* UreaN-17 Creat-0.5 Na-139
K-4.3 Cl-102 HCO3-25 AnGap-12
___ 04:30AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.6
IMAGING:
========
___ CXR
No acute cardiopulmonary abnormality.
___ PORTAL ABDOMEN
Moderate to severe colonic fecal burden with a nonobstructive
bowel gas
pattern.
Brief Hospital Course:
___ with hx of DM1, gastroparesis s/p laparoscopic converted to
open pyloroplasty (___) c/b infected seroma, ___
disease, HLD, bipolar disorder, chronic abdominal pain
presenting with recurrent abdominal pain likely ___ constipation
and
gastroparesis in combination, which resolved with increased
bowel regimen.
# RUQ/epigastric pain:
# Nausea: Patient described progressive constipation in the
setting of known gastroparesis with moderate to severe colonic
fecal burden with a nonobstructive bowel gas pattern seen on
CXR. Abdominal pain resolved with increasing bowel regimen,
suspect primarily driven by constipation, potentially triggering
gastroparesis symptoms. Throughout hospitalization, patient has
been very upset, insisting that our gastroenterology colleagues
see her while in the hospital, with vociferous vocalizations at
nursing staff repeatedly. We increased her lactulose to daily
dosing and also provided her with miralax upon discharge.
# Type 1 DM: Home regimen is Levemir 12u qAM and 20u qHS,
patient reports that in the hospital she uses glargine 20u qHS,
without am dose. While she was here with us, we dose reduced
basal insulin to 14u qHS with Humalog SS sliding scale 2+1
50>150. She preferred to carb count while with us. There was
episode of hypoglycemia to ___ in setting of over correction. In
discussion with ___, patient will be discharged on her home
insulin regimen without change.
# Bipolar disorder:
- Continue home asenapine 5 mg PO daily
# ___:
- Continue carbidopa/levodopa ___ TID
# Hepatitis B:
- Continue home tenofovir 300 mg PO daily
# Seizure disorder:
- Continue home carbamazepine 800 mg PO BID
# HLD:
- Continue home simvastatin 40 mg PO daily
# Hypertension:
While in house, held patient's home lisinopril 15 mg as SBP 100s
off this medication. Discussed holding it on discharge, but
patient preferred to continue. In this case, discussed she
should monitor blood pressures at home closely and call PCP
should BP be low or should she have symptoms such as
dizziness/weakness.
TRANSITIONAL ISSUES:
====================
[] Increased bowel regimen to lactulose 15 mL daily + PRN
miralax, patient instructed to titrate as needed
- No changes made to home insulin regimen
[] Discussed holding home lisinopril given SBP 100s in house off
this medication, she strongly preferred to continue, please
titrate as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 1 mg PO DAILY:PRN nausea, anxiety
2. ASENapine 5 mg SL DAILY
3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. CarBAMazepine 800 mg PO BID
6. Simvastatin 40 mg PO QPM
7. Lisinopril 15 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Carbidopa-Levodopa (___) 1 TAB PO TID
11. Lactulose 15 mL PO EVERY OTHER DAY
12. Levemir 12 Units Breakfast
Levemir 20 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Lactulose 15 mL PO DAILY
RX *lactulose 10 gram/15 mL 15 ml by mouth once a day Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a
day Refills:*0
3. ASENapine 5 mg SL DAILY
4. Aspirin 81 mg PO DAILY
5. CarBAMazepine 800 mg PO BID
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Cetirizine 10 mg PO DAILY
8. Levemir 12 Units Breakfast
Levemir 20 Units Bedtime
9. Lisinopril 15 mg PO DAILY
Would prefer to hold as SBP 100s while off, please monitor BP
carefully
10. LORazepam 1 mg PO DAILY:PRN nausea, anxiety
11. Omeprazole 40 mg PO DAILY
12. Simvastatin 40 mg PO QPM
13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
History of gastroparesis
Type 1 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for abdominal pain, thought secondary to
constipation and your gastroparesis. While you were here, you
were given medications to help you have a bowel movement and you
subsequently felt better. You were seen by our diabetes doctors
and also our gastroenterologists per your request. No changes
were made to your insulin. We have increased your bowel regimen
and you can titrate it as needed to make sure you have bowel
movements which will help prevent further episodes.
Please take care and take all your medications as prescribed. We
did temporarily hold your blood pressure medication because your
systolic blood pressure was in the 100 range while here. You
preferred to continue to take this on discharge, hence we
discussed monitoring your blood pressure very carefully while at
home and to call your primary care doctor if you feel dizzy.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19973580-DS-13 | 19,973,580 | 27,373,602 | DS | 13 | 2161-11-22 00:00:00 | 2161-11-24 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / ___
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with PMH of GERD, depression, former tobacco
use, and no known pulmonary history with recent admission for
respiratory distress and wheezing, diagnosed with likely COPD. 2
weeks prior to that she had been admitted with community
acquired pneumonia. She was discharged on ___ with inhalers,
and a ___ outpatient note states that she was using them
incorrectly, and felt immediate relief once instructed on
correct usage. Of note, sputum culture from ___ shows sparse
growth of GNRs. The patient received azithromycin only at this
recent admission.
In the evening yesterday the patient started feeling short of
breath, but thought it would pass. She tried her inhalers
without much effect. After continuing SOB by 3AM she decided to
come to the ED. Since leaving the hospital on ___ her breathing
has been ok, but she has been wheezy and has had a cough, mostly
dry but sometimes productive of green sputum. She has also had
runny nose. Otherwise she denies fevers/chills or muscle aches.
In ED initial VS: 98.4 ___ 32
Placed on BiPAP
Patient was given: Duonebs, IV methylprednisolone 125mg,
azithromycin 500mg IV
Imaging notable for: CXR showing pulmonary vascular congestion
and mild pulmonary edema.
VS prior to transfer: 98.6 108 118/67 20 100% bipap
On arrival to the MICU, patient was on BiPAP and felt much
improved in terms of SOB.
REVIEW OF SYSTEMS: Positive per HPI. Otherwise ROS negative.
Past Medical History:
BREAST CANCER
DEPRESSION
BENIGN POSITIONAL VERTIGO
KNEE PAIN
OSTEOARTHRITIS
TKR ___
Lumpectomy
TAH/BSO
Social History:
___
Family History:
No family history of lung disease. Mother deceased at ___
(melanoma). Father deceased at ___ (___).
Physical Exam:
ADMISSION:
GENERAL: Anxious and mildly distressed, but speaking in full
sentences, alert, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Diffuse wheezing, with good air movement throughout, fine
crackles heard at the bases b/l
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: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses
NEURO: Moving all extremities with purpose
DISCHARGE:
VITALS: 98.1 158/88 80 20 94/RA
GENERAL: Anxious and mildly distressed, but speaking in full
sentences, alert, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Faint wheezing improved from prior, with good air
movement throughout, fine crackles heard at the bases b/l
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: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses
NEURO: Moving all extremities with purpose
Pertinent Results:
Admission labs:
___ 04:55AM BLOOD Neuts-59 Bands-0 ___ Monos-3* Eos-1
Baso-1 Atyps-2* ___ Myelos-0 AbsNeut-16.70* AbsLymp-10.19*
AbsMono-0.85* AbsEos-0.28 AbsBaso-0.28*
___ 04:55AM BLOOD WBC-28.3*# RBC-5.01 Hgb-13.3 Hct-43.9
MCV-88 MCH-26.5 MCHC-30.3* RDW-15.8* RDWSD-50.4* Plt ___
___ 04:55AM BLOOD ___ PTT-32.7 ___
___ 04:55AM BLOOD Glucose-170* UreaN-23* Creat-0.6 Na-139
K-5.3* Cl-100 HCO3-25 AnGap-19
___ 04:55AM BLOOD ALT-23 AST-31 AlkPhos-110* TotBili-0.3
___ 04:55AM BLOOD Albumin-4.3 Calcium-9.2 Phos-6.5* Mg-2.1
___ 05:43AM BLOOD ___ pO2-49* pCO2-80* pH-7.18*
calTCO2-31* Base XS-0
___ 05:10AM BLOOD Lactate-1.6
___ 08:02AM BLOOD Lactate-3.7* K-3.6
___ 05:43AM BLOOD O2 Sat-74
PERTINENT/DISCHARGE LABS:
___ 06:20AM BLOOD WBC-15.0* RBC-4.27 Hgb-11.5 Hct-36.5
MCV-86 MCH-26.9 MCHC-31.5* RDW-15.9* RDWSD-49.1* Plt ___
___ 06:40AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-139
K-4.1 Cl-99 HCO3-24 AnGap-20
___ 06:15AM BLOOD LD(LDH)-269* CK(CPK)-41
___ 06:15AM BLOOD proBNP-507*
___ 06:40AM BLOOD IgG-749 IgA-134 IgM-237*
___ 01:44PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Micro:
___ 1:51 pm URINE
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Time Taken Not Noted Log-In Date/Time: ___ 1:45 pm
Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 11:14 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 5:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH x2
Imaging:
CXR ___
Right basal consolidation has increased concerning for
progression of
infectious process. Cardiomegaly is mild, unchanged.
Mediastinum is stable. Lungs overall clear.
TTE ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
basal to mid inferior wall and inferoseptum. The remaining
segments contract normally (LVEF = 50-55 %). Overall left
ventricular systolic function is mildly depressed. Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w possiblCAD. Normal right ventricular
cavity size and systolic function. Mild mitral regurgitation.
Mild pulmonary hypertension.
PFTs ___:
FVC 1.77 (58%)
FEV1 1.17 (50%)
FEV1/FVC 65 (85%)
no change with bronchodilators
VC 2.08 (69%)
TLC 4.34 (85%)
Brief Hospital Course:
___ year old with significant remote smoking history and recent
diagnosis of likely COPD (PFTs scheduled but not yet performed)
presenting with hypercarbic respiratory failure likely ___ COPD
exacerbation.
=================
ACTIVE ISSUES
=================
# Hypercarbic respiratory failure: She had been admitted
___ for PNA and found to have wheezing treated with
steroids and nebs, which was thought to represent reactive
airways in setting of new PNA and no known diagnosis of COPD.
She was then readmitted ___ for dyspnea and hypoxemia, and
treated with short steroid burst and azithromycin. Per patient,
she was discharged home and felt well while on prednisone, but
had worsening dyspnea once the burst completed. She presented to
ED for dyspnea, VBG ___ suggesting acute CO2 retention. She
was started on BiPAP and given IV solumedrol 125 x1 and nebs,
with improvement in her breathing and normalization of her pH.
Given prior, though remote smoking history and substantive
wheezing on exam, it was thought this may represent underlying
COPD. However, picture is not entirely clear, and last CT Chest
on ___ showed tree in ___ lesions. She should have pulmonary
follow up with PFTs and repeat CT scan prior to discharge. Long
steroid taper as she has had rebound dyspnea after 2 prior
shorter bursts. Of note, CXR did show a RLL opacity so she was
started on CTX/azithro for a 5 day course of CAP treatment. PFTs
demonstrated obstructive disease most consistent with COPD, no
significant improvement with bronchodilators. NIF -45.
Ambulatory sats >90 on RA. BNP slightly elevated to 507.
Immunoglobins, aldolase pending on discharge. SLP consulted with
no c/f aspiration. Patient significantly improved on discharge
# Lactic acidosis: Patient had a mild lactic acidosis with max
lactate of 4, without hypotension or evidence of poor organ
perfusion. Etiology remained unclear but her lactate improved
slowly. She was started on thiamine for possible deficiency.
# Hypertension: Patient with no previous history of HTN. BP
140-170s/80-100s on the floor. Improved on amlodipine to
140s-150s. Discharged on Amlodipine 5 mg PO QDaily
# CAD: Presumed diagnosis based on regional hypokinesis on
recent TTE. She was unable to complete her recent stress test
due to dyspnea. Should reschedule after discharge. She was
continued on ASA81mg, simvastatin 40mg. Also consider starting
B-blocker.
#Depression: continued fluoxetine
#GERD: continued esomeprazole
TRANSITIONAL ISSUES
-Prednisone taper over 10 days
-Started on Advair/Spiriva
-follow up CT likely in 6 months, but will defer to outpatient
pulm
-Should get repeat stress test as outpatient
-Will defer decision to connect to cardiology to PCP
-___ be started on b-blocker and ACEi as an outpatient given
her cardiac disease -per discussion with pulm, cardio-selective
BB should not have a significant effect on her airway disease
-Pulm to follow pending laboratory studies
-___ WBC count at PCP ___ - was 15.0 on discharge, downtrending.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing
2. Esomeprazole Magnesium 40 mg oral DAILY
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
4. FLUoxetine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath /
wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every ___ hours as needed Disp #*1 Inhaler Refills:*0
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*0
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1
dose inhaled twice a day Disp #*1 Disk Refills:*0
5. PredniSONE 50 mg PO DAILY Duration: 2 Doses
This is dose # 1 of 5 tapered doses
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. PredniSONE 40 mg PO DAILY Duration: 2 Doses
Start: After 50 mg DAILY tapered dose
This is dose # 2 of 5 tapered doses
7. PredniSONE 30 mg PO DAILY Duration: 2 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 3 of 5 tapered doses
8. PredniSONE 20 mg PO DAILY Duration: 2 Doses
This is dose # 4 of 5 tapered doses
9. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 5 of 5 tapered doses
10. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inhaled daily Disp #*30 Capsule Refills:*0
11. Aspirin 81 mg PO DAILY
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
13. Esomeprazole Magnesium 40 mg oral DAILY
14. FLUoxetine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Hypercarbic respiratory failure
SECONDARY
Reactive airway disease
Hypertension
Leukocytosis
Lactic acidosis
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing to receive your care at ___. You were
admitted with respiratory failure, and briefly required
intensive breathing treatments. You subsequently improved with
medications that help open up your airways, and underwent
testing which demonstrated that you have an obstructive airway
disease, which is likely a combination of underlying COPD from
previous smoking with inflammation from your respiratory
infections you've experienced recently. You were started on
steroids for treatment, which you should take for 10 more days
through ___. You were also started on new inhaled medications
to prevent further exacerbations. You have follow up
appointments listed below for further management with lung
disease specialists.
Please see below for an updated list of your medications and
upcoming appointments.
We wish you the best with
Followup Instructions:
___
|
19973587-DS-19 | 19,973,587 | 23,312,973 | DS | 19 | 2143-07-18 00:00:00 | 2143-07-18 12:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues
Attending: ___
Chief Complaint:
Weakness, chest pain and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is an ___ year old female ___ metastatic
ovarian cancer x ___ year s/p chemo who presented with weakness,
pleuritic chest pressure along with shortness of breath x 4 day.
As the week went on her weakness worsened but her shortness of
breath and chest pain got better. She felt so weak that all she
wanted to do was lay in bed. She has a cat a home and she felt
too weak to even care for her cat. Pain has improved but
continues to worsen with breathing. She does not wake up short
of breath. She does have report worsening dyspnea on exertion
but none at rest. She sleeps in a recliner because of her L hip
operation ___ years ago. She reports anorexia and decreased po
intake. She feels like her cancer is getting to her and that she
is failing.
When she urinates she gets a body chill but no dysuria.
In ER: (Triage Vitals:4 98.2 72 131/53 16 98% ra )
Meds Given: ceftriaxone
Fluids given: 2L
Radiology Studies: CTA- large pericardial effusion/pulmonary
edema/pleural effusion
consults called: cardiology
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ -] Fever [+] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ +] __15___ lbs. weight loss over ___ year ____
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[+ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore
throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[ +] Shortness of breath [+] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ +] Palpitations - x 1 week [ ] Edema [ ] PND [ ] Orthopnea
[ ] Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea - improved with nausea pill [+] Vomiting- gatorade,
no blood, no bile x 1 [] Abd pain [] Abdominal swelling [ -]
Diarrhea [ -] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[- ] Dysuria- but chill with urination [ ] Incontinence or
retention [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [+]dry skin on her hands
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ +] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[ +] depression and feeling overwhelmed- she has thought about
suicide but reassures me that she would never take her own life.
[-]Suicidal Ideation [ ] Other:
ALLERGY:
[X ]Medication allergies
Confirms tetracycline - thinks it gave her a rash but she is not
sure. [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
PAST ONCOLOGY HISTORY:
- ___: admitted with fatigue and abdominal pain. A CT abdomen
and pelvis (___) showed multiple areas consistent with
metastatic ovarian carcinoma, including omental metastases,
retroperitoneal lymphadenopathy, moderate ascites, an
indeterminate 9 mm liver lesion, and a 10 mm pulmonary nodule at
the right lung base.
- ___: a CT chest showed left side pleural effusion, a right
lower lobe 1.1 cm nodule, mediastinal lymphadenopathy, moderate
pericardial effusion and nodularity of the right breast with a
right axilla lymphnode. A mammogram and breast US ruled out
breast malignancy. An head CT was negative for metastases.
- ___ thoracentesis. The cytology on the pleural fluid was
negative for malignancy. On ___ she also underwent
paracentesis, the pathology examination on the cell block
obtained from the ascitic fluid showed adenocarcinoma with
immunohistochemistry consistent with ovarian cancer (CK7, WT-1,
p53 and MOC31 positive, CK20, CDX2 and calretinin negative).
.
___ cycle 1 Carboplatin (AUC 5) D1 q21d
___ cycle 2 Carboplatin (AUC 5) D1 q21d
___ cycle 3 Carboplatin (AUC 5) D1 complicated by
thrombocytopenia, cycle 4 delayed of 1 week
___ cycle 4 Carboplatin (AUC 5) D1 q28d
___ cycle 5 Carboplatin (AUC 5) D1 q28d
___ cycle 6 Carboplatin (AUC5)
___ restaging CT of Torso shows partial response to
chemotherapy
___ clinical disease progression
___ start chemotherapy with Doxil 30 mg/m2 q28d
.
OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
- Pericardial effusion small to moderate sized, no tamponade on
Echo ___ and CT Torso ___.
- Chronic afib s/p pacer for sick sinus syndrome
- H/o mesenteric thromboembolism
- HTN
- Hyperlipidemia
- Type II diabetes
- Pulmonary artery hypertension (moderate on ECHO ___
- Possible MI ___
- Gait instability
- Hypothyroidism
- H/o C.diff
- ___ Left hip replacement s/p fall/fracture
- ___ Ventral hernia repair with mesh c/b c. diff
- ___ ___ thromboembolectomy
- ___ Exploratory laparotomy for hemoperitoneum (possible
pancreatic laceration) s/p MVA
Social History:
___
Family History:
No family history of cancer, except breast cancer in 1 niece
(daughter of her brother)- confirmed on admission.
Dad/brother/half siblings died of heart disease.
Physical Exam:
1. VS T = 97.5 P 83 BP = 163/69 RR = 18 O2Sat on __97% RA __
GENERAL: Thin female laying in bed
Nourishment: OK
Grooming: very good, + makeup
Mentation: alert speaks in full sentence
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: slightly injected
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[X] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
Elevated JVP with + HJR
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[X] Vascular access [] Peripheral [] Central site:
2+ DPP b/l
5. Respiratory [ ]
Crackles at the bases
6. Gastrointestinal [X] WNL
[X] Soft [] Rebound [] No hepatomegaly [X] Non-tender [] Tender
[] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [] WNL
RLE ___ strength
LLE - ___ stength which she states is baseline since her hip
surgery
___ strength dorsiflexion b/l
8. Neurological [X WNL
[ X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
Petechiae at the L ankle
[X] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [+] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
Pertinent Results:
___ 06:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:30PM URINE BLOOD-TR NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 06:30PM URINE RBC-1 WBC-27* BACTERIA-MANY YEAST-NONE
EPI-0 TRANS EPI-<1
___ 06:30PM URINE HYALINE-4*
___ 06:30PM URINE MUCOUS-RARE
___ 04:20PM GLUCOSE-153* UREA N-16 CREAT-0.9 SODIUM-138
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
___ 04:20PM estGFR-Using this
___ 04:20PM ALT(SGPT)-21 AST(SGOT)-50* ALK PHOS-80 TOT
BILI-0.5
___ 04:20PM LIPASE-17
___ 04:20PM cTropnT-0.06* proBNP-___*
___ 04:20PM ALBUMIN-3.7
___ 04:20PM WBC-10.3 RBC-4.30 HGB-13.0 HCT-39.7 MCV-92
MCH-30.2 MCHC-32.7 RDW-14.6
___ 04:20PM NEUTS-79.9* LYMPHS-11.4* MONOS-5.6 EOS-2.5
BASOS-0.6
___ 04:20PM PLT COUNT-390
-------------------
Admission CTA
1. No pulmonary embolism or aortic dissection. Large pericardial
effusion,
worse since prior study.
2. Bilateral small effusions, with pulmonary edema.
3. Mediastinal and axillary adenopathy are larger since prior
study
---------------
ECG: atrial fib Q in V1 and V2, - Q in V2 is new.
---------------
___ TTE: IMPRESSION: Prominent pericardial effusion without
echocardiographic evidence of tamponade physiology. Serial
evaluation is suggested.
Compared with the prior study (images reviewed) of ___, the
effusion is larger inferolateral and the estimated PA systolic
pressure is higher.
---------------
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
The patient is a ___ year old female with HTN, HLD, know
metastatic ovarian cancer s/p 6 cycles of carboplatin and 4
cycles of doxin who presents with shortness of breath, chest
pain found to have increase pericardial effusion, pulmonary
edema and elevated BNP.
.
Shortness of breath, chest pain with pericardial effusion
- the etiology of these symptoms was not clear but improved to
nearly her baseline just with treatment of her UTI
- she was initially thought to have mild heart failure, but her
symptoms improved without significant diuresis and she was
nearly at her baseline at discharge
- she was evaluated by Cardiology given the pericardial
effusion, who found no clinical evidence of tamponade, and
recommended a non-urgent TTE
- the TTE was done, showing increased pericardial effusion
without tamponade and it was recommended to follow this as an
outpatient
- I and the on-call Oncology fellow talked with her and her
daughter ___ about the possibility that this effusion was due
to her cancer, and suggested that she and her Oncologist discuss
this further in the outpatient setting
- in addition, her imaging showed that her disease burden in her
lungs may be spreading -- defer to Oncology in the outpatient
setting to discuss the risks and benefits of further treatment
- her discomfort was easily managed with her home dose of
oxycodone SR during this admission
.
Chills, weakness and urinary tract infection
- the weakness was ultimately attributed to a urinary tract
infection
- she was found to have UA ___ WBCs, and UCx with >100,000 E.
Coli UTI sensitive to cefazolin (so cephalexin by extension),
resistant to cipro and TMP/SMX and intermediate to
nitrofurantoin
- as a result she was given 2 days of ceftriaxone in the
hospital, remained afebrile and her symptoms improved -- this
was transitioned to an additional 10 days of cephalexin at
discharge
- she and her family noted she has failed this antibiotic before
-- but I emphasized it should be susceptible given the culture
data, and that we did not have many other good options
(Augmentin may be a possibility), and encouraged her to call or
return if she began to feel worse -- they understood
- she and her family noted that she has had recurrent infections
-- we reviewed the importance of staying hydrated, and I think
the idea of suppressive therapy would be good to touch on in the
outpatient setting
.
HTN, HL with persistent afib and sinus node dysfunction, S/P SJM
PPM implanted in ___
- she was continued on her home amlodipine, isosorbide
mononitrate, ASA, dabigatran
.
Other
- she was continued on her home mirtazapine, and sertraline was
increased to 25mg daily from 12.5mg daily given her anxiety
- continued docusate, pantoprazole and levothyroxine
.
Diabetes
- she is on no agents at home and was given only sliding scale
insulin as needed as an inpatient
.
Code Status
- She was kept full code this admission. Per the admitting
physician, she "at first said that she did not want
resuscitation but then seemed unsure. During her last admission
she was DNR/DNI." This should be addressed in the outpatient
setting with her Oncologist in light of her possible disease
progression despite chemotherapy (see above).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 5 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Sertraline 12.5 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Docusate Sodium 100 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Mirtazapine 15 mg PO HS
11. Oxycodone SR (OxyconTIN) 10 mg PO HS:PRN pain
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dabigatran Etexilate 150 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Mirtazapine 15 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. Oxycodone SR (OxyconTIN) 10 mg PO HS:PRN pain
10. Pantoprazole 40 mg PO Q24H
11. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
12. Cephalexin 500 mg PO Q12H Duration: 10 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection, complicated
Pericardial effusion, gradually enlarging, unknown etiology
Metastatic ovarian cancer, on monthly chemotherapy
Atrial fibrillation with sinus node dysfunction, with a pacer
Hypertension
Hyperlipidemia
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent. (hard of hearing at baseline)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with weakness, shortness of breath and chest
pain. You were found to have a urinary tract infection, and
were given antibiotics. Your symptoms improved greatly after
this, as they have with treatment of your prior infections. You
were also found to have an increased pericardial effusion (fluid
around the heart). You were seen by the cardiologists for this
(heart doctors) and it was determined that this should be
observed, and no further diagnostic testing or treatment was
indicated at this time.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19973795-DS-9 | 19,973,795 | 23,822,974 | DS | 9 | 2194-11-06 00:00:00 | 2194-11-06 08:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / morphine
Attending: ___.
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
amterior /posterior L3-S1 decompression and fusion
History of Present Illness:
Patient had progressive inability to ambulate secondary to
neurogenic claudication
Past Medical History:
Hypertension/ scoliosis/ spinal stenosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Awake and alert/ vss
Lungs clear to ausc.
Abdomen soft, NT
Extremities - moderate bilateral pedal swelling
Calves soft, NT
weakness diffusely ___ throughout both lower extremities
Pertinent Results:
___ 12:42AM GLUCOSE-96 UREA N-17 CREAT-0.7 SODIUM-137
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-14
___ 12:42AM estGFR-Using this
___ 12:42AM CRP-0.7
___ 12:42AM WBC-6.0 RBC-4.05 HGB-13.3 HCT-39.9 MCV-99*
MCH-32.8* MCHC-33.3 RDW-11.8 RDWSD-42.7
___ 12:42AM NEUTS-58.5 ___ MONOS-11.4 EOS-4.0
BASOS-1.3* IM ___ AbsNeut-3.53 AbsLymp-1.48 AbsMono-0.69
AbsEos-0.24 AbsBaso-0.08
___ 12:42AM ___ PTT-29.3 ___
___ 12:42AM PLT COUNT-344
Brief Hospital Course:
Patient was admitted and underwent an anterior and posterior
lumbar decompression and fusion procedure in a staged fashion.
She had post-operative atelectasis and was given an incentive
spirometer. Her strength and sensation improved in both legs. at
the time of discharge she was able to stand for short periods of
time and had a bowel movement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 60 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Methadone 10 mg PO DAILY
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain -
Moderate
6. Potassium Chloride 40 mEq PO DAILY
7. TraZODone 200 mg PO QHS:PRN insomnia
Discharge Medications:
1. Cyclobenzaprine 5 mg PO TID:PRN spasms
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 50 mg PO DAILY diuretic
RX *hydrochlorothiazide 50 mg 1 tablet(s) by mouth once a day
Disp #*25 Tablet Refills:*0
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth every twelve (12) hours Disp #*14 Capsule
Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 package by mouth once a day Disp
#*60 Tablet Refills:*0
7. Gabapentin 600 mg PO TID
8. Methadone 10 mg PO QHS
9. potassium chloride 40 meq oral BID
10. TraZODone 100 mg PO QHS:PRN insomnia
11. DULoxetine 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Scoliosis/ spinal stenosis
Discharge Condition:
Awake and alert/ vss/ Incision clean and dry/ moving both legs
well
Discharge Instructions:
Keep incisions clean and dry/ ambulate as tolerated with brace
Physical Therapy:
Ambulate as tolerated / use corset for comfort
Treatments Frequency:
Keep incisions clean and dry/
Followup Instructions:
___
|
19974480-DS-2 | 19,974,480 | 23,201,377 | DS | 2 | 2147-03-29 00:00:00 | 2147-03-29 17:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
tramadol / Pneumovax 23 / Penicillins / Sulfa (Sulfonamide
Antibiotics) / ibuprofen
Attending: ___
Chief Complaint:
Brain Mass
Major Surgical or Invasive Procedure:
___ biospy of brain tumor
History of Present Illness:
___ yo F presented for outpatient work up of altered mental
status. Pt's husband first felt like she wasn't herself 3 weeks
ago. She seemed withdrawn and depressed at that time. Over the
last two days pt has become more confused, unable to make meals,
laughing at inappropriate times. Husband brought her to ___ who
ordered MRI which was done today and shows a large frontal
lesion
that crosses midline with associated vasogenic edema. Pt denies
HA, vision changes, numbness, weakness or tingling. "I don't
have
any symptoms."
Past Medical History:
HTN, hyperlipidemia, osteoporosis, s/p left knee replacement,
s/p right hip replacement, chronic sinusitis, panic disorder
Social History:
___
Family History:
unable to obtain
Physical Exam:
On Admission:
O: T: 98.9 HR:84 BP:121/65 RR:16 Sat:100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Inattentive, Awake and alert, cooperative with
exam, depressed mood, laughs inappropriately at times
Orientation: Oriented to person, "hospital" and ___ with
choices
Language: paucity of speech
Difficulty with multi step commands
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields unable to test due to inattention
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: + ataxia on on finger-nose-finger
On Discharge:
Pertinent Results:
MR HEAD W & W/O CONTRAST ___
Large heterogeneously enhancing mass, approximately 6.5AP x
4.7CCx4.7TR cm, likely intra-axial, with extensive surrounding
vasogenic edema centered in the bifrontal region, left more than
right and causing effacement and exerting local mass effect as
described above. Correlation with noncontrast CT can be helpful
for hemorrhage versus mineralization.
Differential diagnosis includes GBM, lymphoma, metastasis, etc.
Neurosurgery consult, further workup and followup as needed.
CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS ___
1. No evidence of malignancy in the abdomen or pelvis.
2. Simple hepatic cysts.
CT CHEST W/CONTRAST ___
No evidence of intrathoracic malignancy.
MR HEAD W/ CONTRAST ___
Rim enhancing mass involving bilateral medial frontal lobes on
the corpus
callosum is again demonstrated for surgical planning. Diagnostic
considerations include glioblastoma, or lymphoma if the patient
is
immunocompromised. Metastasis less likely.
Brief Hospital Course:
___ y/o F with headaches and AMS who presented for an outpatient
MRI which showed a large bifrontal tumor. She was seen in the ED
and admitted to neurosurgery for further evaluation and
management. She was alert and oriented x3 and full strength
throughout. She was started on decadron and keppra.
On ___, she remained stable on exam. OR planning was
intitiated and husband was consented.
On ___, patient remained stable. MRI WAND was done and she was
NPO for OR.
Patient was taken to the OR for a Frameless image-guided
stereotactic brain biopsy (See Operative report for further
details). Patient had a postoperative Non-contrast Head CT which
was showed expected postoperative changes. She was transferred
to the PACU and transferred to step-down once stable. She
remained neurologically stable on exam. Patient was also
evaluated by Radiation Oncology for further treatment planning
On ___, patient remained stable on exam, she was transitioned
to q4 neuro checks and telemetry was discontinued.
On ___, the patient was at her baseline neurologically. ___
cleared her for home with rehab but her family wished that she
be re-screened to see if she would qualify for rehab.
On ___, the patient was doing well with no issues over night.
She was discharged to home in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection yearly
2. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
3. Atorvastatin 40 mg PO QPM
4. azelastine 137 mcg nasal BID
5. Losartan Potassium 50 mg PO DAILY
6. ClonazePAM 0.5 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. Milk of Magnesia 30 mL PO PRN constipation
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. ClonazePAM 0.5 mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Losartan Potassium 50 mg PO DAILY
5. Milk of Magnesia 30 mL PO PRN constipation
6. azelastine 137 mcg nasal BID
7. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection yearly
8. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.6 mg 1 capsule by mouth daily as needed
Disp #*20 Capsule Refills:*0
9. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily while on
steroids Disp #*30 Tablet Refills:*0
10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as
needed for pain Disp #*50 Tablet Refills:*0
11. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth Twice a day Disp
#*60 Tablet Refills:*2
12. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 4 tablet(s) by mouth Every 8 hours Disp
#*21 Tablet Refills:*0
13. Dexamethasone 2 mg PO Q8H
2mg PO q8h x 1 week
2mg PO Q12h x 1 week
2mg PO Daily x 1 week
Off
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth Every 8 hours Disp
#*42 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bilateral frontal lobe tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
brain.
*** You underwent a biopsy. A sample of tissue from the lesion
in your brain was sent to pathology for testing.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19974520-DS-19 | 19,974,520 | 23,580,334 | DS | 19 | 2152-01-20 00:00:00 | 2152-01-22 17:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Novocain / Asparagus
Attending: ___.
Chief Complaint:
COUGH and FEVER
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx bronchiectasis presenting with ongoing purulent
cough, fevers and weakness for one month failing a 10-day course
of Augment. She has had a productive cough since the beginning
of ___ which is continuing to worsen. She reports
greenish/yellow sputum with no blood ___ sputum. Notes that her
ribs on the right hurt "from coughing". Has been taking
guaifenesin (Mucinex) and Tylenol and not feeling better. Has
had reduced PO because she feels globally weak. Queasy feeling
but no bowel movement changes and no vomiting. Notes her ankles
are more swollen than usual. She also endorses fatigue and night
sweats.
She reports her symptoms of fever (as high as 102), sputum,
cough, and SOB began ___ ___. She began a course of Augmentin
on ___ after visiting her PCP but the script was changed to
levofloxacin when a CXR showed multifocal pneumonia. However,
she reports not taking the levofloxacin and choosing to finish
the Augment course instead. Her symptoms improved slightly on
antibiotics, but resumed when her course finished. She presented
to her pulmonologist Dr. ___ on ___ with worsening
purulent sputum, fever to 102, chest pain and fatigue. On exam
she was tachycardic, sat 96%RA, afebrile, coughing thick green
sputum, decreased breath sounds ___ lower left lobe and rhonchi
diffusely, and edema ___ legs bilaterally to mid shins. CXR
obtained at the visit (___) showed LLL and lingular
infiltrates with effusion concerning. Also of note is that
bronchoalveolar lavage ___ ___ grew aspergillus. She was sent to
ED by her pulmonologist for further evaluation.
Past Medical History:
1. Osteoporosis.
2. Basal cell carcinoma of the right forehead, surgically
removed
3. Gastroesophageal reflux.
4. Weight loss.
5. Tinnitus.
6. Vertigo
7. Bronchiectasis chest CT scan.
8. Heart murmur (MVP)
9. Panic disorder
Social History:
___
Family History:
Father died of brain tumor ___ his ___. Mother died ___ ___ of
heart disease. She does not have any siblings.
Physical Exam:
ADMISSION PHYSCIAL EXAM:
=========================
VS - 98.5 114/58 90 18 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased BS on L base, soft rales at the right base
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ pitting edema to mid-shin
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=========================
VS - Tc 97.6 Tm 98.3 BP 115/61 HR 95 RR 18 O297%RA
GENERAL: woman lying ___ bed ___ NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition, mild fissuring ___ tongue along central
sulcus, OP clear
CARDIAC: RRR, S1/S2, ___ systolic murmur radiating to left
apex, gallops, or rubs
LUNG: basilar crackles on left side, high-pitched
end-inspiratory sound heard inconsistently bilaterally ___ along
upper and lower lung fields
ABDOMEN: nondistended, +BS
EXTREMITIES: trace edema to mid-shin
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
=================
___ 10:55AM BLOOD WBC-10.2*# RBC-3.42* Hgb-9.6* Hct-30.6*
MCV-90 MCH-28.1 MCHC-31.4* RDW-14.6 RDWSD-46.7* Plt ___
___ 10:55AM BLOOD Neuts-79.1* Lymphs-10.1* Monos-9.4
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.11* AbsLymp-1.03*
AbsMono-0.96* AbsEos-0.05 AbsBaso-0.03
___ 02:48PM BLOOD Glucose-91 UreaN-11 Creat-0.4 Na-132*
K-6.1* Cl-90* HCO3-30 AnGap-18
___ 02:48PM BLOOD Albumin-3.2*
___ 02:54PM BLOOD Lactate-1.6 Na-133 K-4.6
DISCHARGE LABS:
=================
___ 06:15AM BLOOD WBC-7.0 RBC-3.29* Hgb-9.2* Hct-29.1*
MCV-88 MCH-28.0 MCHC-31.6* RDW-14.6 RDWSD-46.9* Plt ___
___ 06:15AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-135
K-4.6 Cl-94* HCO3-35* AnGap-11
___ 06:15AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
PERTINENT FINDINGS:
====================
Labs:
------
___ 06:40AM BLOOD calTIBC-293 VitB12-735 Folate-15.7
Ferritn-67 TRF-225
___ 02:48PM BLOOD Albumin-3.2*
Micro:
------
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 05:00PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-2
___ 05:00PM URINE Mucous-RARE
___ 05:00PM URINE Hours-RANDOM UreaN-280 Creat-26 Na-154
___ 2:42 pm BLOOD CULTUREx2
Blood Culture, Routine (Pending):
___ 11:39 am SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested ___ cases of treatment
failure ___
life-threatening infections..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
___ 5:15 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 2:38 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated
Imaging:
----------
___
Sinus tachycardia. Low limb lead voltage. Biatrial abnormality.
Delayed
R wave transition. Compared to the previous tracing of ___
the rate has increased. Otherwise, no diagnostic interim change.
Read by: ___
___ Axes
Rate PR QRS QT QTc (___) P QRS T
107 171 80 ___ 70 -10 35
CXR ___
Compared to chest radiographs since ___, most recently
___. Large scale pneumonia ___ the left lower lobe and lingula
is new, a
smaller region of consolidation ___ the right lung base has a
different
distribution than before. Previous right upper lobe pneumonia
left a region of bronchiectatic scarring. Moderate left pleural
effusion is new.
Multifocal pneumonia could be due to bronchiectasis, chronic
aspiration, or even cryptogenic organizing pneumonia. Volume of
left pleural effusion must be followed for any indication that
the patient may be developing empyema. Heart size normal.
No pneumothorax.
CTA Chest ___:
1. Irregular inferior lingular, right upper lobe and bilateral
lower lobe
consolidations with areas of peribronchial nodularity compatible
with
multifocal pneumonia.
2. Small left-sided pleural effusion.
3. Worsening widespread bronchiectasis with bilateral lower lobe
predominance with multiple areas of mucous impaction.
4. Mild hilar and mediastinal adenopathy, increased since ___,
potentially reactive.
5. No evidence of pulmonary embolism or aortic abnormality.
TTE ___:
The left atrium is normal ___ size. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and global systolic function (3D LVEF = 63 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is mild
bileaflet leaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. A late systolic jet of The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild mitral valve
prolapse with trivial mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of ___, the estimated LV filling pressure is
elevated; other findings are similar.
Brief Hospital Course:
___ hx bronchiectasis presenting with ongoing purulent cough,
fevers, and weakness for one month failing a 10-day course of
Augmentin. She visited her pulmonologist Dr. ___
collected a sputum sample and a CXR. The CXR showed
bronchiectasis and left lower and lingular lobe infiltrates
concerning for a multifocal pneumonia as well as a left pleural
effusion. She was referred to the ED, where a CTA was performed.
There was no evidence of PE and the left-sided pleural effusion
was revealed to be minimal. Influenza and respiratory viral
antigen screens were also performed and were negative.
Legionella urinary antigen was performed and was negative. Blood
cultures were also drawn and the results are still pending,
though no growth has been noted after 3 days.
Because the patient presented with an apparent multifocal
pneumonia that had lasted several weeks and failed a course of
Augmentin, she was started on broad-spectrum antibiotics of
Cefepime/Levofloxacin/vancomycin to cover typical causes of
community-acquired pneumonia as well as Pseudomonas, MRSA, and
atypical causes of pneumonia. Furthermore, she received acapella
and incentive spirometry to promote pulmonary hygiene. She
received three days of IV vancomycin, cefepime, and
levofloxacin. Her finalized sputum cultures grew beta-lactamase
negative Haemophilus influenzae and normal respiratory flora, so
she is being discharged on a 7-day course of levofloxacin 750MG
PO, which should have sufficient coverage against H. influenzae
and other typical causes of community-acquired pneumonia.
Laboratory tests also revealed an albumin of less than 3 and
hemoglobin ___ the ___ range. The patient reported a history of
poor PO intake during the past few months and reports a
primarily vegetarian diet. This finding was concerning for poor
nutrition. She was seen by a nutritionist and was recommended
meal supplementation, for example, with Ensure.
The patient also reported some uncertainty ___ going home to live
independently and met with one of our social workers to explore
options that may lend her some help at home. Finally, she was
also evaluated by ___ and was deemed fit and able to go home
without the need for physical therapy. She was discharged with
regular diet.
TRANSITIONAL ISSUES:
======================
[ ] Complete 7 day course of PO Levofloxacin 750mg Qdaily (Last
___.
[ ] Follow up with PCP office, esp. regarding anemia and
fatigue. Consider Iron supplementation and dietary modification
___ the future.
[ ] Follow up with pulmonologist Dr. ___ antibiotic
course finishes for PFTs and repeat CXR
[ ] Osteoporosis, not currently on Calcium supplementation, may
want to consider.
#Full code
___ (Friend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
2. estradiol 0.01 % (0.1 mg/gram) vaginal unknown
3. Omeprazole 40 mg PO BID
4. Vitamin B Complex 1 CAP PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Magnesium Citrate 300 mL PO ONCE
Discharge Medications:
1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
2. Omeprazole 40 mg PO BID
3. Vitamin B Complex 1 CAP PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. estradiol 0.01 % (0.1 mg/gram) vaginal unknown
6. Magnesium Citrate 300 mL PO ONCE
7. Levofloxacin 750 mg PO Q24H Pneumonia Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
8. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose
Apply to areas of chest pain, 12 hours on, 12 hours off.
RX *lidocaine 5 % Apply thin layer over affected area once a day
Refills:*0
9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5
mL 10 mg by mouth every six (6) hours Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
---------
-Pneumonia
-Anemia
SECONDARY
------------
-Bronchiectasis
-Hyponatremia
-Osteoporosis
-GERD
-Panic Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
shortness of breath and concern for pneumonia.
WHAT WAS DONE DURING YOUR HOSPITAL STAY?
==========================================
- An x-ray and CAT scan of your chest showed signs of pneumonia
___ addition to your known diagnosis of bronchiectasis.
- You were started on IV antibiotics.
- Sputum cultures as well as blood and urine cultures were sent
off.
- Sputum cultures grew a likely source of infection, a bacteria
called Haemophilus influenzae.
- A blood count test revealed you have moderate anemia.
- You were transitioned to oral antibiotics, called
Levofloxacin.
- You were deemed to be stable for discharge.
WHAT SHOULD YOU DO FOLLOWING DISCHARGE?
=========================================
- Please take your medications as regularly prescribed.
-- Finish your 7 day course of Levaquin antibiotics (LAST DAY
= ___
- Follow up with your ___ at your PCP's office on ___ at 10:45 AM
- Follow up with your pulmonologist, Dr. ___ on
___ at 9:10. You may call to make a new appointment
if you prefer later time.
It was a pleasure taking care of you during your hospital stay.
If you have any questions about the care you received, please do
not hesitate to ask. We wish you the best ___ health ___ the
future.
Sincerely,
Your Inpatient ___ Care Team
Followup Instructions:
___
|
19974576-DS-12 | 19,974,576 | 20,930,639 | DS | 12 | 2122-03-20 00:00:00 | 2122-03-20 17:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
vomiting, diarrhea, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with metastatic intraperitoneal mucinous adenocarcinoma of
presumed appendiceal primary s/p 3 cycles of carbotaxol
targeting
presumed gynecologic primary tumor without significant response,
then with exlap (___) concerning for appendiceal primary
presenting now with acute onset nausea/vomiting/diarrhea/fever.
Interview conducted in ___ w/ family at bedside. She was in
USOH until yesterday AM when she rather suddently developed
watery diarrhea (nonbloody) and nonbloody nonbilious emesis and
has been unable to keep down fluids for 24 hrs. She had chills
at
home and diffuse abdominal pain and was unable to keep down
fluids so came to the ED. No sick contacts. No headache. No body
aches. No dysuria, no CP/SOB.
Regarding onc history: she saw her oncologist ___ and per
notes
it seems that they discussed that treatment would be palliative;
with that in mind and evidence of disease progression despite
therapy at the time, she had previously expressed to them that
she would not want more chemo if the intent is palliative. They
planned to see her in 4 weeks for follow up.
ED course:
T 100.0 HR 102 BP 97/50 RR 18 98%RA. 3L IVF given along with
5mg IV morphine and 4mg IV Zofran. CT a/p with contrast showing
significant worsening of metastatic disease burden in the abd
and
pelvis with large predominattly cystic masses in pelvis and
widespread omental caking and peritoneal mets. parenchymal
cystic
lesions in the liver spleen of also enlarged since prior study.
No e/o SBO or intraperitoneal free air. Labs with WBC 16 up from
10 in ___, Hct stable at 33 Plts 343. 80% pmns. Chem with na of
132 and bun/cr ___. LFTs normal lipase 15. uA not consistent
with infectious process. lactate 2.2. HR down to 77 prior to
transfer.
Past Medical History:
PMH:
- Asthma
- Osteoporosis
- Denies hypertension, diabetes, thromboembolic disease
PSH:
- Abdominal surgery to remove her placenta post-partum (pt
unclear re details, occurred after vaginal delivery, via small
infraumbilical 4cm vertical incision)
- Ex lap, drainage of ascites, omental bx, peritoneal bx,
ovarian
bx, ___, ___
___:
- ___ (4 deceased in neonatal period)
- SVD x 11
- One pregnancy c/b ? retained placenta, requiring abdominal
surgery via vertical 4cm infraumbilical incision
PGYN:
- Menopausal, late ___
- Denies postmenopausal bleeding
- Not currently sexually active
- Denies hormonal replacement therapy or history of OCPs
- Never had a Pap smear (pt denies and nothing in CHA records
since ___
- Denies history of pelvic infections or sexually transmitted
infections
- Denies history of fibroids or cysts
Social History:
___
Family History:
- Sister died of liver cancer
- No known family history of breast, uterine, ovarian, cervical
or colon cancer
- No known history of bleeding or clotting disorder
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: T afeb 110/60 64 18 94-96% RA
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly,
nontender.
Large midline well healed scar
LIMBS: 1+ edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed
Pertinent Results:
___ 06:30AM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-133
K-4.0 Cl-102 HCO3-25 AnGap-10
___ 06:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.6
CT abdomen
IMPRESSION:
1. Significant worsening of metastatic disease burden in the
abdomen and
pelvis, with large predominantly cystic masses in the pelvis and
widespread
omental caking and peritoneal metastases.
2. Parenchymal cystic lesions in the liver spleen of also
enlarged since the
prior study.
3. No evidence of bowel obstruction or intraperitoneal free air.
Brief Hospital Course:
___ with metastatic intraperitoneal mucinous adenocarcinoma of
presumed appendiceal primary s/p 3 cycles of carbotaxol
targeting
presumed gynecologic primary tumor without significant response,
then with exlap (___) concerning for appendiceal primary
presenting admitted with acute onset
nausea/vomiting/diarrhea/fever.
# nausea/vomiting/diarrhea/chills - concerning for infectious
process given acute onset the day of ED presentation and absence
of concerning acute pathology on abdominal exam. WBC elevated at
16 c/w infectious process also. Viral gastroenteritis seemed
most
likely explanation. CT with significant worsening of metastatic
disease burden in the abd and pelvis likely contributor, but
worsening disease alone should not cause this constellation of
sx
(vomiting/diarrhea) unless some obstructive process which is not
suggested by imaging. LFTS/lipase reassuring. fevers up to
102.4 during
hospitalization.
Over course of her hospitalization diarrhea improved, appetite
returned (though still weak), and had no vomiting. WBC improved
also. C diff/norovirus negative.
# Hypotension - resolved after hydration
# Hypoxia - developed hypoxia on HD#2 in context of a fever
102.6. CXR normal. Exam unrevealing and so a CTA was obtained.
BNP elevated. With stopping of IVF and one dose of Lasix,
hypoxia improved. Did not obtain an echocardiogram in light of
overall prognosis and this was in setting of very aggressive
hydration
#Metastatic intraperitoneal mucinous adenocarcinoma of presumed
appendiceal primary.
Discussed with patient and her daughters several times. It was
clear that they understood that the patient did not want any
more chemotherapy and that her prognosis was grim. We had
difficulty with conversations regarding code status as discussed
in palliative care note and my notes. The only thing that
patient discussed was the desire to die at home.We did try and
facilitate home hospice enrollment with ___, but this
was not set up before discharge due to holiday.
Did not set up home health nurse given insurance issues.
TRANSITIONAL ISSUES:
- continue to engage family regarding hospice and code status
- potentially pursue echocardiogram if pulm edema becomes an
issue again
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea
6. Fentanyl Patch 12 mcg/h TD Q72H
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
8. Venlafaxine XR 75 mg PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Fentanyl Patch 12 mcg/h TD Q72H
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Venlafaxine XR 75 mg PO DAILY
ONLY MEDICATION STOPPED WAS COLACE
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis
Metastatic intraperitoneal mucinous adenocarcinoma of
presumed appendiceal primary
Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___, it was a pleasure to care for you during this
hospitalization. We believe you picked up a viral illness and
you have improved with fluids. We expect that your diarrhea will
slowly improve for the next few days
Followup Instructions:
___
|
19974576-DS-13 | 19,974,576 | 24,449,283 | DS | 13 | 2123-03-18 00:00:00 | 2123-03-19 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilaudid
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
NGT
History of Present Illness:
___ M with advanced metastatic
intraperitoneal mucinous adenocarcinoma of presumed appendiceal
primary presents with worsening of abdominal pain, nausea,
vomiting.
Per review of records, initially presented for care in ___ in ___. At that point, she was having
abdominal
pain, diarrhea, bloating, decreased appetite, early satiety, and
a 25-pound weight loss over the preceding few months. She
underwent a CT scan, which showed a right adnexal hypodense
lesion. A pelvic ultrasound showed a multiseptated cystic lesion
without vascularization. On ___, she underwent an
exploratory laparotomy and drainage of 20 mL of ascites that
showed malignancy on pathology. There was a biopsy of a right
ovarian mass, which showed inflammation but no evidence of
malignancy. A biopsy of an omental mass was positive for
metastatic adenocarcinoma. She had elevated CEA and CA-125. She
subsequently moved to the ___ area where she presented for
care. An omental biopsy on ___, showed metastatic
mucinous adenocarcinoma. The differential diagnosis included a
GI
or appendiceal primary, pancreaticobiliary, ovarian, or
uterine/cervical primary. She underwent a thorough GI
evaluation,
which was negative. She was started on neoadjuvant chemotherapy
with carboplatin and paclitaxel with the assumption that this
represented a gynecologic malignancy.
The patient was last seen at ___ ___ for similar
symptoms,
s/p chemo most recently last year with carbotaxol but did not
elect to pursue further chemotherapy if intent was purely
palliative. Underwent ex-lap in ___ for planned
surgical
debulking, extensive tumor burden at that time resulted in
failure of debulking procedure, pt was advised to pursue HIPEC
at
___, unclear if she established care. She did elect to return
to ___ to spend time with family; developed worsening
abdominal distension approximately 3 weeks ago with some serous
leakage of fluid around her umbilicus. This was managed with an
ostomy appliance, has not noted any drainage for past 4 days.
Now
having worsening abd pain, nausea, vomiting, and inability to
tolerate PO. Last BM 4 days ago, underwent CT scan in ED that
showed concern for mass effect from tumor on small bowel.
In the ED, initial vitals were: 97.6 82 106/67 16 100% RA. Exam
notable for cachectic woman, with distended abdomen, hypoactive
bowel sounds, with ostomy in place without output in the bag,
severe tenderness to light palpation, with diffuse guarding.
Labs
showed WBV of 11.8, H/H of 11.7/37.3, Plt 645. BMP notable for
Na
of 131, K 3.9, Cl 95, HCO3 23, BUN 11, Cr of 0.6. LFTS
unremarkable with an alk phos of 150. Lactate 1.2. Imaging
showed
marked progression of primary and metastatic tumor burden.
Received 2 mg IV morphine and was started on LR. ACS was
consulted and recommended NG tube decompression. Decision was
made to admit to medicine for further management.
On the floor, patient reports the history above and c/o
abdominal
pain.
Review of systems: 10-point ROS was performed and is negative
except as noted in the HPI.
Past Medical History:
PMH:
- Asthma
- Osteoporosis
- Denies hypertension, diabetes, thromboembolic disease
PSH:
- Abdominal surgery to remove her placenta post-partum (pt
unclear re details, occurred after vaginal delivery, via small
infraumbilical 4cm vertical incision)
- Ex lap, drainage of ascites, omental bx, peritoneal bx,
ovarian
bx, ___, ___
___:
- ___ (4 deceased in neonatal period)
- SVD x 11
- One pregnancy c/b ? retained placenta, requiring abdominal
surgery via vertical 4cm infraumbilical incision
PGYN:
- Menopausal, late ___
- Denies postmenopausal bleeding
- Not currently sexually active
- Denies hormonal replacement therapy or history of OCPs
- Never had a Pap smear (pt denies and nothing in CHA records
since ___
- Denies history of pelvic infections or sexually transmitted
infections
- Denies history of fibroids or cysts
Social History:
___
Family History:
- Sister died of liver cancer
- No known family history of breast, uterine, ovarian, cervical
or colon cancer
- No known history of bleeding or clotting disorder
Physical Exam:
UPON ADMISSION:
Vital Signs: 98.7 PO 94 / 60 79 16 95 RA
General: ___ woman crying, in moderate distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, decreased breath
sounds
at the bases bilaterally
Abdomen: moderately distended, TTP, focal guarding in the LUQ,
+rebound tenderness
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
UPON DISCHARGE:
VS: 98.2 100 / 56 80 16 95% ra
General: ___ female, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, decreased breath
sounds at the bases bilaterally
Abdomen: moderately distended, TTP, focal guarding in the LLQ,
+rebound tenderness, area of localized hyperpigmented skin
overlying umbilicus with no drainage
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS UPON ADMISSION:
___ 10:05PM BLOOD WBC-11.8* RBC-4.63 Hgb-11.7 Hct-37.3
MCV-81* MCH-25.3* MCHC-31.4* RDW-15.1 RDWSD-43.9 Plt ___
___ 10:05PM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-131*
K-3.9 Cl-95* HCO3-23 AnGap-17
___ 10:05PM BLOOD ALT-11 AST-20 AlkPhos-150* TotBili-0.4
___ 10:05PM BLOOD Albumin-2.9*
LABS UPON DISCHARGE
___ 08:00AM BLOOD WBC-9.6 RBC-3.74* Hgb-9.4* Hct-30.4*
MCV-81* MCH-25.1* MCHC-30.9* RDW-15.3 RDWSD-44.8 Plt ___
___ 08:00AM BLOOD Glucose-78 UreaN-4* Creat-0.4 Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
___ 07:50AM BLOOD ALT-6 AST-12 AlkPhos-103 TotBili-0.3
___ 08:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.5*
EKG on admission:
Sinus rhythm. There is an early transition that is non-specific.
Low voltage in the precordial leads. Non-specific ST-T wave
changes. The Q-T interval is prolonged. Compared to the previous
tracing of ___ these findings are new.
CT abdomen and pelvis w/contrast:
IMPRESSION:
1. Markedly increased primary and metastatic tumor burden.
Metastatic
deposits extend through the anterior wall defect into the
"ostomy".
2. Distention of proximal loops of small bowel with relative
decompression but node discrete transition point in the distal
ileum, compatible with partial obstruction likely due to mass
effect by the large intra-abdominal cystic mass.
Abdominal KUB:
IMPRESSION:
No intraperitoneal free air. Normal bowel gas pattern.
CXR:
IMPRESSION:
In comparison with the study of ___, there are
lower lung
volumes. No evidence of vascular congestion or acute focal
pneumonia.
There has been placement of a nasogastric tube that extends to
the lower body of the stomach. Residual contrast material is
seen in the colon.
Brief Hospital Course:
___ with metastatic intraperitoneal mucinous adenocarcinoma of
presumed appendiceal primary not currently receiving treatment
who presented with abdominal pain, abdominal distension, emesis
found to have partial small bowel obstruction.
Patient had CT scan upon admission that showed increased primary
and metastatic tumor burden as well as a partial bowel
obstruction. Surgery was consulted and recommended no surgical
intervention. NGT was placed to intermittent suction with
minimal output. NGT placed to gravity and pt had nausea and
abdominal pain. NGT was then placed back on to suction with
relief of symptoms. NGT was to gravity prior to discharge and
patient's pain was stable.
Imaging noteable for worsening of patient's malignancy. Pt has
been out of the country (___) for nearly a year and has
received some medical treatment there (antibiotics per her
family). Patient reported that she would not want chemotherapy
or surgery. Palliative care was consulted and met with the
patient. After an extensive goals of care discussion, pt was
made DNR/DNI and is going home with hospice services.
**TRANSITIONAL ISSUES**
-Patient was discharged with "Hospice comfort kit contents"-
acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl
10 mg suppository, haloperidol 5 mg/1 ml oral solution,
lorazepam 5 mg/1ml oral solution, senna-s
-Also wrote script for fentanyl patch if needed
-Please maintain patient's comfort
-MOLST form was signed on ___. DNR/DNI, do not hospitalize
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour Place on skin every three days Disp #*3
Patch Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Disp #*170 Gram Refills:*0
ALSO DISCHARGED WITH PRESCRIPTIONS FOR:
"Hospice comfort kit contents"- acetaminophen 650 suppository,
atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol
5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution,
senna-s
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Metastatic intraperitoneal mucinous adenocarcinoma
Partial small bowel obstruction
Hypotension
Thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
**WHY DID YOU COME TO THE HOSPITAL?**
-You came to the hospital with belly pain
**WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?**
-We took a picture of your belly (CT scan) and it showed that
you have a small blockage in your bowels and growing size of
your cancer
-We placed a tube through your nose in your belly to help with
your bloating, nausea and pain
**WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?**
-You will be going home with hospice care. You and your family
will receive help from nurses.
-___ have an appointment with your oncologist at ___ on
___ (see below for more details).
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
19975602-DS-16 | 19,975,602 | 28,809,966 | DS | 16 | 2181-06-18 00:00:00 | 2181-06-18 18:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Head injury after fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH
after a syncopal episode.
Patient is amnestic to event. Patient's son witnessed him
stumbling backwards and hitting his head with laceration but no
loss of consciousness. He was brought to ___
where CT head shows 5mm parafalcine vessel hemorrhage, without
edema or shift. Labs were notable for WBC 5.9, Hgb 13.2, Cr 1.0,
TropT < 0.03, U/A unremarkable. He was given Keppra IV and
transferred to ___.
Patient currently has no symptoms whatsoever and denies pain.
In the ED, initial VS were: 98.9 76 190/111 16 98% RA
Exam notable for: depression in the posterior occiput with 3 cm
horizontal laceration, wound is explored with no evidence of
fracture underneath, ___ clear bilaterally no battle signs. No
tenderness to palpation over the midline of the back but
abrasions over the mid thoracic spine. Regular rate and rhythm,
Clear to auscultation bilateral with normal chest rise
bilaterally, abdomen soft, nontender nondistended, pelvis is
stable, moving all extremities with no tenderness to palpation
Labs showed:
- WBC 10.4 PMN 84.9
- Hgb 13.2
- normal Plt, ___
- Cr 0.8
Imaging showed:
- NCHCT: 5mm right parafalcine SAH, no skull or cervical
fractures
Patient received: no medications or fluids
Neurosurgery was consulted:
Likely syncopal fall. The patient is neurologically intact on
exam. Reviewed imaging and consulted with Dr. ___. Bleed
meets
ED obs criteria and there are no acute neurosurgical needs.
Recommending possible medicine admission for syncopal workup.
Hold aspirin, may resume in 3 days if needed.
Transfer VS were: 98.1 69 121/78 14 100% RA
On arrival to the floor, patient reports that he felt queasy and
dizzy immediately before the fall without chest pain, SOB, light
headedness, blurred vision. He denies post fall loss of bowel /
bladder control, headache, blurred vision, dysarthria, focal
numbness, weakness.
Last fall was "a few months ago," while shopping, preceeded by
leg weakness, no trauma, no medical attention. Leg weakness
lasted ___ minutes, he was able to get up under his own power.
He
denies other antecedent symptoms or post fall symptoms.
He also has chronic stable occasional urinary incontinence
described as dripping without sensation of need to void. This
has
been present for years and has not changed. Denies straining,
dribbling, hesitancy, need for diapers.
Denies fever, cough, sore throat, chills, chest pain, SOB, abd
pain, N/V/D, bloody stools, dysuria, hematuria, swollen joints,
rash, focal numbness, weakness, other recent falls.
Past Medical History:
DM2
HTN
CKD
HLD
Bipolar
Anemia
Social History:
___
Family History:
Does not know too much about his family history, father had a
stroke, no known aneurysms.
Physical Exam:
===========================
ADMISSION PHYSICAL EXAM:
===========================
VS: 98.6 161/83 57 18 98% RA
Weight: 75.52 kg
GENERAL: WNWD man in NAD
HEENT: 3in curvilinear horizontal occipital laceration, s/p
staples, c/d/i, flattened occiput, tender, anicteric sclera,
PERRL, EOMI, MOM, OP clear
NECK: supple, no elevated JVD
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, nontender in all quadrants, no
rebound/guarding, +BS
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&O, CN II-XII intact, SILT, ___ strength BUE/BLE, no
clonus, dysmetria, HKS normal
SKIN: warm and well perfused
=======================
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: 98.1 PO 131 / 81 96 16 98 RA
GENERAL: Sitting in bed, NAD
HEENT: 3in curvilinear horizontal occipital laceration, s/p
staples, c/d/i, flattened occiput, tender, anicteric sclera,
PERRL, EOMI, MOM, OP clear
NECK: supple, no elevated JVD
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&O, CN II-XII intact, ___ strength BUE/BLE, no
clonus, dysmetria. Reflexes present in biceps and knees
bilaterally, slightly diminished left patellar reflex.
Cerebellar function intact.
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 03:53PM GLUCOSE-130* UREA N-10 CREAT-0.8 SODIUM-145
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
___ 03:53PM estGFR-Using this
___ 03:53PM CK(CPK)-125
___ 03:53PM CK-MB-4 cTropnT-0.01
___ 03:53PM WBC-10.4* RBC-4.35* HGB-13.2* HCT-39.1*
MCV-90 MCH-30.3 MCHC-33.8 RDW-13.2 RDWSD-43.5
___ 03:53PM NEUTS-84.9* LYMPHS-8.6* MONOS-5.6 EOS-0.2*
BASOS-0.1 IM ___ AbsNeut-8.84* AbsLymp-0.90* AbsMono-0.58
AbsEos-0.02* AbsBaso-0.01
___ 03:53PM PLT COUNT-222
___ 03:53PM ___ PTT-24.7* ___
PERTINENT IMAGING:
CT HEAD SECOND OPINION (___):
1. 5 mm hyperdense extra-axial focus along the right
parafalcine region,
compatible with provided history of small subarachnoid
hemorrhage.
2. No evidence of calvarial fracture. Soft tissue swelling and
a small
subgaleal hematoma noted along the posterior occiput.
3. No evidence of cervical spinal fracture or traumatic
malalignment.
4. Moderate cervical spinal degenerative changes, as above.
TRANSTHORACIC ECHOCARDIOGRAM (___):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is mild regional left ventricular systolic
dysfunction with basal to mid inferior and inferolateral
hypokinesis. Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
arch is mildly dilated. The number of aortic valve leaflets
cannot be determined. 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.
LVEF 45%.
IMPRESSION: Mild regional LV systolic dysfunction c/w prior
myocardial infarction in the RCA territory.
DISCHARGE LABS:
___ 06:25AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-145
K-3.2* Cl-105 HCO___-27 AnGap-13
___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Carbamz-4.7
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
___ year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH
after a syncopal episode. Seen by neurosurgery (with no
recommendations for surgery at this time), admitted to the floor
for observation and further workup of syncope. Patient was
stable and doing well during admission.
ACUTE ISSUES:
=============
# ___
# Fall with headstrike
# Syncope and
# New diagnosis of HFrEF:
Patient presented with a right parafalcine SAH (diagnosed on a
head CT at OSH) after a falling episode, where he landed and hit
the back of his head. Preceded by a prodrome of lightheadedness;
his fall most consistent with neurocardiogenic syncope of
unclear trigger. Pt did not have any preceding chest pain or
exertional symptoms to suggest ischemia, nor has he had any
throughout his hospital course.
Pt was neurologically intact on admission with no urgent
surgical intervention recommended by a neurosurgical consult.
Patient was evaluated with EKG, telemetry, orthostatic vitals,
cardiac enzymes, and an echocardiogram that demonstrated the
presence of a right bundle branch block (EKG). Transthoracic
echocardiogram performed on ___ demonstrated evidence of a
prior RCA MI, with inferior wall akinesis and a depressed EF at
45%. His cardiac biomarkers remained negative throughout
admission. Patient was given routine neurological exams (q4)
that showed no neurological changes. Per neurosurgery
recommendations, interval imaging was not performed; nor was any
further antiepileptic medication started. Pt recommended to
follow up at the concussion clinic ___ weeks after his
presentation. Angiography (to evaluate for the presence of
aneurysms) was considered as well, however given the traumatic
nature of the patient's presentation, neurosurgery did not
believe this to be necessary. Patient will follow up with
neurology, cardiology, and his PCP in the outpatient setting
once leaving the hospital.
- Recommended holding ASA until ___ in setting of recent ___
- Staple removal from occipital wound to be performed 10d after
placement at ___ ___ (on ___.
# Urinary incontinence
Patient without bladder obstructive symptoms and history of
carbamazepine, lithium and risperidone presents with chronic
stable urinary incontinence. Patient is also taking a diuretic
for BP control. Likely a medication effects as these medications
are associated with urinary incontinence but given clinical
scenario of ___, this urinary incontinence was monitored closely
during his hospital stay.
CHRONIC ISSUES:
===============
# DM2
Last A1c 5.7 ___, not on any medications. Presented without
overt
hyperglycemia. A1c is 5.4 on ___, obtained for risk
stratification purposes.
# HTN: hypertensive I/s/o. Continued valsartan, amlodipine, and
HCTZ. Was giving metoprolol to further control pressures.
# CKD: presents below prior readings of 1.3-1.6 in ___.
# HLD: stable. Continued pravastatin and held home potassium
chloride.
# Bipolar: mood stable. Continued home Carbamazepine 200 mg QAM
/ 400 mg QPM
and risperidone 2 mg QD. Carbamazepine level at discharge was
4.7, within the therapeutic range.
# Anemia: presents above prior baseline of ___ in ___. Stably
at baseline at time of discharge.
TRANSITIONAL ISSUES:
====================
#CODE: Full (presumed)
#CONTACT: ___ (son/HCP) ___
[ ] MEDICATION CHANGES:
- Added: Atorvastatin 40mg (if tolerates can increase to 80mg)
- Held: Aspirin 81mg. Do not restart until at least ___
given recent subarachnoid hemorrhage.
[ ] NEW DIAGNOSIS OF HEART FAILURE WITH REDUCED EJECTION
FRACTION:
- Pt euvolemic at time of discharge.
- Discharge weight: 76.98kg
- Discharge creatinine: 0.9
- Recommend Pt follow up with cardiology as scheduled for
further consideration of outpatient stress test, possible
cardiac catheterization.
[ ] SUBARACHNOID HEMORRHAGE:
- Pt to hold on aspirin until ___.
- Maintain blood pressure control with sBP < 160. He was under
this threshold without PRN hydralazine by discharge; consider
uptitrating home medicines as needed to achieve this effect.
- To follow up in Cognitive Neurology clinic by calling the
follow-up number.
Mr. ___ is clinically stable for discharge today. The
total time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. CarBAMazepine 200 mg PO QAM
4. Potassium Chloride 20 mEq PO BID
5. RisperiDONE 2 mg PO DAILY
6. Valsartan 160 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. CarBAMazepine 400 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
2. amLODIPine 10 mg PO DAILY
3. CarBAMazepine 200 mg PO QAM
4. CarBAMazepine 400 mg PO QPM
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Potassium Chloride 20 mEq PO BID
Hold for K > 4.5
9. Pravastatin 40 mg PO QPM
10. RisperiDONE 2 mg PO DAILY
11. Valsartan 160 mg PO DAILY
12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until at least ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Subarachnoid hemorrhage
- New diagnosis of heart failure with reduced ejection fraction
(EF 45%)
SECONDARY DIAGNOSIS:
- Right bundle branch block
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 ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
- You had a fall and a small brain bleed.
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- We looked at the electrical activity of your heart and the
squeeze of your heart. This showed that your heart was not
squeezing as well as it should.
- Our neurosurgeons did not recommend any further evaluation for
your brain bleed.
WHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL?
- Please call the cognitive neurology clinic for ___ week follow
up.
- Please go to your appointments as scheduled.
- Weigh yourself every day, and call your doctor if your weight
goes up more than three pounds in a day.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19975710-DS-21 | 19,975,710 | 20,266,816 | DS | 21 | 2129-11-30 00:00:00 | 2129-12-04 11:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubated ___
History of Present Illness:
___ year old female with a history of diabetes, hypertension,
hyperlipidemia and obesity discharged from ___
___ today following total right hip replacement for
osteoarthritis three days ago presenting with shortness of
breath and found to have sats of 60% requiring intubation.
In ED initial VS: HR 63 BP 110/58 RR 18 SO2 100% while
intubated
Labs significant for:
WBC 17.3 (86% neutrophils)
Hbg 8.1
Hct 26.2
___ 14103 (was 287 on ___
Trop-T 0.27
Lactate 1.1 -> 0.7
Arterial blood gas with pH 7.27, pCO2 51, pO2 198, HCO3 24
UA: Moderate leuks, negative nitrates, 23 ___
Patient was given: Heparin for concern of DVT and started on
vancomycin, cefepime and azithromycin due to concern of
pneumonia
Imaging notable for:
Bedside echo revealing RV with good function and no evidence of
RH strain and no pericardial effusion. Good AS
EKG showing normal sinus rhythm with TWI in V3, no ST changes or
Q waves
Consults: Orthopedics
On arrival to the FICU, unable to obtain additional history as
patient was intubated and sedated.
REVIEW OF SYSTEMS: Unable to obtain as patient was intubated and
sedated.
Past Medical History:
Essential Hypertension
Hypothyroidism
Aortic Valve Stenosis
Body Mass Index ___ - Severely Obese
Chronic Kidney Disease, Stage 3
Diabetes Mellitus Type 2 in Obese
Endometrial Carcinoma
Gastroesophageal Reflux Disease
Hyperlipidemia
Iron Deficiency Anemia
Osteoarthritis
Social History:
___
Family History:
Mother passed away at the age of ___ due to cancer.
Physical Exam:
Admission Physical Exam
========================
GENERAL: intubated and sedated
LUNGS: Course breath sounds bilaterally
CV: Regular rate and rhythm with holosystoic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, with mild lower extremity
edema
SKIN: incision on right hip with mild erythema and scant
drainage, inferior portion of incision with surrounding
Discharge Physical Exam
========================
GENERAL: NAD, well appearing
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, JVP not appreciated
CV: RRR, S1/S2, loud III/VI systolic murmur over RUSB, no
gallops
or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: obese abdomen, soft, nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, 1+ edema to knees
bilaterally
(reports baseline from amlodipine)
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, ___
strength
in upper extremities, face symmetric, sensation grossly intact,
PERRL
Pertinent Results:
Admission Labs
===============
___ 07:00PM BLOOD WBC-17.3* RBC-3.01* Hgb-8.1* Hct-26.2*
MCV-87 MCH-26.9 MCHC-30.9* RDW-17.7* RDWSD-55.8* Plt ___
___:00PM BLOOD Neuts-86.0* Lymphs-6.4* Monos-6.2
Eos-0.4* Baso-0.2 Im ___ AbsNeut-14.86* AbsLymp-1.10*
AbsMono-1.07* AbsEos-0.07 AbsBaso-0.03
___ 07:00PM BLOOD ___ PTT-26.0 ___
___ 07:00PM BLOOD Glucose-143* UreaN-30* Creat-1.1 Na-136
K-5.3 Cl-102 HCO3-21* AnGap-13
___ 07:00PM BLOOD ___
___ 07:00PM BLOOD cTropnT-0.27*
___ 07:00PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8
___ 07:40PM BLOOD Type-ART pO2-198* pCO2-51* pH-7.27*
calTCO2-24 Base XS--3
___ 07:08PM BLOOD Lactate-1.1
Micro/Other Pertinent Labs
===========================
___ 11:06 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:10 am Mini-BAL
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000
CFU/ml.
___ 8:11 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ 9:08 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 02:14PM BLOOD Ret Aut-1.8 Abs Ret-0.05
___ 07:00PM BLOOD ___
___ 07:00PM BLOOD cTropnT-0.27*
___ 02:25AM BLOOD CK-MB-9 cTropnT-0.29*
___ 07:30AM BLOOD CK-MB-8 cTropnT-0.30*
___ 11:57AM BLOOD CK-MB-9 cTropnT-0.25*
___ 02:02PM BLOOD cTropnT-0.49*
___ 10:15PM BLOOD cTropnT-0.45*
___ 05:23AM BLOOD cTropnT-0.94*
___ 02:14PM BLOOD calTIBC-160* ___ Hapto-357*
Ferritn-97 TRF-123*
___ 02:14PM BLOOD Iron-20*
Imaging
========
CTA CHEST ___
1. No evidence of pulmonary embolism or aortic abnormality.
2. Cardiomegaly and diffuse bilateral ground-glass opacities and
paraseptal thickening, suggestive of pulmonary edema.
3. Moderate right pleural effusion and small left pleural
effusion.
TTE ___
The left atrial volume index is normal. The right atrial
pressure could not be estimated. There is normal left
ventricular wall thickness with a normal cavity size. There is
mild-moderate left ventricular regional systolic
dysfunction with severe hypokinesis of the distal half of the
anterior and anterior septum, distal inferior and
apical walls (see schematic) and preserved/normal contractility
of the remaining segments. Quantitative
biplane left ventricular ejection fraction is 37 %. Left
ventricular cardiac index is normal (>2.5 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender.
The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (valve area less than
1.0 cm2). There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve
prolapse. There is moderate mitral annular calcification. There
is mild to moderate [___] mitral regurgitation.
Due to acoustic shadowing, the severity of mitral regurgitation
could be UNDERestimated. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe aortic valve
stenosis. Normal left ventricular cavity size with
regional systolic dysfunction most c/w CAD (mid-LAD
distribution). Moderate pulmonary artery systolic
hypertension. Mild-moderate mitral regurgitation.
CXR ___
Increased pulmonary edema and right pleural fluid.
CXR ___
1. Interval improvement of bilateral airspace opacities
consistent with
improved aeration.
2. Mild to moderate bilateral pleural effusions right worse
than left, that are unchanged from prior exam.
3. Support lines and tubes are unchanged
CORONARY ANGIOGRAPHY ___
LM- The left main coronary artery has no angiographically
apparent disease.
LAD- The left anterior descending coronary artery. The vessel is
diffusely calcified. There is a proximal 90% stenosis. The
lesion is is a culprit stenosis.
Circ- The circumflex coronary artery has no angiographically
apparent disease.
OM1- The first obtuse marginal coronary artery. The vessel is
small in diameter. There is a 90% stenosis.
RI- The ramus intermedius has no angiographically apparent
disease.
RCA- The right coronary artery. There is a proximal 40% steno
**A 6 ___ EBU3.5 guide provided adequate support. Crossed
with a Prowater wire into the distal LAD. Predilated with a 2.5
mm balloon and then deployed a 3.0 mm x 12 mm DES at 16 atm.
Final angiography revealed normal flow, no dissection and 0%
residual stenosis
CXR ___
Support lines and tubes unchanged. Bilateral effusions right
greater than
left are stable. Pulmonary edema has slightly worsened.
Cardiomediastinal silhouette is stable. No pneumothorax is
seen.
Discharge Labs
===============
___ 06:01AM BLOOD WBC-12.7* RBC-3.73* Hgb-10.8* Hct-34.1
MCV-91 MCH-29.0 MCHC-31.7* RDW-17.8* RDWSD-55.8* Plt ___
___ 06:01AM BLOOD ___ PTT-22.2* ___
___ 06:01AM BLOOD Glucose-167* UreaN-18 Creat-0.9 Na-141
K-4.3 Cl-102 HCO3-25 AnGap-14
___ 06:01AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.4*
Brief Hospital Course:
___ year-old female with a history of diabetes, HTN, HLD,
recently
discharged from ___ on ___ following
total right hip replacement, who presented with shortness of
breath found to be in acute hypoxic respiratory failure in
setting of fluid overload likely due to NSTEMI and severe AS,
now
s/p DES to LAD, with course c/b possible HAP.
#CORONARIES: s/p DES to LAD, 90% occlusion OM1, 40% RCA
#PUMP: EF 37%
#RHYTHM: NSR
ACTIVE ISSUES:
===============
#NSTEMI: Two vessel disease (LAD, OM1) now s/p DES to LAD with
new apical akinesis. Continued patient on atorvastatin 80mg
daily, ASA daily, and Plavix daily. Given apical akinesis, plan
for treatment with triple therapy for the next three months with
INR goal ___. Will need repeat TTE at that time with
consideration of discontinuation of warfarin.
#CHF EF 37%:
#Severe AS
New heart failure (TTE in Atrius system from earlier this year
without contractile dysfunction) secondary to NSTEMI. Patient
volume overloaded on arrival, now 7.2L negative and grossly
euvolemic. Started torsemide 10mg daily. Will continue
metoprolol succinate 12.5mg daily, amlodipine 10mg daily, and
valsartan 160mg BID.
#Severe AS:
Follow up for TAVR v SAVR eval in the outpatient setting.
#Respiratory failure:
Now resolved, likely in setting of volume overload and possible
pneumonia. Initially was treated with antibiotics for HAP, but
discontinued given signs of infection. She was treated with
vanc/cefepime from ___ and ceftriaxone to ___.
___
Baseline creatinine 0.9 on admission, then developed ___ to 1.6,
likely in setting of contrast load from cardiac catheterization
and diuresis. Resolved.
#Iron-deficiency anemia: s/p pRBC ___ for hgb 7, ___ for
hgb<10
study, ___ for hgb<10 study, ___ for hgb<10 study. Received
course of IV iron. She was transfused to Hb 10 for study in
which she was entered.
#s/p hip replacement
Orthopedics aware of patient but not actively following. No
acute
issues. She will follow up with orthopedics at ___
___.
#Fungal rash:
Continued miconaozole powder.
CHRONIC/STABLE ISSUES:
=======================
# Insulin Dependent Diabetes:
Placed on ISS.
# Hypothyroidism:
Continued levothyroxine 88mcg PO daily
# HLD:
Continued home dose of 20 mg simvastatin
# GERD:
Continued home omeprazole 20 mg BID
# HTN: hypotensive while in ICU in setting of NSTEMI
- Consider restarting home metoprolol tartrate 50 bid and
valsartan-hydrochlorothiazide 320-25 as pressures tolerate
TRANSITIONAL ISSUES:
====================
Discharge weight: 102.2kg
Discharge Cr: 0.9
Medication changes
[] Started warfarin for apical akinesis after MI. Will continue
with warfarin with goal INR ___.
[] Started aspirin 81mg daily and Plavix 75mg daily. Will need
to continue on DAPT for 12 months. Can consider discontinuation
of Plavix at that time.
[] Started torsemide 10mg daily
[] Started irbesartan 150mg BID for hypertension (given issues
with valsartan purity). Adjust based on BP.
[] Stopped simvastatin and replaced with atorvastatin
Other issues:
[] Please recheck Chem10 in ___ days to assess for stable Cr on
torsemide 10mg daily. If loses or gains more than ___ lbs,
readjust dosing or discontinue.
[] Repeat INR on ___ and adjust warfarin dosing accordingly.
Goal INR ___.
[] Repeat TTE in 3 months to assess for improvement in apical
akinesis and ability to stop anticoagulation as well as aortic
stenosis
[] Arrange for outpatient follow-up for evaluation for TAVR vs
SAVR
[] Discharged on DAPT for 12 months. Should not stop for any
reason without consulting cardiologist. Can discontinue Plavix
at that time.
[] f/u anemia and iron studies. Patient received IV iron
[] Consider switching to metoprolol and amlodipine to carvedilol
given possible contribution to fluid retention.
[] Consider adding spironolactone if tolerated for HFrEF.
[] Arrange for orthopedic follow up with Dr. ___ at NEB
___ or ___ ***
#CONTACT: ___, ___ ___,
Daughter, ___
#CODE: Full code (discussed with next of kin by CCU team)
Medications on Admission:
1. amLODIPine 10 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Cyanocobalamin 100 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 0.8 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. GlipiZIDE 5 mg PO BID
8. aspart 15 Units Breakfast
aspart 18 Units Bedtime
9. Levothyroxine Sodium 88 mcg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Omeprazole 20 mg PO BID
12. Simvastatin 20 mg PO QPM
13. LORazepam 1 mg PO PRN prior to flying
14. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
15. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line
16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. Enoxaparin Sodium 30 mg SC Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
4. Docusate Sodium 100 mg PO BID
5. irbesartan 150 mg oral BID
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Torsemide 10 mg PO DAILY
8. Warfarin 2 mg PO DAILY16
Goal INR ___
9. aspart 15 Units Breakfast
aspart 18 Units Bedtime
10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
11. amLODIPine 10 mg PO DAILY
12. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line
13. Cyanocobalamin 100 mcg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. FoLIC Acid 0.8 mg PO DAILY
16. Gabapentin 300 mg PO BID
17. GlipiZIDE 5 mg PO BID
18. Levothyroxine Sodium 88 mcg PO DAILY
19. LORazepam 1 mg PO PRN prior to flying
20. MetFORMIN (Glucophage) 500 mg PO BID
21. Omeprazole 20 mg PO BID
22. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
23. Polyethylene Glycol 17 g PO DAILY
24. Senna 8.6 mg PO BID:PRN Constipation - First Line
25. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute systolic heart failure ___ to NSTEMI
SECONDARY DIAGNOSIS:
====================
Aortic stenosis
Hypertension
Hypothyroidism
DM2
CKD3
GERD
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 the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you had been feeling
short of breath and had swelling in your legs. This was felt to
be due to a condition called heart failure, where your heart
does not pump hard enough and fluid backs up into your lungs.
- You were found to have had a heart attack and it was thought
to be the cause of your new heart failure.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have fluid in your lungs with low oxygen
levels in your blood. You had a temporary breathing tube placed
(intubation) to support your breathing while in the ICU. You
were given a diuretic medication through the IV to help get the
fluid out.
- Your heart arteries were examined (cardiac catheterization)
which showed a blockage of one of the arteries, the left
anterior descending (LAD). This was opened by placing a tube
called a stent in the artery. You were given medications to
prevent future blockages.
- You received an ultrasound of your heart (echocardiogram)
which showed that parts of your heart were found to be moving
less than normal. This increases your risk of forming clots
within your heart that can spread throughout the body and also
cause a stroke. , and you were started
WHAT SHOULD I DO WHEN I GO HOME?
================================
- It is very important to take your aspirin and clopidogrel
(also known as Plavix) every day. These two medications keep the
stents in the vessels of the heart open and help reduce your
risk of having a future heart attack. If you stop these
medications or miss ___ dose, you risk causing a blood clot
forming in your heart stents and having another heart attack.
Please do not stop taking either medication without taking to
your heart doctor.
- It is also very important to take your warfarin (also known as
Coumadin) to reduce the risk of developing clots within your
heart that can then cause strokes.
- Please follow-up with your doctor to have your INR level
checked to make sure your warfarin is at appropriate levels.
- You are also on other new medications to help your heart, such
as atorvastatin, metoprolol, valsartan, and torsemide (replaces
your hydrochlorothiazide).
- Your weight at discharge is 102.2kg. 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.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19975747-DS-15 | 19,975,747 | 28,362,274 | DS | 15 | 2148-08-29 00:00:00 | 2148-08-29 13:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female presenting with epigastric and back pain.
Patient notes that
her pain started yesterday at 6:30 ___ after dinner.
Specifically, she describes
an epigastric pain that is burning in character. It radiates
around the right upper and left upper quadrants around to the
back. The pain is constant and severe. Pain is accompanied with
nausea as well as vomiting. Patient has had multiple episodes of
emesis. She describes no fever or chills. Patient does not have
any urinary changes. Patient continues to have normal bowel
movements.
Patient does not have any red flags with regards to her back
pain. She does
not describe any stool incontinence. She has no urinary
retention. She has no
saddle anesthesia. Patient's past medical history significant
for breast cancer
status post mastectomy and C-section x2. She also has GERD.
Patient drinks
alcohol only occasionally. She is a family history significant
for ulcerative colitis.
Past Medical History:
PMH
breast cancer ___ years ago s/p mastectomy
GERD
PSH
2 c sections
Social History:
___
Family History:
family history significant for ulcerative colitis.
Physical Exam:
Physical Exam on Admission:
98 110 149/87 18 97% RA
gen: NAD
CV: regular, mildly tachycardic
pulm: nonlabored breathing on room air
abd: soft, mildly distended, mildly tender to palpation in
epigastric region
Physical Exam on Discharge:
Vitals: 24 HR Data (last updated ___ @ 2347)
Temp: 98.3 (Tm 98.8), BP: 154/93 (129-168/71-93), HR: 87
(80-98), RR: 18, O2 sat: 97% (97-99), O2 delivery: Ra Fluid
Balance (last updated ___ @ 1456)
Last 8 hours No data found
Last 24 hours Total cumulative 2055ml
IN: Total 2155ml, PO Amt 735ml, IV Amt Infused 1420ml
OUT: Total 100ml, Urine Amt 0ml, NGT 100ml
Physical exam:
Gen: NAD, AxOx3, NGT with bilious output
Card: RRR
Pulm: no respiratory distress
Abd: Soft, non-tender, non-distended
Ext: No edema, warm well-perfused
Pertinent Results:
Labs on Admission:
___ 01:30PM BLOOD WBC-11.8* RBC-4.61 Hgb-14.2 Hct-43.3
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.0 RDWSD-41.3 Plt ___
___ 01:30PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-142
K-4.6 Cl-96 HCO3-29 AnGap-17
___ 01:30PM BLOOD ALT-15 AST-36 AlkPhos-61 TotBili-0.3
___ 01:30PM BLOOD Lipase-25
Labs on Discharge:
___ 07:55AM BLOOD WBC-7.2 RBC-4.03 Hgb-12.4 Hct-38.4 MCV-95
MCH-30.8 MCHC-32.3 RDW-12.1 RDWSD-42.1 Plt ___
___ 07:55AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-142
K-3.5 Cl-104 HCO3-25 AnGap-13
___ 07:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
IMAGING:
===============================
___: CTA CHEST ; CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
1. High-grade small-bowel obstruction with transition point in
the low mid
abdomen. Small volume pelvic free fluid. No pneumoperitoneum
or organized fluid collections.
2. Marked distension of the stomach for which enteric tube
decompression is recommended.
3. Distal esophageal wall thickening likely reflective of
esophagitis from
recent vomiting.
4. No pulmonary embolism or acute aortic pathology.
5. 4 mm left upper lobe pulmonary nodule. See recommendations
below.
6. Evidence of prior granulomatous disease in the chest.
7. Mild cylindrical bronchiectasis and mild airway wall
thickening suggestive of chronic bronchitis.
Brief Hospital Course:
___ in good health, PMHx breast cancer s/p mastectomy ___ y/a
and 2 c sections, presented with abdominal pain, nausea, and
vomiting. A CT abd/pelvis demonstrated a SBO with transition
point. A nasogastric tube was placed for decompression on
admission and she was started on IVF and made NPO. She continued
to have regular bowel movements. On the morning of ___, her
abdominal pain and nausea were significantly improved. She had
an abdominal X-ray with PO contrast that showed contrast passing
through the colon without any signs of a small bowel
obstruction. Her NG tube was removed on the morning of ___. She
was started on a clear liquid diet, which she tolerated well,
and then was advanced to a regular diet without any issues. She
continued to have regular bowel movements.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Omeprazole Dose is Unknown PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Gabapentin 300 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure providing care for you during your stay at
___.
WHY I CAME TO THE HOSPITAL?
- You came to the hospital because you were vomiting, feeling
nauseas, and having abdominal pain.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
- A CT scan showed that you had a small bowel obstruction, which
was causing your symptoms. We placed a nasogastric tube to
relieve the pressure in your stomach, which provided significant
relief of your pain and nausea. We started you on IV fluids and
kept you from eating until your symptoms improved. We got x-rays
that showed improved in the small bowel obstruction and removed
your nasogastric tube.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- You should follow up with your primary care provider within
one week of discharge from the hospital
- You should take your usual medications as prescribed
- You should continue to eat your regular diet
We wish you the best of luck!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19975898-DS-13 | 19,975,898 | 25,531,568 | DS | 13 | 2159-12-12 00:00:00 | 2159-12-13 14:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid / Demerol / ribavirin / venlafaxine
Attending: ___.
Chief Complaint:
SI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of liver transplant went to ___ with anxiety/AMS.
Transferred to ___ for further w/u given h/o transplant and
due to lack of psychiatry at ___. No f/c, CP, SOB, N/V/D,
abdominal pain. Patient arrived from ___ on ___ and
endorsed SI. Of note patient had inpatient psych admission in
early ___ for SI.
He was seen by psychiatry in the ED due to SI - ___ was
placed, pt unable to leave AMA. Psych bed search was initiated.
Patient was also started on olanzapine 15 mg daily and ativan 1
mg PO TID. Per psych recs, his home imipramine and remeron were
held given concern that his anxiety / SI may have been med
related mood disorder.
In the ED:
- Labs were significant for normal white count, BUN/Cr 34/1.1,
INR 1.1, normal LFTs, negative utox, negative serum tox; tacroFK
6.6.
- Imaging revealed patent hepatic vasculature. Unremarkable
liver Doppler examination
- The patient was started on his home medications as well as
psych medications per psych recs.
Vitals prior to transfer were: 97.2 64 107/67 18 98% RA
Upon arrival to the floor, VS were 97.5, 134/94, HR 81, RR 10,
SaO2 99% RA. Patient denied SI, but reported ongoing
intermittent anxiety. Denied fever, sob, cough, abd pain, n/v,
diarrhea.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, 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:
PAST PSYCHIATRIC HISTORY:
Hospitalizations: possible hospitalization ___ years ago for
'mental break' ___ drug use
Current treaters and treatment: no mental health providers
___ and ECT trials: trialed multiple SSRIs, SNRIs and
benzodiazepines; patient uncertain as to exact names; most
recently started Venlafaxine XR; also on Mirtazapine for unclear
indication since OLT
Self-injury: denied; however, ideation with research for plan
Harm to others: asked to be restrained
Access to weapons: denied
PMH:
-HCV cirrhosis s/p OLT with HCV in donor liver s/p treatment
with Harvoni and ribaviron
-nephrolithiasis
-Chronic lower back pain
-HTN
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY: mother ___, EtOH dependence,
Alzheimer's Dementia), father (EtOH ___, sister and son
(___)
Physical Exam:
ADMISSION:
Vitals: 97.5, 134/94, HR 81, RR 10, SaO2 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: well healed surgical scars from prior transplant,
soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred.
PSYCH: denies SI
DISCHARGE:
VS:98.0 109/67 66 16 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, normal thyroid exam, no JVD
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, large RUQ
healed scar
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no jaundice
Neuro: no asterixis, AAOx3, denies active SI/HI
Pertinent Results:
ADMISSION
___ 04:40AM ___ PTT-36.7* ___
___ 04:40AM WBC-4.7# RBC-4.28*# HGB-12.3*# HCT-36.8*
MCV-86 MCH-28.7 MCHC-33.4 RDW-12.7 RDWSD-39.5
___ 04:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:40AM tacroFK-6.6
___ 04:40AM ALBUMIN-5.1 CALCIUM-9.7 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 04:40AM LIPASE-12
___ 04:40AM ALT(SGPT)-18 AST(SGOT)-18 ALK PHOS-115 TOT
BILI-0.7
___ 04:50AM LACTATE-1.0
___ 04:40AM GLUCOSE-106* UREA N-34* CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ 01:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
INTERIM
___ 06:45AM BLOOD tacroFK-7.4
DISCHARGE
___ 06:35AM BLOOD WBC-4.0 RBC-3.85* Hgb-11.2* Hct-32.7*
MCV-85 MCH-29.1 MCHC-34.3 RDW-12.6 RDWSD-38.0 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-91 UreaN-32* Creat-1.0 Na-141
K-4.0 Cl-107 HCO3-23 AnGap-15
___ 06:45AM BLOOD ALT-19 AST-16 AlkPhos-101 TotBili-0.6
___ 06:35AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0
___ 06:35AM BLOOD tacroFK-7.8
IMAGING:
RUQ U/S (___):
-IMPRESSION:
1. Patent hepatic vasculature. Unremarkable liver Doppler
examination.
2. Unchanged 9 mm right upper pole nonobstructing renal
calculus. No
hydronephrosis.
3. Stable mild splenomegaly.
STUDIES:
-Urine cx: negative
-Blood cx:
Brief Hospital Course:
___ hx of liver transplant and depression presented to ED with
suicidal ideation, admitted to medicine for further monitoring
while awaiting safe transfer.
# Suicidal Ideation: patient presented to ___ with anxiety
/ SI. Transferred for further mgmt given receives care at ___.
He was seen in the ED and wassectioned by psychiatry, may not
leave AMA. He remained medically stable in the ED x3 days
without placement in psychiatry. Although medically cleared,
patient was transferred to medicine floor. Per psych notes,
patients may have had some component of med-related mood
disorder causing manic symptoms from imipramine and remeron. The
imipramine and remeron were discontinued and patient was started
on olanzapine 15mg qHS with Ativan 1mg TID for breakthrough
anxiety and vistaril 25mg PRN for anxiety. On arrival to the
floor patient reported no active suicidal ideation. His 1:1 and
section were discontinued after being cleared by psychiatry. He
was discharged on
olanzapine 15mg qHS with olanzapine 5mg qHS PRN if unable to
fall asleep within x1 hour and vistaril 25mg PRN for anxiety. He
was provided with the contact information for social work at the
___ and the social worker for the
Liver Transplant service was contacted to further assist the
patient in establishing psychiatric care. An appointment was
made for him with his PCP ___ 2 days from discharge.
# Liver transplant: s/p OLTx ___omplicated
by HCV recurrence s/p treatment with harvoni/RBV as well as mild
ACR ___. RUQ in ED showed patent hepatic vasculature. Tacro
level on ___ was 6.6. He was evaluated by hepatology in the ED
who reported he was doing well. He was continued on tacrolimus
2mg q12hours, mycophenolate 500mg BID, asa 81mg/Plavix 75mg
daily for common hepatic stent. He will follow-up with his
Hepatologist as an outpatient.
# Hypertension: he was continued on his home amlodipine,
metoprolol
# Chronic back pain: he was continued on his home gabapentin,
cyclobenzaprine
TI:
[] f/u w/psychiatry - will need to call insurance company to
find out which providers he is eligible for, will likely need
referral from PCP
[] f/u w/social work
# CODE STATUS: Full Code
# CONTACT: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Cyclobenzaprine ___ mg PO HS
5. Metoprolol Tartrate 25 mg PO BID
6. Mirtazapine 30 mg PO QHS
7. Mycophenolate Mofetil 500 mg PO BID
8. Tacrolimus 2 mg PO Q12H
9. OLANZapine 5 mg PO BID
10. Imipramine 10 mg PO QHS
11. Gabapentin 600 mg PO QHS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Cyclobenzaprine ___ mg PO HS
5. Gabapentin 600 mg PO QHS
6. Metoprolol Tartrate 25 mg PO BID
7. Mycophenolate Mofetil 500 mg PO BID
8. OLANZapine 15 mg PO QHS
You may take an additional 5mg at night if difficulty falling
asleep
RX *olanzapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Tacrolimus 2 mg PO Q12H
10. OLANZapine 5 mg PO QHS:PRN insomnia
___ take in addition to nighttime dose if difficulty falling
asleep after 1 hour
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
11. HydrOXYzine 25 mg PO QHS:PRN insomnia, anxiety
Please take only as needed for anxiety or insomnia
RX *hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Medication-induced mood disorder
Suicidal ideation
SECONDARY DIAGNOSES:
OLT
HTN
Chronic lower back pain
Discharge Condition:
Appearance: Clean and casual
Behavior: Cooperative, engaged in interview, appropriate eye
contact
Mood: 'Fine'
Affect: Euthymic, mood congruent
Thought process: Linear, logical, goal directed.
Thought Content: Devoid of any delusional thoughts or paranoia,
denies AH/VH, SI, or HI.
Judgment: Improving
Insight: Improving
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital due to concern about hurting
yourself and anxiety. You were evaluated by the Psychiatry team
who stopped your imipramine and mirtazapine and started you on
olanzapine 15mg which you should take every night. It is very
important that you follow-up with your Psychiatrist. If you
begin to feel suicidal or not in control of your feelings please
immediately return to the ED.
Thank you for letting us be a part of your care!
Your ___ Team
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
Followup Instructions:
___
|
19975981-DS-2 | 19,975,981 | 25,927,585 | DS | 2 | 2157-09-16 00:00:00 | 2157-09-17 16:53:00 |
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:
Prolapsed fibroid
Major Surgical or Invasive Procedure:
total abdominal hysterectomy
History of Present Illness:
___ premenopausal female with long hx of menorrhagia and
newly diagnosed fibroids presenting initially to ___
___
this AM and then transferred to ___ with
episode of heavy vaginal bleeding. She reports monthly menses up
until ___ when she began having daily bleeding
requiring pad or tampon changes nearly hourly. She reports two
days of no bleeding in ___ when she noted heavy watery
discharge followed by resumption of bleeding. She denies vaginal
pain and pelvic pain although she endorses taking Aleve
sometimes
for cramping. She did not know she had fibroids until her
evaluation by pelvic ultrasound today. She has not had any
medical care in ___ years due to insurance issues. She went to
the ED today because she noted a large gush of blood and began
to
feel lightheaded and dizzy. She denies CP, SOB and palpitations.
Patient found to have hct of 22 around noon followed by hct 18
at
CHA after IV hydration. She received half a unit of blood prior
to transfer to ___. A transfusion of an additional 2 units has
started in the ED. Pelvic ultrasound shows a 22cm multifibroid
uterus as well as a large fibroid prolapsing into the vagina.
The
endometrium is thickened with fluid and clot and ?polyp.
The patient reports she is still having some ongoing bleeding,
but less than before.
Of note, pt reports approx. 50lbs of unintentional weight loss
since ___ while caring for her mother who was dying with
dementia. She reports she had less of an appetite and "wasn't
really eating."
Past Medical History:
POb:
- TAB X ___ (___)
- SVD x 1 - HTN in preg
- SAB x 1 - no D&C
PGyn:
- menarche at ___ -> regular monthly ___ with ___ days of
bleeding
- menorrhagia bleeding through a pad or super tampon every hour
for the first 3 days at least
- denies hx of abnl paps and STIs
- hx of ovarian cyst removed in pregnancy at ___ - benign - open
PMH:
- obesity
PSH:
- open ovarian cystectomy as above
- D&E x ___
Meds: aleve for cramps occasionally
Allergies: NKDA
Social History:
___
Family History:
___: denies hx of gyn CA, colon CA, diabetes
Physical Exam:
Admission physical exam:
O: T 97.6 HR 78 BP 171/87 RR 18 O2 100%RA - bps
160S-170S/70S-80S
NAD, well-appearing, obese
RRR
CTAB
Abd soft, obese, ND, well-healed midline incision inferior to
umbilicus
Upon discharge physical exam
VSS, AF
Gen: NAD, A&O x 3
ENT: large neck
CV: RRR, S1 S2
Pulm: CTAB, no r/w/c
Abd: soft, appropriately tender, ND, no r/g/d
Ext: no c/c/e
Incision: c/d/i
Pertinent Results:
___ 08:00PM ALT(SGPT)-12 AST(SGOT)-15
___ 08:00PM %HbA1c-5.2 eAG-103
___ 08:00PM WBC-6.9 RBC-3.86* HGB-7.5* HCT-26.2* MCV-68*
MCH-19.5* MCHC-28.7* RDW-23.9*
___ 08:00PM PLT COUNT-296
___ 01:10PM WBC-5.3 RBC-3.42* HGB-6.5* HCT-23.0* MCV-67*
MCH-19.1* MCHC-28.4* RDW-23.6*
___ 01:10PM PLT COUNT-301
___ 11:21AM TSH-1.0
___ 11:21AM HCG-<5
___ 11:21AM WBC-5.2 RBC-3.61* HGB-6.8*# HCT-23.8* MCV-66*
MCH-18.7*# MCHC-28.4*# RDW-23.6*
___ 11:21AM PLT COUNT-307
___ 11:21AM ___ PTT-31.0 ___
___ 11:21AM ___ 10:06PM ___ PTT-29.1 ___
___ 10:06PM ___ 10:00PM GLUCOSE-84 UREA N-7 CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-111* TOTAL CO2-24 ANION GAP-10
___ 10:00PM estGFR-Using this
___ 10:00PM NEUTS-65.3 ___ MONOS-7.9 EOS-2.9
BASOS-0.6
___ 10:00PM PLT COUNT-336
Final Report
INDICATION: History of fibroid prolapsing and vaginal bleeding.
COMPARISONS: Pelvic ultrasound from outside hospital from
___.
TECHNIQUE: Transabdominal and transvaginal exam was performed,
the latter to
better assess the uterus and adnexa.
FINDINGS: The uterus measures 22.7 x 10.3 x 14.2 cm and is
markedly enlarged.
Multiple fibroids are noted, the largest in the left aspect of
the fundus
measuring 10.9 x 9.0 x 9.1 cm. The endometrium is markedly
distorted. A
focal echogenic lesion measuring approximately 2.9 cm has focal
vascular flow
and may represent a polyp or submucosal fibroid. There is
echogenic material
within the endometrium that is likely hemorrhage and blood clot
as well as
fluid. Transvaginal exam was limited due to a large prolapsed
fibroid which
was reportedly visualized on direct inspection. This is
probably demonstrated
as a structure prolapsing through the cervix on image 26. The
ovaries are not
visualized.
IMPRESSION:
1. Markedly enlarged fibroid uterus.
2. Distorted endometrium with hemorrhage, fluid and a
vascularized
intraluminal structure that could represent a polyp or
submucosal fibroid.
3. A prolapsed fibroid, reportedly visualized on direct
inspection, is
partially imaged.
4. Non-visualization of the ovaries.
The study and the report were reviewed by the staff radiologist
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
for observation of her prolapsed uterus. The patient initially
presented with a hematocrit of 18 from the outside hospital
where she received ___ unit of PRBC. The patient then received a
total of 5 units of PRBC for pre-op optimization.
On ___. she then underwent a total abdominal hysterectomy,
along with 3 additional units of PRBCs intraop as well as 1 unit
of FFP. Please see the operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV pain medications. On
post-operative day 1, her urine output was adequate so her foley
was removed and she voided spontaneously. Her diet was advanced
without difficulty and she was transitioned to oral pain meds.
On POD #2, the patient experienced some abdominal discomfort ___
gas pain. Her diet was backed down, and she was ultimately able
to transition her diet.
A goiter was noted on a physical exam, though her TSH was
normal, we recommend an outpatient follow-up with a thyroid
ultrasound. Also, the patient had blood pressures that were
elevated, though she did not receive any anti-hypertensives. We
also recommend that she follow-up with her primary care doctor
as well.
By post-operative day 3, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. Her hematocrit was 30 upon
discharge. She was then discharged home in stable condition with
outpatient follow-up scheduled.
Medications on Admission:
Aleve prn pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*2
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*2
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Do not take more than 4000mg acetaminophen in 24 hours
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Prolapsed fibroid
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 at ___
___ for your prolapsed fibroid and have
since received a total abdominal hysterectomy. You have
recovered well, and met all of your post-operative milestones,
including, pain controlled with medications, walking
independently, urinating spontaneously and tolerating a regular
diet. We have determined that you are in a stable condition to
go home. Please follow-up as scheduled, and follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* 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
* 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) for 3
months
* No heavy lifting of objects >10 lbs 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.
* Your staples will be removed at your follow-up appointment on
___.
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
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19975995-DS-10 | 19,975,995 | 26,284,923 | DS | 10 | 2111-03-18 00:00:00 | 2111-03-18 23:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RLQ pain, fever, and vomiting
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy ___
___ placement of three drains into pelvic abscesses ___
History of Present Illness:
Mr. ___ is a ___ previously health M presented with
three-day -old migratory RLQ pain, fever, and vomiting.
He reports after having Chipotle on ___ evening (three days
prior to presentation), he woke up from an excruciating LLQ pain
and had an episode of non-bloody, non-bilious emesis. He went to
the ___ ED, and got an KUB, which was unremarkable
according to patient. He was cleared and discharged after having
some Zofran and Tylenol. While nausea and vomiting has subsided,
the pain migrated to supraumbilicus. Patient reports that he
woke
up feeling feverish yesterday morning (temp unmeasured), which
resolved with Tylenol. Appetite has been poor since symptom
occurred and he only had a few crackers since pain onset. Early
this AM, the pain migrated to RLQ and has worsen. Pain
exacerbates with movement. He reports haven't had any bowel
movement in 3 days, deviating from his normal BM habit of ___
times a day. Pain has become unbearable this morning and he came
to the ___ ED.
At the ___ ED, he was febrile ___. He was given NS bolus,
Morphine 4mg IV, Acetaminophen 1000mg, and Zofran 4mg. Patient
reports pain and nausea are alleviated after IV meds. Basic labs
were ordered, and CT has yet to be performed. ACS is consulted
for abdominal pain.
Patient denies chills, diarrhea, hematochezia, lightheadedness,
vertigo, cough, SOB, chest pain, and change in urination.
Patient
denies recent travels, sick contacts, or antibiotic use.
Past Medical History:
PMHx:
None
PSHx:
None
Social History:
___
Family History:
Father - HTN
No known inflammatory bowel disease
Physical Exam:
Admission Physical Exam:
Discharge Physical Exam:
GEN: NAD, resting comfortably reclined in bed. Soeaking in clear
and fluent sentences
CTAB, RRR
Abd: obese, soft, slight tenderness to palpation around drain
insertion sites and lateral abdomen bilaterally; nontender at
lap appy sites with steristrips in place on midline low abdomena
nd periumbilical, no staining n lower set, min shatining anguine
on umbilical steris; 3 ir drains- LLQ, Rmid lateral, midline low
abd-- all dry dressings, ir drains in place, serosang out of
right lateral, clear serous in left lat and midline
2+ DP
Pertinent Results:
___ 05:39AM BLOOD WBC-14.5* RBC-4.25* Hgb-12.6* Hct-38.9*
MCV-92 MCH-29.6 MCHC-32.4 RDW-13.5 RDWSD-45.3 Plt ___
___ 11:48AM BLOOD Neuts-88.6* Lymphs-2.9* Monos-7.0
Eos-0.3* Baso-0.4 Im ___ AbsNeut-25.27* AbsLymp-0.83*
AbsMono-1.99* AbsEos-0.08 AbsBaso-0.10*
___ 05:39AM BLOOD Plt ___
___ 05:39AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-135
K-3.9 Cl-100 HCO3-25 AnGap-14
___ 11:48AM BLOOD ALT-10 AST-15 AlkPhos-83 TotBili-0.9
___ 05:39AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.1
Brief Hospital Course:
Following initial surgical evaluation in the ED, the patient was
sent for a CT of his Abdomen and Pelvis which demonstrated acute
appendicitis with two appendicoliths and extensive surrounding
soft tissue stranding. The patient was started on Flagyl and
Ancef and was not deemed to be a non-operative candidate. He was
consented for a Laparoscopic Appendectomy brought back to the
operating room. During the procedure, the appendix was noted to
be liquefied in the midportion and disintegrated with
manipulation releasing multiple large fecaliths into the
peritoneum, which were retrieved and extracted. Otherwise, he
tolerated the procedure well and was sent to the PACU
post-operatively. For further details on the operation, please
refer to the operative note on ___. Over the ensuing three
days, Mr. ___ progressed well; he was tolerating a regular
diet and given PO pain control. On POD 3 however, he began to
develop nausea, vomiting and sustained leukocytosis concerning
for a developing intra-abdominal infection. Subsequent CT
demonstrated numerous rim enhancing collections that were
drained by ___ on ___. Three drains were left in place and
the patient progressed well over the next several days. His diet
was progressed in a step-wise fashion. By the time of discharge,
he was tolerating a regular diet, voiding and stooling normally,
pain was controlled with PO medications and he was independently
ambulating with no issues. He is to follow up with Dr. ___
in 10 days and will receive a CT scan at that point. He was
discharged on the aforementioned antibiotic regimen and was
discharged home with ___ services to help with his 3 JP drains
that were left in place.
___ will help with drain care, recoding output
total 14 days antibiotics, will dc with another 6 days
ct scan ___- pt made aware
call dr ___- will call him, discussed drain care and ___
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 (One) tablet(s) by mouth
every twelve (12) hours Disp #*12 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a
day Disp #*30 Capsule Refills:*1
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 (One) tablet(s) by mouth every eight
(8) hours Disp #*18 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) to
six (6) hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated gangrenous appendicitis
postop ileus
Intra-abdominal abscesses
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 ___ with ruptured appendicitis and
underwent a laparoscopic (minimally invasive) removal of your
appendix. Because your appendix was ruptured, you developed
fluid collections in your abdomen that were drained by our
interventional radiologist. Your infection has since improved
and you are ready for discharge home to continue your recovery.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency. Do not drive until your
pain no longer limits your motion- make sure you can make quick
moves without stopping because of pain.
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:
Your visiting nurses should help you with your drains and their
care. The nurses ___ go over with you how to take care of your
drains. Please record how much comes out of your drains and what
it looks like, and record this on a paper log.
****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.
o Your incisions may be slightly red. 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.
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
- If you develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10cc/ml for 2 days in a
row, please have the ___ call Interventional Radiology at ___
at ___ and page ___. This is the Radiology fellow on
call who can assist you.
Followup Instructions:
___
|
19975995-DS-11 | 19,975,995 | 29,336,309 | DS | 11 | 2111-03-29 00:00:00 | 2111-03-29 18:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Change in ___ Drain output
Major Surgical or Invasive Procedure:
___ drain placement
History of Present Illness:
Mr. ___ is a ___ M s/p lap appendectomy ___ for acute
appendicitis c/b multiple intrabdominal abscesses s/p ___ drain
placement ___. He was discharged home on ___ on course of
oral cipro/flagyl which he completed ___.
He presents today with complaint of increased purulent drain
output. He reports that over the preceding 4 days, all 3 JP
drains were putting out minimal serosanguinous fluid (<10cc
total
daily from all 3 drains). He reports that this morning, however,
he noted the drainage from drains #2 and #3 was thick,
cheese-like and foul-smelling. He reports approximately 20cc
purulent output from drains #2 and #3 with minimal output from
drain #1. He also reports that drain ___ have become
dislodged
as he felt it moved. He denies fevers/chills, worsening
abdominal
pain, diarrhea/constipation, nausea/vomiting, or any other
abdominal symptoms.
Past Medical History:
Past Medical History:
None
Past Surgical History:
___ Laparoscopic appendectomy
___ ___ drain placement x3
Social History:
___
Family History:
Father - HTN
No known inflammatory bowel disease
Physical Exam:
GEN: NAD, well appearing
HEENT: NCAT
CV: RRR
RESP: breathing comfortably on room air
GI: multiple well healing incisions (in the mid abdomen,
suprapubic region and LLQ) used for previous ___ drains and
appropriately covered with bandages, RLQ ___ Drain appropriate
and bandaged pulling white-yellow fluid to bulb suction, right
buttock ___ drain pulling serosanguinous fluid to bulb suction,
abdomen soft, appropriately TTP, no masses or hernia, no
guarding distension or rebound tenderness
EXT: well perfused
Pertinent Results:
___ 06:03AM BLOOD WBC-9.8 RBC-4.23* Hgb-12.5* Hct-38.6*
MCV-91 MCH-29.6 MCHC-32.4 RDW-12.6 RDWSD-41.6 Plt ___
___ 04:15AM BLOOD Neuts-72.9* Lymphs-12.6* Monos-12.4
Eos-0.9* Baso-0.6 Im ___ AbsNeut-10.43* AbsLymp-1.81
AbsMono-1.78* AbsEos-0.13 AbsBaso-0.09*
___ 06:03AM BLOOD Plt ___
___ 06:03AM BLOOD Glucose-93 UreaN-5* Creat-0.6 Na-136
K-4.0 Cl-97 HCO3-25 AnGap-18
___ 06:03AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
Brief Hospital Course:
Mr. ___ returned to ___ several weeks ago following an
episode of Acute Appendicitis s/p Laparoscopic Appendenctomy c/b
gangrenous and perforated appendix. Upon return to hospital
following his procedure, he was found to have 3 abdominal fluid
collections and abscesses that were subsequently drained by ___.
He was discharged with the drains and ___ services but noticed
that the output changed substantially in one of the drains. As
directed, he returned to the ED most recently on ___ for
further workup and management.
During this admission, repeat CT imaging demonstrated a large
pelvic fluid collection that was subsequently drained by ___ via
a posterior approach. He tolerated the procedure well. For the
procedure report, please see the note in the OMR. In the several
days following the procedure, the patient's diet was advanced
and pain was appropriately controlled. By the time of discharge,
the patient was independently ambulatory, tolerating a PO diet,
voiding and passing flatus. He was discharged with the
appropriate follow up and given a course of oral antibiotics.
CT:
1. Interval increase in size of midline pelvic abscess, now
measuring 8.3 x
7.3 cm which extends to the left anterior pelvis.
2. Three pigtail catheters in place with interval resolution of
the left-sided
fluid collection and marked decrease in size of the two
remaining collections.
No new fluid collections identified.
3. New mild right-sided hydroureteronephrosis, with transition
point in the
distal right ureter as it courses in the region of phlegmonous
changes in the
right lower quadrant.
4. Wedge-shaped area of hyperdensity surrounding a hypodense
tubular structure
in segment VIII, more pronounced compared to prior study, which
could
represent a potentially thrombosed branch of the middle hepatic
vein with
thrombophlebitis, or less likely, cholangitis surrounding a
dilated duct.
This could be further assessed with MRCP.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*11 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*17 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pelvic Abscess
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 for management of your
abdominal discomfort and a workup to determine the cause of your
changing drain output. Upon evaluation with CT imaging, it was
determined that you had a large pelvic fluid collection
consistent with an abscess; a collection of infected material in
your abdomen. You were re-started on IV antibiotics and you
received a drain that was placed in the fluid collection via
radiologic intervention. The drain entered your abdomen via your
backside. Two of your previously placed abdominal drains were
removed during this admission; thus, you will return home with 1
drain exiting in your abdomen, and 1 drain exiting from your
backside. A visiting nurse service will be helping you maintain
your drains as they did previously. You will return to clinic
for a follow up appointment in one week. You will continue on an
oral antibiotic regimen until ___. You recovered well from
this process and you are ready to return home to finish your
recovery. Please remain in ___ until at least ___ so you are
nearby the hospital should any issues arise.
If you notice any change in the color or consistency in the
output of your drains, have increasing abdominal pain,
experience nausea, vomiting, fever, chills or increasing redness
around the drain sites, please call the number listed below or
return to the ER.
Followup Instructions:
___
|
19976024-DS-13 | 19,976,024 | 29,806,870 | DS | 13 | 2135-11-30 00:00:00 | 2135-11-30 20:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right lower quadrant pain
Major Surgical or Invasive Procedure:
laparscopic appendectomy
History of Present Illness:
___ with no significant PMH presenting with 2 days of RLQ pain.
Patient states symptoms have been localized to the RLQ for the
past day, desribes the pain as 'sharp' and 'crampy.' Pain
radiates somewhat to right flank with slight testicular pain.
Denied nausea, vomiting, fevers or chills.
Denied dysuria, diarrhea or hematochezia. Denied a history of
renal stones, penile discharge or other genitourinary
complaints.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
PE: VS:97.9 68 130/55 16 100%
General: in no acute distress, lying comfortably in bed
HEENT: mucus membranes moist, nares clear, trachea at midline
CV: regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally
Abd: + bowel sounds, tender to palpation in RLQ, slight right
flank tenderness non-distended. No hernias, masses or scars.
Equivocal psoas/obturator signs. Negative Rosving's.
MSK: warm, well perfused
Neuro: alert, oriented to person, place, time
Physical examination upon discharge: ___
vital signs: t=98.2, hr=68, bp=126/72, rr=18, oxygen saturation
96%
General: NAD
CV: ns1, s2, -s3, -s4
LUNGS; clear
ABDOMEN: soft, tender, port sites with DSD
EXT: no pedal edema bil., no calf tenderness
MENTATION: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:30AM BLOOD WBC-12.8* RBC-4.56* Hgb-14.1 Hct-41.3
MCV-90 MCH-30.9 MCHC-34.2 RDW-12.9 Plt ___
___ 05:30AM BLOOD Neuts-80.9* Lymphs-12.0* Monos-4.5
Eos-1.9 Baso-0.6
___ 05:30AM BLOOD Glucose-98 UreaN-21* Creat-0.8 Na-140
K-4.1 Cl-105 HCO3-27 AnGap-12
___ 05:30AM BLOOD ALT-20 AST-27 AlkPhos-51 TotBili-0.6
___ 05:30AM BLOOD Albumin-4.7
___ 05:43AM BLOOD Lactate-1.3
___: cat scan of abdomen and pelvis:
Acute appendicitis.
Brief Hospital Course:
The patient was admitted to the hospital with right lower
quadrant pain. Upon admission, he was made NPO, given
intravenous fluids, and underwent imaging. On cat scan he was
reported to have a dilated, hyperemic appendix surrounded by fat
stranding. There was no evidence of perforation. Based on these
findings, he was taken to the operating room where he underwent
a laparoscopic appendectomy. The operative course was stable
with minimal blood loss. He was extubated after the procedure
and monitored in the recovery room.
His post-operative course has been stable. His incisional pain
has been controlled with intravenous analgesia with conversion
to oral agents. He has been tolerating a regular diet and
voiding without difficulty. His vital signs have been stable
and he has been afebrile. On POD #1, he was discharged home in
stable condition. Follow-up appointment was made with the acute
care service.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
avoid driving while on this medication,may cause drowsiness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Senna 1 TAB PO BID:PRN constipation
4. Acetaminophen 650 mg PO Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right lower quadrant
pain. You underwent a cat scan which showed appendicitis. You
were taken to the operating room to have your appendix removed.
You are slowly recovering from your surgery and preparing for
discharge home with the following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19976911-DS-9 | 19,976,911 | 27,576,166 | DS | 9 | 2139-10-17 00:00:00 | 2139-10-21 22:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
___: Dual-Chamber Pacemaker Placement
History of Present Illness:
Mr. ___ is a ___ y/o man with a PMH of cirrhosis c/b ascites
from hemochromatosis, HTN, gout, peripheral vascular disease,
and polyneuropathy, who presents with lightheadedness. He was
recently seen in his PCP's office two days prior to admission
with a one week history of pre-syncope and dizziness. Was
hypertensive to 170/70 mmHg standing (158/54 mmHg) bradycardic
at the time to 46 (baseline in the ___. He was thought to have
orthostatic hypotension and instructed to hold his Lasix for 3
days and return if his symptoms worsened. He subsequently
reported that he was feeling more dizzy and weak and that he
felt as though he were going to fall despite using his cane.
In the ED, initial vitals were: T 97.9F P 35 BP 157/54 RR 16 O2
98% RA
Labs were notable for: Na+ 131, K+ 5.3, Cl- 97, HCO3- 25, BUN
12, Cr 0.9, Gluc 122. WBC 10.6, H/H 13.2/37.9, Plt 131. Diff:
73.8% Neut, 11.7% Lymph, 11.6% Monos, 1.2% Eos. ___ 13.9, PTT
34.5, INR 1.3. Trop-T <0.01.
EKG was notable for complete heart block with escape rhythm of
38 bpm and no ischemic changes.
In the unit, he reported that these symptoms occurred suddenly
three days prior to admission (___) while he was making his
morning tea. He felt dizzy and "lousy" and said that he had
never felt this way before. He had no syncope, no loss of
consciousness, no chest pain, palpitations, shortness of breath,
orthopnea, or PND. Denied fevers, chills, nausea, vomiting,
diarrhea, constipation, abdominal pain, hematuria, hematochezia,
melena, hearing loss, tinnitus, or visual changes. No history of
recent travel and no significant time spent outdoors (other than
time spent reading the newspaper on his deck).
Past Medical History:
Hemochromatosis
Cirrhosis (c/b ascites and pleural effusion)
Gouty arthritis
Hypertension
PVD (peripheral vascular disease)
Obesity
Polyneuropathy
Macrocytosis without anemia
Cholecystectomy
Ventral hernia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
===============
ADMISSION EXAM:
===============
VS: P 40 BP 153/43 mmHg O2 97% RA
General: Pleasant, elderly man, in NAD.
HEENT: Anicteric sclera. MMM, OP clear. PERRL.
Neck: Supple, JVP 8 cm. Normal carotid upstroke.
CV: Bradycardic and regular, normal S1/S2. III/VI harsh early
systolic murmur, with no thrills or heaves.
Abd: Obese, soft, non-tender. NABS. Large mid-line abdominal
scar. No ascites.
Ext: Warm and well-perfused. 2+ pitting edema. 2+ DP pulses.
Skin: No rashes or lesions.
Neuro: A&Ox3. Distal sensation intact to light touch. Gait
deferred.
===============
DISCHARGE EXAM:
===============
VS: per Metavision
General: Pleasant, elderly man, in NAD.
HEENT: Anicteric sclera. MMM, OP clear. PERRL.
Neck: Supple, no JVD. Normal carotid upstroke.
CV: RRR, normal S1/S2. III/VI harsh early systolic murmur, with
no thrills or heaves. Pacer dressing site c/d/i.
Abd: Obese, soft, non-tender. NABS. Large mid-line abdominal
scar. No ascites.
Ext: L arm in sling. Warm and well-perfused. 1+ pitting edema.
2+ DP pulses.
Skin: No rashes or lesions.
Neuro: A&Ox3. Distal sensation intact to light touch. Gait
deferred
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 04:36PM ___ PTT-34.5 ___
___ 04:36PM PLT COUNT-131*
___ 04:36PM NEUTS-73.8* LYMPHS-11.7* MONOS-11.6 EOS-1.2
BASOS-0.8 IM ___ AbsNeut-7.80* AbsLymp-1.24 AbsMono-1.23*
AbsEos-0.13 AbsBaso-0.09*
___ 04:36PM WBC-10.6* RBC-3.69* HGB-13.2* HCT-37.9*
MCV-103* MCH-35.8* MCHC-34.8 RDW-14.1 RDWSD-53.3*
___ 04:36PM cTropnT-<0.01
___ 04:36PM estGFR-Using this
___ 04:36PM GLUCOSE-122* UREA N-12 CREAT-0.9 SODIUM-131*
POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-25 ANION GAP-14
==================
PERTINENT RESULTS:
==================
Echocardiogram (___):
Conclusions
The left atrium is moderately dilated. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve is not well seen.
There is severe aortic valve stenosis (valve area <1.0cm2). The
transvalvular mean and peak gradient does not meet severe aortic
stenosis severity. However, by continuity equation there is
severe aortic stenosis. The stroke volume index is low at 37
ml/m2 using Teicholz and also LVOT Doppler assessment possibly
indicating paradoxical low flow low gradient physiology in
setting of normal left ventricular ejection fraction. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Suboptimal image quality. Likely severe aortic
stenosis (see details above). Mild symmetric left ventricular
hypertrophy with normal biventricular regional/global systolic
function.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
CXR (___):
Moderate left pleural effusion and left lower lobe atelectasis
are unchanged and pre see the insertion of new left trans
subclavian right atrial ventricular pacer leads, continuous from
the left pectoral generator. Thereis no pneumothorax or
mediastinal widening. Right lung is clear.
CXR (___):
No unfavorable change, stable appearance of the pacer leads and
moderate left effusion.
___ 5:18 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 5:18 am SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
===============
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-8.0 RBC-3.37* Hgb-11.9* Hct-34.4*
MCV-102* MCH-35.3* MCHC-34.6 RDW-14.2 RDWSD-54.0* Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-132*
K-3.9 Cl-97 HCO3-25 AnGap-14
___ 05:40AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ y/o man with a PMH of HTN and hemochromatosis
complicated by decompensated cirrhosis (ascites), who presented
with a one week history of lightheadedness and dizziness without
chest pain and syncope, found to be in complete heart block.
ACUTE ISSUES:
=============
# Complete heart block: Patient presented with a history of
lightheadedness over the past week prior to presentation. Denied
worsening of symptoms with exertion. The patient was without
chest pain, orthopnea, PND, or oxygen requirement to suggest
heart failure, and was hemodynamically stable. The patient was
found to be in complete heart block; Lyme serologies were
negative and electrophysiology was consulted, with
recommendation for permanent pacemaker. A permanent dual chamber
pacemaker was successfully placed on ___. The patient received
3 doses of IV Vancomycin as ___ prophylaxis, without
complications. Follow-up with electrophysiology was arranged at
the time of discharge.
# Severe aortic stenosis. The patient has a history of aortic
stenosis, for which he states that he has not had cardiology
workup for in the past. He was discharged with instructions to
follow-up with both electrophysiology and cardiology for further
evaluation and monitoring on an outpatient basis. He will be
called with an appointment date and time for cardiology
follow-up.
# Urinary difficulty: The patient reported difficulty urinating
after Foley catheter was removed. He was prescribed tamsulosin
0.4mg qhs with improvement in symptoms. He was given a
prescription to continue on tamsulosin for concern of BPH, which
can be addressed during his follow-up appointment with his
primary care physician.
#Hypertension: The patient had a history of hypertension, and
presented to the hospital taking both atenolol and
spironolactone. He was restarted on spironolactone while
admitted, but beta-blocker was held at the time of discharge.
CHRONIC ISSUES
# Cirrhosis. In the setting of known hemochromatosis. No ascites
or stigmata of cirrhosis on examination. The patient continued
on his home doses of diuretics, without worsening LFTs.
# Gout: Continued home-dose allopurinol ___ mg daily.
# B12 deficiency: Continued home-dose cyanocobalamin 50 mcg
daily.
TRANSITIONAL ISSUES:
====================
- The patient has a mildly dilated ascending aorta. Based on
___ ACCF/AHA Thoracic Aortic Guidelines, if not previously
known or a change, a follow-up echocardiogram is suggested in ___
year; if previously known and stable, a follow-up echocardiogram
is suggested in ___ years.
- Re-assess need for tamsulosin at the time of follow-up;
patient had urinary retention after discontinuing Foley catheter
during hospitalization
- Patient completed 3-day course of ___ Vancomycin
prior to discharge
- discontinued home atenolol on discharge
# Code Status: FULL
# Emergency Contact: Cousin ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 25 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Cyanocobalamin 50 mcg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Cyanocobalamin 50 mcg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
Your primary care physician ___ determine if you need to
continue to take this medication
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Bradycardia
Complete Heart Block
Secondary Diagnosis:
Aortic Stenosis, Severe
Hypertension
Cirrhosis
Gout
Vitamin B12 Deficiency
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 providing care for you at ___
___. You were admitted to the hospital for
lightheadedness which was caused by a slow heart rate. Testing
showed that your heart's electrical activity wasn't as good as
it should be, and you needed a pacemaker as a result.
The pacemaker was placed on ___, which you tolerated well.
Your heart rate improved after you received your pacemaker. You
had some difficulty urinating at first, for which you were
started on a medication called tamsulosin. Your primary care
doctor ___ determine whether you need to stay on this
medication long-term or not.
It is important that you take all of your medications as
prescribed, and that you attend all of your follow-up
appointments as scheduled.
We wish you the best of health,
Your cardiology team at ___
Followup Instructions:
___
|
19977310-DS-17 | 19,977,310 | 22,535,910 | DS | 17 | 2152-01-22 00:00:00 | 2152-01-22 13:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Catapres
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Hemodialysis
Blood transfusion
Tunnelled dialysis line removal
History of Present Illness:
___ year old male with ESRD recently started on HD, hypertension,
hyperlipidemia presented from HD with rigors.
.
Pt in USOH at home and through his HD session yesterday until
the end, when he spiked a fever to 101.8 and rigors. Blood
cultures were obtained and he was sent to the ED. This morning,
he denies cough/SOB/rhinorrhea, abdominal pain, diarrhea, neck
stiffness, dysuria or urinary frequency but reports "stinky,
concentrated urine" and intermittent sharp pain at HD line site.
.
In the ED, initial VS T 100.5, HR- 97, BP- 147/91, RR- 24, SaO2-
100% 2L NC. Another set of blood cultures were drawn and he was
given vancomycin, gentamicin and tylenol. Renal fellow alerted,
and the patient was admitted for further work-up.
.
On arrival to the floor, vital signs were Temp 100.1 F, BP
173/78, HR 92, R 18, O2-sat 93% RA. The patient was asymptomatic
and comfortable. He confirmed the above story this morning,
again reporting no symptoms beyond some line site tenderness and
purulent urine. Renal fellow examined his RIJ tunnelled line and
reported that it appears infected, request ___ line
removal and temporary line placement
Past Medical History:
ESRD
-diabetic nephropathy
-hypertensive nephrosclerosis
-started HD ___
___
Hypertension
Hyperlipidemia
COPD
Diabetes mellitus, on insulin
Gastroesophageal reflux disease
Anemia
Hernia repair
Osteoarthritis
s/p right knee replacement
Dishydrotic eczema
Social History:
___
Family History:
Multiple family members with diabetes and hypertension.
Physical Exam:
ADMISSION
VS - T 100.1 F, BP 173/78, HR 92, R 18, O2-sat 93% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD. HD line in place R chest, minimally
tender, dressing c/d/i (purulence and erythema per Renal fellow
eval)
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 - Obese, NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no open ulcers noted on lower extremities
LYMPH - no cervical LAD
NEURO - awake, A&Ox3
.
DISCHARGE
VS T 98.2 152/77 78 18 100/RA ___ 107 ___ low 34/24h)
GENERAL - Alert, interactive, well-appearing, walking around
slowly in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD. HD line site nontender, no erythema,
dressing c/d/i
HEART - PMI non-displaced, RRR, nl S1-S2, II-III/VI holosystolic
murmur throughout precordium, best LUSB
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - Obese, NABS, soft/NT/ND, no masses
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - dry; desquamating plaques across dorsal hands
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, gait slow but narrow-based and stable
without assistance
Pertinent Results:
ADMISSION LABS
___ 08:15PM WBC-9.0 RBC-3.21* HGB-8.5* HCT-25.8* MCV-80*
MCH-26.4* MCHC-32.8 RDW-18.2*
___ 08:15PM NEUTS-81.1* LYMPHS-8.0* MONOS-3.6 EOS-7.1*
BASOS-0.2
___ 08:15PM PLT COUNT-188
___ 08:15PM GLUCOSE-45* UREA N-34* CREAT-5.1*# SODIUM-140
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14
___ 08:23PM LACTATE-1.4
.
DISCHARGE LABS
___ 07:50AM BLOOD WBC-9.6 RBC-3.38* Hgb-8.9* Hct-27.0*
MCV-80* MCH-26.2* MCHC-32.9 RDW-18.5* Plt ___
___ 07:50AM BLOOD Glucose-97 UreaN-34* Creat-5.5*# Na-135
K-4.5 Cl-97 HCO3-30 AnGap-13
___ 07:50AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1
___ 01:53AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:53AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
___ 01:53AM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 01:53AM URINE CastHy-3*
.
MICRO
.
___ BLOOD CULTURE - NEGATIVE (FINAL)
___ URINE CULTURE - NEGATIVE (FINAL)
___ BLOOD CULTURE - NGTD
___ BLOOD CULTURE - NGTD
___ 6:20 pm SWAB CVC EXIT SITE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
IMAGING
.
___ CXR
FINDINGS: PA and lateral views of the chest were obtained. A
right IJ
dialysis catheter is seen with its tip in the expected location
of the
cavoatrial junction. There is mild pulmonary venous congestion
with probable mild pulmonary edema. No large pleural effusions
are seen. In the presence of pulmonary edema the possibility of
a superimposed mild/early pneumonia is impossible to exclude,
though none is clearly seen. No pneumothorax. Heart size is top
normal though stable. Aortic calcifications are noted. Bony
structures appear intact though there are degenerative spurs
along the mid thoracic spine.
IMPRESSION: Mild pulmonary edema without definite signs of
pneumonia though post-diuresis films may be obtained to further
assess if clinically warranted.
.
___ TTE
Conclusions
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 regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. There is a very small
pericardial effusion.
IMPRESSION: Aortic valve sclerosis. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Trace aortic regurgitation.
Dilated thoracic aorta. Increased PCWP. No discrete vegetation
identified.
CLINICAL IMPLICATIONS: The patient has a moderately dilated
ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic
Guidelines, if not previously known or a change, a follow-up
echocardiogram is suggested in 6 months; if previously known and
stable, a follow-up echocardiogram is suggested in ___ year. 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:
___ with ESRD presents from HD w/rigors and fever, found to have
infected-appearing HD line site; symptoms resolved with IV
antibiotics qHD.
.
1. MSSA HD Line infection
Patient presented with fever and rigors. Line site appeared
infected, was pulled. Patient initially received vancomycin
(___), then cefazolin (___) after entry site swab and
catheter tip both grew MSSA. Blood cultures all negative or NGTD
at time of discharge (note: two sets drawn on ___ were drawn at
HD and in ED, before initiating vancomycin in the ED). Patient
afebrile and without rigors within 12h of line pull. Possible
new systolic murmur auscultated on exam and not previously
documented, but no evidence of vegetations on TTE. Discharged
w/plan for 2 weeks cefazolin qHD (___ alerted by
Renal fellow).
.
2. CKD/HD access
Stage V ESRD, recently initiated on HD (started on ___.
Some access difficulties with fistula at ___ since
last discharge led patient to have additional RIJ tunnelled line
placed at ___ outpatient center (this is the line that was
affected, above). Renal and transplant teams assessed his
fistula and felt it was sufficiently mature & ready for
dialysis; HD nurses found access to be positional but possible
and were able to access it using a smaller gauge needle during 3
HD sessions here.
.
3. Hypertension
Some elevated BPs to the 160s-180s here; his qHD labetolol and
amlodipine were increased in frequency to QD, with better BP
control.
.
4. DM
Longstanding DM2, on long-acting + sliding-scale insulin at
home. Reports recent difficulty with early AM symptomatic
hypoglycemia. Home regimen of 75U lantus qAM was decreased to
40U qAM here - even with this dose reduction he experienced
symptomatic hypoglycemia to the ___ here (responded to juice).
Discharged on 40U w/instructructions to log ___ use at
home for discussion at PCP ___ appt next week.
.
5. Hyperlipidemia
Continued home simvastatin.
.
6. COPD
Patient was breathing comfortably on room air. Noted to be no
longer smoking.
.
7. Chronic low back pain
Patient on oxycodone PRN at home but reports he minimizes use
because it clouds his thinking. Honored patient request to hold
oxycodone here; pain control w/tylenol PRN was sufficient.
.
8 Dishydrotic eczema
Continued home regimen (confirmed in most recent dermatology
note): clobetasol 0.05% ointment BID + aquaphor w/gloves to
hands qHS.
.
TRANSITIONAL ISSUES
1. Follow-up fingerstick/blood sugar log, adjust insulin scale
PRN.
2. Address chronic back pain medication needs/side effects.
3. Check-in re: any ongoing difficulties w/HD access at
outpatient HD center.
4. BP check (losartan/amlodipine now QD).
Medications on Admission:
1. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please take after dialysis on the days that you have dialysis.
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Please take after dialysis on the days that you have dialysis.
5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical BID (2
times a day): Apply to hands and forearms twice a day for two
weeks per month maximum. Do not apply elsewhere.
7. hydrocortisone valerate 0.2 % Cream Sig: One (1) Appl Topical
BID (2 times a day) as needed for itchy skin: apply to itchy
skin on groin twice daily for two weeks per month maximum. Do
not apply
elsewhere. (STOPPED ALREADY AS OUTPATIENT AT LAST DERM APPT)
8. halobetasol propionate 0.05 % Ointment Sig: One (1)
application Topical twice a day: Apply to back of hands twice a
day. Avoid use on face, armpits, and groin. (STOPPED ALREADY AS
OUTPATIENT AT LAST DERM APPT)
9. oxycodone 5 mg Capsule Sig: ___ Capsules PO every six (6)
hours as needed for CHRONIC LOW BACK pain. (PATIENT WEANED SELF
OFF RECENTLY)
10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Seventy
Five (75) units Subcutaneous once a day: Please take in the
morning.
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. NPH insulin human recomb 100 unit/mL Suspension Sig: AS
DIRECTED Subcutaneous once a day: please continue your home
insulin regimen unchanged.
9. cefazolin 10 gram Recon Soln Sig: One (1) Recon Soln
Injection HD PROTOCOL (HD Protochol).
10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 bottle* Refills:*0*
12. clobetasol 0.05 % Ointment Sig: One (1) application Topical
twice a day: apply to hands and forearms twice a day for two
weeks per month maximum. Do not apply elsewhere.
13. Aquaphor Ointment Sig: One (1) application Topical once a
day: apply to hands under cotton gloves at least once daily,
especially after bathing.
Disp:*1 100 cc tube or closest equivalent* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Dialysis line infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___.
You were admitted to the hospital with fever and rigors. We
found you had an infection of your dialysis line. We started you
on antibiotics and pulled the line. Your symptoms resolved
within 24 hours.
We are able to perform dialysis here through your fistula, so no
additional line was needed.
We kept you in the hospital for more intravenous antibiotics and
to perform an echocardiogram (ultrasound of your heart) because
we heard a new heart murmur. The echo showed no evidence of
bacteria on the heart valve, which is good.
We made the following changes to your medications:
1. STARTED CEFAZOLIN - YOU WILL RECEIVE ___ GRAMS AT EACH
DIALYSIS SESSION FOR TWO WEEKS
2. INCREASED AMLODIPINE TO *EVERY DAY*
3. INCREASED LOSARTAN TO *EVERY DAY*
4. STOPPED OXYCODONE (YOU HAD ALREADY WEANED YOURSELF OFF AT
HOME)
.
Please review the attached medication list with Dr. ___ at
your next appointment.
Followup Instructions:
___
|
19978119-DS-15 | 19,978,119 | 20,178,379 | DS | 15 | 2189-04-28 00:00:00 | 2189-04-29 20:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amiodarone / gemcitabine / Abraxane
Attending: ___.
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of CAD s/p PCI (___), metastatic pancreatic cancer
s/p ___ on FOLFOX, Afib on enoxaparin, chronic urinary
retention, and current C Diff colitis on fidaxomicin who p/w
lethargy and hypotension c/f infection found to have elevated
troponins and pancolitis.
Of note, the patient was recently admitted from ___ for
E.coli bacteremia s/p ceftriaxone and urinary
Retention/bilateral hydronephrosis, for which he was discharged
with a foley. He is currently receiving fidaxomicin for C.diff
colitis. At rehab on ___, the patient had increasing lethargy.
At the OSH he has soft pressures to the systolics ___. Labs
showed leukocytosis to 22, Trop I 1.5, creatinine 2.2 (baseline
1.0), positive UA. CXR showed infiltrate vs. atelectasis. He
received Flagyl, 3+ L crystalloid. He was then transferred to
___.
In the ED, initial vitals: 97.9 72 108/68 16 97% RA.
- Labs were significant for Lactate: 1.4, Trop-T: 0.76, CK: 63
MB: 2, Cr 1.8, Na 128, Wbc 22.2 (N:88.0 L:3.0 M:6.7 E:0.8
Bas:0.2), UA with rare bacteria.
- EKG w/o ischemic changes
- CXR showed patchy opacities in lung bases c/w atelectasis but
cannot exclude infection.
- CT abd/pelvis showed diffuse pancolitis most severely
affecting the descending and rectosigmoid colon, most consistent
with ischemia. It also showed new splenic hypodensity c/w
infarct and stable metastases.
- Pt received IVF 1000 mL, IV CefePIME 2 g, IV Vancomycin 1000
mg and was started on IV Norepinephrine
- Cardiology consulted and thought his high troponin was a trop
leak due to hypoperfusion/demand ischemia. Recommended to trend
cardiac enzymes; no indication for heparin gtt.
- Surgery consulted, and recommended nothing to do.
On arrival to the MICU, patient is significantly lethargic but
no acute distress. He was somewhat confused, but ultimately
oriented x3. He initially reported some lower abdominal pain but
then denied. He also denied shortness of breath or chest pain.
Past Medical History:
PAST ONCOLOGIC HISTORY: Reconciled in OMR.
Pancreatic cancer stage IIB (T3N1M0) now with progressive
metastatic disease
- ___ Admitted to the ___ with 2-week history
of
gradual onset of generalized malaise, dark urine, acoholic
stools, and eventual painless jaundice. Found to have
obstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and
subsequent US/CT showed moderate intrahepatic and extrahepatic
biliary ductal dilatation to the level of the pancreatic head
without overt mass seen (lack of IV contrast). US showed,
"Moderate intrahepatic and extrahepatic biliary ductal
dilatation
to the level of the pancreatic head. The CBD measures 17 mm at
the hilum. Limited evaluation of the pancreas does not
demonstrate any pancreatic head mass. Cholelithiasis without
evidence of acute cholecystitis. Borderline splenomegaly."
Follow up CT showed, "Dilated intrahepatic and extrahepatic bile
ducts. No obvious mass but evaluation is limited without
contrast. Markedly dilated urinary bladder with mild left
hydroureteronephrosis and distal right ureter dilatation
possibly
from obstructive uropathy. No calculus. There is an enlarged
prostate gland with a suspected TURP defect."
- ___ ERCP for stent placement, brushings negative for
malignancy. He was discharged on ___.
- ___ Seen by his PCP who arranged for EUS at ___. TB down to 3.8 at that point with
improved symptoms.
- ___ EUS performed by Dr. ___ showed, "No
celiac
adenopathy was seen. Reactive gastrohepatic ligament adenopathy
seen. Two SB-IPMNs noted; one in the body and the larger one in
the head. A solid mass was seen surrounding the distal CBD,
measuring 1.2 cm. The CBD was dilated proximal to the mass up
to
1.2 cm in size. A small, suspicious-appearing lymph node was
seen around the distal CBD. FNA performed, prelim results show
neoplastic ___ final pathology positive for
malignant cells, CONSISTENT WITH ADENOCARCINOMA.
- ___ ___ resection revealed pancreatic
adenocarcinoma
pT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative,
extensive perineural invasion present, margins clear by 2 mm at
the SMV.
- ___ Signed consent for APACT Trial ___ ___
- ___ CT torso showed celiac adenopathy and a possible new
liver met
- ___ MR liver showed likely liver met and adenopathy
- ___ Began discussion of HALO trial
- ___ FNA of the liver lesion via EUS showed metastatic
adenocarcinoma
- ___ Signed consent for HALO, randomized to control arm
- ___ C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2
D1,8,15
- ___ C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2
D1,8,15
- ___ CT torso showed response to therapy
- ___ C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2
D1,8,15
- ___ C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2
D1,8,15
- ___ CT torso showed further reduction in liver mets, new
pneumomitis
- ___ Holding chemo for pneumonitis. Start steroids. Off
study ___ ___ control arm of the HALO trial.
- ___ Much improved on steroids.
- ___ CT torso showed progression of liver mets and
development of numerous new liver mets as well as progression of
portal adenopathy.
- ___ C1D1 FOLFOX6
- ___ C2D1 FOLFOX6
- ___ CT torso showed progression of known disease and some
increased pulmonary nodules. Rising tumor markers.
- ___ C3D1 FOLFOX6
- ___ C3D15 dose of FOLFOX held for admission to OSH for MI
- ___ CT torso showed stable lung nodules and enlargement
of
multiple hepatic metastatic lesions and the local recurrence in
the tumor bed.
- PLANNED ___ Resume chemotherapy with C4D1 FOLFOX6
PAST MEDICAL HISTORY:
- Metastatic Pancreatic Cancer
- CAD s/p PCI (___)
- pAFib ___, converted to sinus spontaneously)
- HTN
- HLD
- Obstructive Uropathy with BPH - followed by Dr. ___
___
- ___ (baseline Cr 1.5)
- Agent Orange exposure during ___
- Biceps tendon rupture
- Cataracts
PSH:
- Whipple (___)
- TURP
- Left inguinal hernia repair (___)
- Cholecystectomy
- Bicept tendon repair
- b/l cataract surgery
Social History:
___
Family History:
1. Mother died of a ruptured abdominal aortic aneurysm.
2. Father was healthy until his ___.
3. Son died young of coronary artery disease.
4. No family history of malignancies that he is aware of.
Physical Exam:
ADMISSION:
Vitals: T:97.2 BP: 101/48 P: 101 R: 18 O2:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, faint bibasilar
crackles, but no significant wheezes, rales, rhonchi
CV: irreg irreg, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, hypoactive bowel sounds,
no rebound tenderness or guarding, no organomegaly.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or other lesions. port in place.
NEURO: no facial droop, moving extremities, but unable to
participate in formal neurologic exam.
DISCHARGE:
Physical Exam
Vitals- Resting comfortable not febrile to touch, no tachypnea
General- NAD
HEENT- Anicteric sclera, dry MM
Pertinent Results:
ADMISSION/IMPORTANT LABS:
=========================
___ 05:33AM BLOOD WBC-27.1* RBC-3.80* Hgb-11.2* Hct-33.9*
MCV-89 MCH-29.5 MCHC-33.0 RDW-15.7* RDWSD-50.9* Plt ___
___ 04:50AM BLOOD WBC-20.8* RBC-3.42* Hgb-10.0* Hct-29.9*
MCV-87 MCH-29.2 MCHC-33.4 RDW-15.6* RDWSD-49.5* Plt ___
___ 09:10PM BLOOD Neuts-88.0* Lymphs-3.0* Monos-6.7
Eos-0.8* Baso-0.2 Im ___ AbsNeut-19.57*# AbsLymp-0.66*
AbsMono-1.48* AbsEos-0.18 AbsBaso-0.04
___ 09:10PM BLOOD Glucose-104* UreaN-58* Creat-1.8* Na-128*
K-3.8 Cl-97 HCO3-17* AnGap-18
___ 09:10PM BLOOD ALT-27 AST-44* CK(CPK)-63 AlkPhos-321*
TotBili-0.4
___ 09:10PM BLOOD cTropnT-0.76*
___ 05:33AM BLOOD cTropnT-0.81*
___ 02:58PM BLOOD cTropnT-0.71*
___ 08:13AM BLOOD Lactate-1.4
LABS AT DISCHARGE:
=================
___ 05:51AM BLOOD WBC-13.6* RBC-3.33* Hgb-9.7* Hct-30.8*
MCV-93 MCH-29.1 MCHC-31.5* RDW-18.3* RDWSD-58.7* Plt ___
___ 05:51AM BLOOD Glucose-87 UreaN-21* Creat-0.9 Na-144
K-3.1* Cl-120* HCO3-18* AnGap-9
___ 05:51AM BLOOD ALT-30 AST-95* AlkPhos-526* TotBili-0.5
MICROBIOLOGY:
=============
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ AT 10:49 AM
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
=======
CT Abdomen/Pelvis w/o contrast ___. Diffuse pancolitis, most severely affecting the descending
and rectosigmoid colon. Given the degree of wall thickening and
fat stranding surrounding the distal colon, although nonspecific
and limited in the absence of IV contrast, there is high concern
for ischemia given this appearance. No portal venous gas or
pneumatosis identified. 2. Small amount of ascites is primarily
perihepatic and perisplenic. 3. New apparent wedge-shaped
hypodensity in the spleen is nonspecific, possibly infarction,
less likely metastasis. 4. Stable severe thoracolumbar spine
degenerative change. 5. Stable multifocal hepatic hypodensities
consistent with known metastatic prostate cancer. 6. Trace
pericardial and bilateral layering pleural effusions.
CXR ___
Limited study as result of low lung volumes. Patchy opacities
in the lung
bases may reflect atelectasis but infection or aspiration cannot
be excluded in the correct clinical setting.
CT ABD/PELVIS ___
1. Splenic infarcts.
2. Numerous hypodense masses in the liver are consistent with
history of
metastatic pancreatic cancer.
3. Thrombus within the main portal vein and left portal vein
branches.
4. Colonic wall thickening consistent with colitis is persistent
but improved
compared to ___.
5. Small to moderate amount of nonhemorrhagic ascites is
slightly increased
KUB ___
Comparison to ___. Three views of the abdomen are
provided. Clips are projecting over the middle abdomen. Mild
colonic distension at the level of the transverse and the
descending colon. Colonic air-fluid levels are visualized on
the cross-table view. No evidence of free intra-abdominal air.
Several phleboliths projecting over the pelvis.
ECHO ___
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 58 %). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved regional and global biventricular
systolic function. Mild aortic regurgitation. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of ___,
the severity of aortic regurgitation and mitral regurgitation
are slighlty increased. Left ventricular regional and global
systolic function are similar. The ventricular rate is now
higher with frequent extrasystoles.
LEFT UE US ___
There is normal flow with respiratory variation in the left
subclavian vein.
The left internal jugular and axillary veins are patent, show
normal color
flow and compressibility. The left brachial, basilic, and
cephalic veins are patent, compressible and show normal color
flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Brief Hospital Course:
PLEASE ADMIT TO INPATIENT HOSPICE
BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ with hx of CAD s/p PCI (___), metastatic
pancreatic cancer s/p Whipple (___) on FOLFOX, Afib on
enoxaparin, chronic urinary retention, who presented with severe
C Diff colitis on fidaxomicin and troponemia.
#GOC: Patient has poor prognosis and is extremely weak given
c-diff and metastatic pancreatic cancer. One month ago patient
was quite functional and had actually driven himself to his
oncology appointments. He has declined quite rapidly and is now
unable to move his limbs against gravity. Since patient's mental
status did not allow for a goals of care discussion, an in depth
discussion was held with HCP, and decision was made to change
care to comfort based care. Receiving comfort focused
medications only.
Other medical issues before transition to comfort based care:
# Shock:
Patient with hypotension and evidence of end-organ dysfunction
with lethargy and ___. Given leukocytosis, thought to be septic
shock. Although patient had positive troponin, he was without
chest pain or significant changes on ECG. Thus, troponinemia is
likely a type II demand event. Initial suspected sources of
infection included C.diff given pancolitis and reported history
(although C.diff negative on last admission) as well as
potential PNA based on CXR findings. However, he denied any
respiratory symptoms. Initially, patient was treated with broad
spectrum antibiotics to cover both colitis and pneumonia with IV
vanc, cefepime, flagyl, and PO vanc. C.diff was sent and
returned positive. IV vanc, cefepime was discontinued. He
remained on PO vanc and IV flagyl for treatment of severe C.diff
until transfer to the floor. He was weaned off pressors and his
leukocytosis was downtrending at the time of discharge from the
ICU.
#Severe C-diff colitis: As above he was transferred to the floor
on both IV flagyl and high dose vancomycin. He was evaluated by
speech and swallow who recommended initially that he be made NPO
due to aspiration. He progressed to pureed solids and nectar
thick liquids but had not progressed to meet his nutritional
needs sufficiently. During that time he was started on tube
feeds and the rate was gradual increased without residuals or
worsening of his colitis symptoms. Was initially evaluated by
surgery but no intervention with improvement in symptoms. His
leukocytosis remained somewhat stable. Patient did not improve
but remained stable. On ___ antibiotics were discontinued
and tubefeeds were stopped per above goals of care discussion.
# NSTEMI:
Per cardiology, likely type 2 NSTEMI given absence of symptoms
and no EKG changes. Had not been on beta blocker at home,
therefore after troponins trended down and blood pressures
improved patient was started on metoprolol tartrate 12.5 BID. He
had been on an aspirin 81 every other day at home. Aspirin was
restarted daily. Patient already anticoagulated with enoxaparin,
however, this was held in setting ___ and concern for
possible need for surgical intervention. It was restarted
shortly thereafter without issue. Continued atorvastatin. All
cardiac medications were discontinued as per above goals of
care.
# Acute on chronic renal injury:
Likely prerenal given hypotension/sepsis. Creatinine initially
2.1 but downtrended appropriately in response to fluid
resuscitation and resolution of hypotension. Cr prior to
discharge was 0.9
# Hyponatremia: RESOLVED Likely hypovolemic. Patient
asymptomatic. Na improved after fluids.
# Metabolic acidosis: Lactate WNL. Non anion gab acidosis Likely
due to diarrhea, as patient is noted to have chronic diarrhea
since ___. Urine electrolytes with a pH of 6 and no AG in
conjunction with patient normal potassium make RTA unlikely.
# Afib on enoxaparin: Rate controlled throughout, on lovenox for
anti-coagulation as previously decided by cardiologist given hx
of metastatic pancreatic cancer.
# Metastatic pancreatic cancer:
Chemotherapy with FOLFOX from oncologist, Dr. ___. No
chemotherapy given on this admission. Dr. ___ met with
patient and family and communicated extremely poor prognosis,
and that patient was not candidate for any chemo given poor
functional status.
# Urinary retention: continued indwelling foley which patient
had on transfer from rehab to ___. Attempted voiding trial
with high post void residuals. foley placed back. No UTI.
# Depression: continued citalopram
# GERD: Discontinued omeprazole in light of increasing risk of
C-diff recurrence, changed to famotidine.
TRANSITIONAL ISSUES
===================
-Consider completely liberalizing diet, patient likely
aspirating even on nectar thick liquids.
-#DNR/DNI
-#CONTACT GRANDSON ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Citalopram 20 mg PO DAILY
3. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
4. Gabapentin 400 mg PO BID:PRN shingles
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. LOPERamide ___ mg PO QID:PRN diarreha
7. Omeprazole 40 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
10. lidocaine HCl 3 % topical TID:PRN pain
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. CeftriaXONE 2 gm IV Q 24H
13. Sarna Lotion 1 Appl TP TID:PRN pruritis
14. Tamsulosin 0.4 mg PO QHS
15. Creon 12 3 CAP PO TID W/MEALS
16. Acetaminophen 325 mg PO Q6H:PRN pain
17. Dificid (fidaxomicin) 200 mg oral Q12H
18. Oyster Shell Calcium (calcium carbonate) 500 mg calcium
(1,250 mg) oral BID
19. Ibuprofen 400 mg PO BID:PRN pain
20. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. lidocaine HCl 3 % topical TID:PRN pain
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Sarna Lotion 1 Appl TP TID:PRN pruritis
7. Miconazole Powder 2% 1 Appl TP BID groin
8. Acetaminophen 325 mg PO Q6H:PRN pain
9. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
10. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress
11. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory
distress
12. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
Discharge Disposition:
Extended Care
Facility:
___.
Discharge Diagnosis:
Primary:
Septic Shock
Severe C-diff Colitis
Aspiration
Secondary:
chronic systolic heart failure
HTN
HLD
___
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 admitted to ___ after being found to have low blood
pressures because of a severe c-diff. We gave you special
medication to support your blood pressures and treated your
c-diff with antibiotics. As your c-diff improved we were able to
wean off the blood pressure medications. You had a swallow
assessment which showed that your swallowing muscles were weak
and so we started you on tube feeds to support your nutrition.
After discussion with you and your HCP it was decided not to
continue to pursue treatment and your care became focused on
comfort only. All of your non-comfort medications were
discontinued and you were discharged to hospice.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19978265-DS-21 | 19,978,265 | 23,713,862 | DS | 21 | 2157-05-22 00:00:00 | 2157-05-23 19:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left mandibular angle
fracture and extraction of multiple teeth, 15, 16, 18, 5, 30,
29, and 31.
History of Present Illness:
___ PMHx for alcoholism, heroin use who presents to the ED s/p
fall with displaced left mandibular fracture. Of note, patient
states that she has a hx of alcohol use and was planning to
check into an alcohol detoxification center in the near future.
However, she had 4 pints of Whiskey and stumbled off the train,
and fell on the ground landing on her left mandible. She did not
have LOC, denies nausea/vomiting. Patient was brought into the
ED by her BF and was evaluated by OMFS.
Past Medical History:
Alcohol use
Hepatitis C
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: Stable
General: AAOx3, appears stressed and threatened to leave AMA
HEENT: pupils equal and reactive, EOMI intact, no midface
deformities, pain with biting down, swelling of left mandible.
Cardiac: WNL
Respiratory: Breathing comfortably on room air, right sided
chest
wall tenderness
Abdomen: Soft, non-tender, no rebound or guarding, prior midline
laparotomy scar
Skin: Scar over right lip from bar fight last week, bruise over
right eye brow, prior burn.
Discharge Physical Exam:
Gen: Alert, sitting up in bed.
HEENT: bruising around left mandible, slightly swollen. trachea
midline. neck supple.
Cardiac: RRR
Resp: Breath sounds clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended
Ext: Warm and dry. 2+ ___ pulses.
Neuro: A&Ox3. PERRL. Follows commands, moves all extremities
equal and strong.
Pertinent Results:
___ 09:00AM BLOOD WBC-11.0* RBC-3.61* Hgb-11.2 Hct-36.5
MCV-101* MCH-31.0 MCHC-30.7* RDW-17.1* RDWSD-62.9* Plt ___
___ 11:16AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.7* Hct-32.2*
MCV-102* MCH-30.7 MCHC-30.1* RDW-15.8* RDWSD-59.2* Plt ___
___ 12:36PM BLOOD WBC-11.9* RBC-3.00* Hgb-9.4* Hct-30.3*
MCV-101* MCH-31.3 MCHC-31.0* RDW-16.1* RDWSD-59.7* Plt ___
___ 04:10AM BLOOD WBC-10.0 RBC-3.24* Hgb-10.1* Hct-32.6*
MCV-101* MCH-31.2 MCHC-31.0* RDW-15.9* RDWSD-58.4* Plt ___
___ 09:00AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-135
K-4.4 Cl-100 HCO3-26 AnGap-13
___ 04:20AM BLOOD Glucose-100 UreaN-4* Creat-0.5 Na-131*
K-4.2 Cl-98 HCO3-27 AnGap-10
___ 11:16AM BLOOD Glucose-131* UreaN-2* Creat-0.5 Na-134
K-4.0 Cl-100 HCO3-24 AnGap-14
___ 12:36PM BLOOD Glucose-102* UreaN-4* Creat-0.4 Na-136
K-3.6 Cl-100 HCO3-26 AnGap-14
___ 04:10AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-144
K-3.6 Cl-107 HCO3-26 AnGap-15
___ 09:00AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.8
___ 04:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
___ 11:16AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8
___ 12:36PM BLOOD Calcium-7.6* Phos-3.1 Mg-1.2*
___ CT Sinus/Mandible
1. Mildly displaced left mandibular fracture.
2. Mild irregularity of the right nasal bone may indicate a
fracture.
3. Multiple dental caries. Periapical lucencies right
mandibular third molar.
___ CT Head
1. No acute intracranial process.
2. Mild irregularity of the right nasal bones may indicate a
fracture.
___ CT C-Spine
1. Moderately limited by motion artifact. No convincing
evidence for acute fracture.
2. Left mandibular fracture.
___ Lumbar Sacral Spine
No fracture.
___ Chest PA/Lat
No acute cardiopulmonary process.
___ CT Chest/Abdomen/Pelvis
1. No evidence of acute injury in the torso. No fractures.
2. Small filling defect in the right external iliac vein
concerning for a small thrombus.
3. Status post cholecystectomy and splenectomy.
4. Hepatic steatosis.
___ Unilat lower extremity veins
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. 4.0 cm fluid collection in the right popliteal fossa, which
does not definitely connect to the joint space.
___ Mandible series
Left mandibular angle fracture.
___ MRV Pelvis
Small nonocclusive, nonenhancing thrombus in the right external
iliac vein, as seen previously.
___ Mandible Series
In comparison with the study of ___, there is a fixation
device about the distracted fracture in the region of the angle
of the mandible on the left.
___ Unilat lower extremity vein
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
Ms. ___ is a ___ yo female admitted to the acute care
trauma surgery service on ___own 4 stairs.
Her past medical history is significant for alcoholism and
heroin use. CT imaging showed a left mandibular fracture, a
mildly displaced nasal bone, and a filling defect in the right
external iliac vein. OMFS was consulted and recommended surgical
repair. On ___ informed consent was obtained and she was
taken to the OR for an open reduction internal fixation of left
mandibular angle fracture and extraction of multiple teeth, 15,
16, 18, 5, 30, 29, and 31. She was extubated and taken to the
PACU until stable then transferred to the floor for further
management.
On POD 1 her diet was advanced to full liquids which she
tolerated well and her pain was controlled with PO pain
medications. An MRV confirmed a small nonocclusive, nonenhancing
thrombus in the right external iliac vein.
On POD 2 vascular surgery was consulted for the thrombus and
recommended lower extremity non-invasive studies which were
negative for DVT.
On POD 3 a heparin drip was started.
On POD 4 coumadin therapy was initiated.
Case management and social work were involved in the patients
care plan throughout the hospitalization. Her discharge plan was
complicated by her need for anticoagulation and limited
insurance coverage in ___. Several options were
discussed with the patient such as returning to ___ to
be followed by her primary care provider. She did not want to do
that at this time. The decision was made with the patient to
start Xarelto therapy since she would not have frequent blood
draws. She was given a 2 week supply of medication from the care
plus pharmacy. She plans to go back to ___ to see her
primary care provider and further discuss treatment within the
month. Her primary care was made aware of the plan and agreed to
assist her in obtaining continued therapy. The risks associated
with her diagnosis of deep vein thrombosis and anticoagulation
treatment were discussed and the patient verbalized agreement
and understanding with the plan. Please see case management note
for further details.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged and reports
having a safe place to stay. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. Follow up
appointments were made.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Not to exceed 4,000 mg in 24 hours
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % swish and spit twice a day
Refills:*0
3. Docusate Sodium 100 mg PO BID
hold for diarrhea
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
4. Nicotine Patch 14 mg TD DAILY
DO NOT smoke while wearing this patch. Only wear 1 patch at a
time.
RX *nicotine 14 mg/24 hour apply to skin once a day Disp #*14
Patch 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
6. Rivaroxaban 15 mg PO BID Duration: 21 Days
RX *rivaroxaban [___] 15 mg 15 tablet(s) by mouth twice a
day Disp #*21 Tablet Refills:*0
7. Rivaroxaban 20 mg PO DAILY DVT Duration: 10 Weeks
Please start this dose/frequency after initial 21 days therapy
(on ___.
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day
Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right external iliac DVT
Mildly displaced nasal bone
Left angle mandible fracture and multiple retained roots.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___own
stairs. Imagining revealed that you fractured several bones in
your face and jaw. The oral, maxillofacial surgery team was
consulted and repaired these fractures in the operating room and
removed 7 teeth. You were found to have a deep vein thrombosis
(blood clot) in a vein near your right hip that is partially
blocking blood flow. You are being treated for this with a blood
thinning medication called Coumadin. It is very important that
you take this medication as prescribed and have blood levels
drawn as ordered by your doctor.
You are now ready to be discharged from the hospital to continue
your recovery. Please note the following discharge instructions.
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Showering: You may shower ___ days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick to the braces and can cause gum disease and damage teeth.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better. If your jaws are wired shut with elastics and you
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If you feel that you cannot safely expel the vomitus in
this manner, you can cut elastics/wires and open your mouth.
Inform our office immediately if you elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.
___: Depending on the type of surgery, you may have
elastics and/or wires placed on your braces. Before discharge
from the hospital, the doctor ___ instruct you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.
Medications: You will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal sprays
and pain medications. Use them as directed. A daily multivitamin
pill for ___ weeks after surgery is recommended but not
essential. If you have any questions about your progress, please
call our office at ___.
Followup Instructions:
___
|
19978454-DS-20 | 19,978,454 | 26,077,022 | DS | 20 | 2176-06-08 00:00:00 | 2176-06-12 06:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
melena and abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ year old female with cirrhosis and HCC and history of
uncomplicated diverticulitis reporting abdominal pain and
melena.
Patient reported sharp abdominal pain for about 3 days gradulaly
building and is currently ___. Patient reported her pain
started as a band across her whole abdomen and now also includes
her RUQ. This pain started similarly as her bout of
uncomplicated diverticulitis ___ years ago. Patient's melena
started yesterday, hx of ascities new abd pain and chills. No
ascities.
In the ED, initial vitals: T 99.0 HR 80 BP 118/68 RR 18 SpO2
100 RA
Labs were significant for Hgb 10 Hct 31.1 and Plt 62 (all three
values within her reccent outpatient baseline). Alk Phos 140 and
Lipase 80
Imaging showed no free air or acute pulmonary process on CXR PA
and lateral.
In the ED, patient was given three 1mg doses of dilaudid, 1L NS,
a one time 40mg dose of pantoprazole, and 4mg zofran.
Past Medical History:
- Anemia
- Diveticulitis - ___ years ago at ___
- Liver Cancer - HCC
- Cirrhosis
- HepC - s/p curative therapy (___ trial)
- Rheumatoid Arthritis
- Bunionectomy ~ ___ years ago
Social History:
___
Family History:
Patient has no family history of liver cancer, diverticular
disease, or bleeding or clotting disorders.
Physical Exam:
VS: T 95 BP 129/64 HR 94 RR 16 O2Sat: 94% on RA
GEN: Alert, lying in bed, no acute distress
HEENT: Pinpoint pupils, Dry MM, anicteric sclerae, no
conjunctival pallor
NECK: Supple without LAD, JVP Not-elevated
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 with normal respophasic variation no m/r/g
ABD: Soft, tender to palpation in epigastrium, mildly-distended
EXTREM: Warm, well-perfused, no edema, palpaple pulses
bilaterally: radial, dorsal pedis, posterior tibial
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE EXAM:
Vitals: T 97.9 HR ___ BP 109-131/51-69 RR 16 SaO2 97% on RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear, pinpoint pupils
bilaterally
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Soft, mildly tender to palpation in RLQ, mildly-distended
bowel sounds present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 05:15PM BLOOD WBC-4.0 RBC-3.84* Hgb-9.0* Hct-28.5*
MCV-74* MCH-23.4* MCHC-31.5 RDW-20.2* Plt Ct-57*
___ 02:08PM BLOOD Neuts-65.9 ___ Monos-5.9 Eos-2.6
Baso-0.4
___ 05:15PM BLOOD Plt Ct-57*
___ 06:41AM BLOOD ___ PTT-31.8 ___
___ 06:41AM BLOOD Glucose-79 UreaN-5* Creat-0.8 Na-140
K-3.7 Cl-109* HCO3-21* AnGap-14
___ 06:41AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
___ 12:57PM BLOOD AFP-4.5
___ 06:40PM BLOOD Lactate-1.8
___ 04:45PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 04:45PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-2
___ 04:45PM URINE Mucous-RARE
___ - CT Abdomen Pelvis PO IV Contrast:
Preliminary Report1. Mild non-specific fat stranding in the
right lower quadrant inferior to
Preliminary Reportthe cecum, without evidence of colonic wall
thickening, may be seen in
Preliminary Reportmild/early cecal colitis. No appendicitis or
diverticulitis.
Preliminary Report2. 3 mm heterogeneous focus along the lateral
aspect of segment VI,
Preliminary Reportcorresponding to the ___ better evaluated on
recent MRI dated ___.
Preliminary ReportPreviously described suspicious segment III
lesion is not well visualized on
Preliminary Reportthis single-phase study.
Preliminary Report3. Sequela of portal hypertension including
patent umbilical vein, splenic
Preliminary Reportvarices, and a splenorenal shunt with
resulting downstream left renal vein
Preliminary Reportdilation.
Preliminary Report4. Large hiatal hernia.
Preliminary Report5. Cholelithiasis without evidence of
cholecystitis.
Preliminary Report6. Interval enlargement of an 8 mm, likely
pleural based, pulmonary nodule at
Preliminary Reportthe right lung base.
___ - Abdominal US - No ascites seen. Paracentesis was
therefore canceled.
___ - Chest XRay PA n Lateral- There is no focal
consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact. No
free air below the right hemidiaphragm is seen.
___
1. Mild non-specific fat stranding in the right lower quadrant
inferior to
the cecum, without evidence of colonic wall thickening, may be
seen in
mild/early cecal colitis. No appendicitis or diverticulitis.
2. 3 mm heterogeneous focus along the lateral aspect of segment
VI,
corresponding to the ___ better evaluated on recent MRI dated
___.
Previously described suspicious segment III lesion is not well
visualized on
this single-phase study.
3. Sequela of portal hypertension including patent umbilical
vein, splenic
varices, and a splenorenal shunt with resulting downstream left
renal vein
dilation.
4. Large hiatal hernia.
5. Cholelithiasis without evidence of cholecystitis.
6. Interval enlargement of an 8 mm, likely pleural based,
pulmonary nodule at
the right lung base.
Brief Hospital Course:
Ms. ___ presented to the ___ ED on ___ with three days
of abdominal pain and one day history of melena. In the ED,
initial vitals were normal T 99.0 HR 80 BP 118/68 RR 18 SpO2
100 RA Labs were significant for Hgb 10 Hct 31.1 and Plt 62
(all three values within her recent outpatient baseline). Alk
Phos 140 and Lipase 80. Imaging showed no free air or acute
pulmonary process on CXR PA and lateral. Patient was given three
1 mg doses of Dilaudid, 1L NS, a one time 40mg dose of
pantoprazole, and 4mg zofran. Patient was transferred to ___ 7
inpatient medicine floor.
On the night of presentation, patient was put on ceftriaxone for
concern for spontaneous bacterial peritonitis or other
intraabdominal infectious process. The next morning, Ms.
___ abdominal pain was greatly improved and she was
continued on ceftriaxone. U/S was negative for ascites and no
para was performed. CT abd/pelvis absent for ascites as well,
but noted subtle cecal enhancement c/w early colitis, no
evidence of diverticulitis or appendicitis. She was transitioned
to PO cipro with plan for outpatient colonoscopy.
She had no bloody bowel movements, crits were stable. EGD was
negative for acute findings, grade I varicies were again noted
with no evidence of acute bleed.
She was maintained on her home medications for chronic issues.
No evidence of decompensation of cirrhosis.
TRANSITIONAL ISSUES
- Outpatient colonoscopy
- Complete course of ciprofloxacin
- Short course of oxycodone prescribed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO BID:PRN confusoin
2. Lorazepam 0.5 mg PO QHS:PRN insomnia
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Hydroxychloroquine Sulfate 400 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Hydroxychloroquine Sulfate 400 mg PO DAILY
2. Lactulose 15 mL PO BID:PRN confusoin
3. Lorazepam 0.5 mg PO QHS:PRN insomnia
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
7. FoLIC Acid 1 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Colitis
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 participating in your care at ___
___.
You were admitted because you had evidence of bleeding from your
bowel, as well as bad abdominal pain. You had an endoscopy the
did not evidence a bleeding cause. A cat scan showed a small
amount of inflammation in your large bowel that may have caused
your symptoms. You improved with antibiotics and pain control.
It is important that you complete the course of antibiotics. In
addition, you will need a colonoscopy to evaluate your colitis.
Followup Instructions:
___
|
19978630-DS-9 | 19,978,630 | 21,940,751 | DS | 9 | 2152-08-14 00:00:00 | 2152-08-14 19:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left distal ___ femoral shaft fracture
Major Surgical or Invasive Procedure:
left retrograde femoral nail placement
History of Present Illness:
This is a ___ with hx of Alzheimers and who is non-ambulatory
who presents s/p fall at home with a left mid-shaft femur
fracture. She was being transferred from her wheelchair to her
bed by her daughter and health care worker when they lost grip
on her and she fell to the ground. She was crying in pain and
taken to ___ where xrays showed the aforementioned
fracture. She is very hard of hearing and confused.
Past Medical History:
Alzheimers
Social History:
___
Family History:
Non contributory
Physical Exam:
Exam on discharge:
Vitals: AVSS
General: Well-appearing, breathing comfortably on RA.
Neuro: A&Ox1-2, at baseline
CV: RRR by palp
Pulm: nonlabored breathing, no audible wheezes or crackles
MSK:
-Appropriately tender to palpation
-Dressings c/d/I
-Left Thigh compartments soft
-Sensorimotor exam intact
-Left foot WWP
Pertinent Results:
see OMR for pertinent results
Brief Hospital Course:
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for left
retrograde femoral nail, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
In discussion of dispo planning, multiple conversations
involving the family, medicine, palliative care, and case
management teams were had. Ultimately given the family's goals
of care regarding the patient, it was decided that comfort
measures only would be in the patient's best interest. Given the
frequent demands and needs for care of the patient, it was
thought that nursing home with hospice would be the best setting
for the patient. However, the family wanted the patient to be
brought home with hospice services despite the demands including
wound care, dressing changes, assistance with transfers and
ambulation, and administration for subcutaneous heparin on a
daily basis.
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
weight-bearing as tolerated in the left lower extremity, and
will be discharged on Subcutaneous Heparin twice 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:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. Senna 8.6 mg PO BID
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left distal ___ femoral shaft fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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:
- weight-bearing as tolerated left lower extremity
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 Subcutaneous heparin three times daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
-weight-bearing as tolerated left lower extremity
Treatments Frequency:
-staples to remain in place until follow up visit
Followup Instructions:
___
|
19978766-DS-10 | 19,978,766 | 21,880,865 | DS | 10 | 2165-03-28 00:00:00 | 2165-03-28 13:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
atenolol / Serax / Neurontin
Attending: ___.
Chief Complaint:
Increased abdominal pain
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with history of pancreatitis, gastric ulcers, UGIB.
He presents to ED today with 4 days history of increasing LUQ
pain decrease PO intakes and fevers. Of note the etiology of his
pancreatitis is ETOH abuse and he has an impressive history of
ETOH intake. The patient is well known to Dr. ___ was
planning to operate on him on ___. He endorsed nausea but he
denies emesis SOB, CP, hematemesis, hematochezia or acholic
stools.
Past Medical History:
Alcohol abuse
Alcohol withdrawal
Delirium tremens
Alcohol pancreatitis
pancreatic pseudocyst
anxiety and depression
hypertension
gastric ulcers
UGIB
polysubstance abuse
GERD
Tobacco abuse
withdrawal seizures from stopping Xanax
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
Vitals: 99.6 129/72 86 99% RA
GEN: A&O, NAD
HEENT: NCAT,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, TTP of RUQ and LUQ however, more tender
in LUQ. no rebound or peritonitis
Ext: No ___ edema, ___ warm and well perfused
On Discharge:
VS: 98.7, 64, 102/64, 16, 99% RA
GEN: NAD, A&O x 3
HEENT: NC/AT, PERRL, EOMI
CV: RRR
Pulm: CTAB
Abd: Soft, NT/ND
Extr: Warm, no c/c/e
Pertinent Results:
___ 05:50AM BLOOD WBC-21.3* RBC-3.87* Hgb-11.2* Hct-35.0*
MCV-90 MCH-28.8 MCHC-31.9 RDW-13.9 Plt ___
___ 05:50AM BLOOD Glucose-129* UreaN-12 Creat-0.7 Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
___ 12:45PM BLOOD Lipase-16
___ 12:45 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ BLOOD CULTURE: Pending
___ ABD CT:
IMPRESSION:
1. Interval development of irregular fluid collection between
the body of the pancreas and lesser curvature of the stomach
concerning for an infected pancreatic pseudocyst.
2. Healing splenic infarcts, chronic splenic vein thrombosis,
extensive
portosystemic collaterals in the left upper quadrant.
3. 12-mm hypodensity within segment VI of the liver previously
characterized as hemangioma on an ultrasound from ___.
Findings discussed with the surgical team at the time of initial
review.
4. Several stable renal cysts.
___ CXR:
IMPRESSION: No acute findings including no sign of
pneumoperitoneum.
Brief Hospital Course:
The patient well known for Dr. ___ scheduled for elective
surgical resection on ___ was admitted to the General Surgical
Service for evaluation of fevers and increased abdominal pain.
The abdominal CT was concerning for infected pancreatic
pseudocyst. The patient was started on broad-spectrum
antibiotics. On HD# 2, patient's abdominal pain subsided, he was
afebrile, and his diet was advanced to regular. On HD # 3,
patient was afebrile, his antibiotics were changed to oral, he
tolerated regular diet. The patient underwent preoperative
evaluation by anesthesiology and was discharged home in stable
condition.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Omeprazole
Discharge Medications:
1. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: ___ Tablets PO every eight (8)
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Chronic pancreatitis
2. Pancreatic pseudocyst
3. Chronic splenic vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19978774-DS-16 | 19,978,774 | 20,876,246 | DS | 16 | 2132-08-31 00:00:00 | 2132-08-31 12:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Worsening Chest pain,nausea, vomiting, left arm
numbness and left jaw pain for the past month.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is ___ old gentleman with h/o CABG in ___
with Dr ___, SVG->Diag/Ramus/OM). He had recurrent
chest pain, chest "numbness" in ___ and cath at that time
showed 80% stenosis of the mid LMCA leading into the
proximal LCX, which was stented was a Promus DES by Dr. ___.
He was soon afterward again readmitted on that same ___ with
recurrent chest pain/numbness repeat cath showed that all
vessels
and stent were patent. Coronary spasm was suspected and his meds
were optimized. Recent routine f/u cath was done 4 months ago at
the ___ which according to the patient was
"negative". He admits to doing well up until one month ago when
he began developing recurrent chest pain radiating into his left
arm and left jaw associated with occasional nausea/vomiting. He
was recently treated with erythromycin and steroid pack for
throat infection that he completed 2 weeks ago. He has also been
experinceing difficulty breathing at night waking up SOB. His
paxil was increased for possible anxiety attacks. He has been on
paxil for one year. He arrived in the ER today with complaints
or
worsen left sided chest pains and upper back pain. His CTA
revealed 4x6cm anterior mediastinum hematoma anterior to the
ascending aorta. No PE or dissection noted, sternal wires
intact.
CT surgery was consulted regarding the hematoma.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia
2. CARDIAC HISTORY:
-CABG: ___ with Dr. ___->LAD, SVG->Diag/Ramus/OM
-PERCUTANEOUS CORONARY INTERVENTIONS: ___ Promus DES to LMCA
into LCx
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
GERD
kidney stones surgery ___
Social History:
___
Family History:
Father + CABG and multiple stents
paternal Grand Father +CAD
History of valvular disease in father and breast cancer in
sister.
Physical Exam:
Pulse: Resp:18 O2 sat: RA 100%
B/P Right: 139/70 Left: 142/91
Height: 6ft Weight:200lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x] flushed chest and neck
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [xx] Irregular [] Murmur [] grade ______
Abdomen: Soft [] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [] Edema [] _none____
Varicosities: None [c]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+1 Left:+1
DP Right: doppler Left:absent
___ Right: palp Left:doppler
Radial Right: +1 Left:absent
Carotid Bruit Right: None Left:None
Pertinent Results:
___ 03:49AM BLOOD WBC-8.0 RBC-4.77 Hgb-15.3 Hct-44.4 MCV-93
MCH-32.1* MCHC-34.6 RDW-13.8 Plt ___
___ 03:49AM BLOOD Glucose-194* UreaN-20 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
___ 03:49AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:24PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:49AM BLOOD CK(CPK)-37*
___ 04:24PM BLOOD CK(CPK)-60
ECHO
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with mild inferior wall hypokinesis. The remaining segments
contract normally (LVEF = 50-55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Mild symetric left ventricular hypertrophy with mild
regional systolic dysfunction c/w CAD. Dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
mild regional systolic dysfunction is now seen.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
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.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 11:47
CTA: Contrast bolus timing is adequate for assessment of the
pulmonary
arteries to the subsegmental level. There is no pulmonary
embolism. The
aorta is normal caliber appearance throughout its length. There
is no aortic
aneurysm or dissection.
CHEST CT: There is a hematoma in the anterior mediastinum.
Hyperdense tissue
density is seen in the anterior mediastinum forming an
ill-defined collection
measuring approximately 3 cm AP x 6 cm TV x 8 cm CC. A focal
hyperdensity
along the anterior wall of the ascending aorta is shown to be
calcified on the
non-contrast scan. There are numerous surgical clips from prior
CABG.
The lungs are well expanded and clear. There is no focal
consolidation,
effusion, nodule, mass, or pneumothorax. Subsegmental basilar
atelectasis is
mild. The airways are patent to the subsegmental level. The
thyroid gland
enhances homogeneously. There is no supraclavicular adenopathy.
A prominent
precarinal lymph node measures 11 cm in short axis. There is no
additional
mediastinal, hilar, or axillary adenopathy. The size of the
heart is normal.
Coronary artery calcifications are extensive. There is no
pericardial
effusion.
This exam is not tailored to evaluate subdiaphragmatic
structures. The
adrenal glands and visualized abdominal viscera are
unremarkable.
There are no concerning lytic or sclerotic bony lesions. The
sternotomy is
incompletely fused at the level of the manubrium (3: 43, 3:
56). The
sternotomy wires are intact. The margins of the bone fragments
are sclerotic
indicating that this is likely an incomplete fusion rather than
a dehiscence.
IMPRESSION:
1. Anterior mediastinal hematoma of unknown chronicity. No
active
extravasation.
2. No pulmonary embolism, aortic dissection or aneurysm.
3. Incomplete fusion of the manubrium.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr. ___ was admitted for shortness of breath and chest pain
to the CVICU after undergoing a CTA which revealed the
following:
CHEST CT: There is a hematoma in the anterior mediastinum.
Hyperdense tissue
density is seen in the anterior mediastinum forming an
ill-defined collection
measuring approximately 3 cm AP x 6 cm TV x 8 cm CC. A focal
hyperdensity
along the anterior wall of the ascending aorta is shown to be
calcified on the
non-contrast scan. There are numerous surgical clips from prior
CABG.
The lungs are well expanded and clear. There is no focal
consolidation,
effusion, nodule, mass, or pneumothorax. Subsegmental basilar
atelectasis is
mild. The airways are patent to the subsegmental level. The
thyroid gland
enhances homogeneously. There is no supraclavicular adenopathy.
A prominent
precarinal lymph node measures 11 cm in short axis. There is no
additional
mediastinal, hilar, or axillary adenopathy. The size of the
heart is normal.
Coronary artery calcifications are extensive. There is no
pericardial
effusion.
This exam is not tailored to evaluate subdiaphragmatic
structures. The
adrenal glands and visualized abdominal viscera are
unremarkable.
There are no concerning lytic or sclerotic bony lesions. The
sternotomy is
incompletely fused at the level of the manubrium (3: 43, 3:
56). The
sternotomy wires are intact. The margins of the bone fragments
are sclerotic
indicating that this is likely an incomplete fusion rather than
a dehiscence.
IMPRESSION:
1. Anterior mediastinal hematoma of unknown chronicity. No
active
extravasation.
2. No pulmonary embolism, aortic dissection or aneurysm.
3. Incomplete fusion of the manubrium.
His troponins were negative and pain was controlled with
toradol. He did have complaints of nausea which he had prior to
admission and states it occurs after taking his medications.
A cardiac cath was performed in ___ ( see OMR for
results).
Echo was done at the request of cardiology and was without
significant findings as discussed with Dr. ___ Mr.
___ was discharged to home with script for nicotine patch and
counseled to discuss smoking cessation with his PCP. A script
was also given for ultram for pain.
Medications on Admission:
Lisinopril 2.5mg daily,Norvasc 2.5mg daily,Plavix 75mg daily
lipitor 80mg daily,Asa 81mg daily,Carafate 1gm q 12hrs, paxil
40mg daily, Humalog ___ 40units bid
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Nicotine Patch 14 mg TD DAILY
7. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
indigestion
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Ranitidine 150 mg PO BID
10. Humalog ___ 40 Units Breakfast
Humalog ___ 40 Units Bedtime
11. Paroxetine 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
muscle strain related to recent physical activity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Contact your primary care doctor and or cardiologidt if you
develop chest pain or shortness of breath at rest or with
exertion or any other symptoms that concern you.
Take motrin and tylenol for muscle soreness
Followup Instructions:
___
|
19978842-DS-5 | 19,978,842 | 26,698,803 | DS | 5 | 2113-05-29 00:00:00 | 2113-05-29 09:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / prednisone / Norvasc /
Adhesive tape / Penicillins / vancomycin
Attending: ___.
Chief Complaint:
wound drainage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo woman s/p C5 corpectomy and C4-6 ACDF
___ who has been having minimal wound drainage since ___. No
fevers, chills or sweats at home.
Past Medical History:
C5 corpectomy with C4-6 ACDF ___ with Dr. ___ aneurysm clipping ___
Spinal meningitis
Appendectomy
Lumpectomy
Cervical stenosis
Social History:
___
Family History:
Mother had ___ cancer, past smoker. Denies alcohol or drug
use.
Physical Exam:
Upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck: Anterior neck incision: area of erythema and induration at
the medial pole of incision, kidney bean size palpable
induration, no active drainage
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: decreased in right finger tips digits ___
Upon discharge:
a&o x3
full strength
incision- no active drainage
Pertinent Results:
___ 11:40PM WBC-8.7 RBC-4.10* HGB-13.5 HCT-37.1 MCV-91
MCH-33.0* MCHC-36.5* RDW-13.4
___ 11:40PM NEUTS-64 BANDS-0 ___ MONOS-2 EOS-0
BASOS-0 ___ MYELOS-0
___ 06:30AM BLOOD WBC-12.2* RBC-3.89* Hgb-12.1 Hct-34.6*
MCV-89 MCH-31.2 MCHC-35.1* RDW-13.1 Plt ___
___ 06:30AM BLOOD Glucose-128* UreaN-13 Creat-0.7 Na-141
K-3.4 Cl-102 HCO3-26 AnGap-16
___ CT Neck: Status post C5 corpectomy and C4 through 6
anterior spinal fusion without
evidence of postoperative fluid collection. No evidence of
hardware
complication.
___ CXR
As compared to the previous image, there is a new parenchymal
opacity at the right lung bases, projecting over the basal and
lateral parts of the right costophrenic sinus. Adjacent to this
opacity and located more proximally, between the hilus and the
opacity, are several airways with thickened walls. Although the
abnormality is seen in 1 projection only, the presence of
pneumonia must be is strongly suspected.
Normal size of the cardiac silhouette. Normal hilar and
mediastinal
structures. No pneumothorax. Status post vertebral fixation.
At the time of dictation and observation, 08:33, on the ___, the referring physician ___ was not ___.
Therefore, the findings were posted to the radiology dashboard.
In addition, a high priority email was sent to the referring
physician and the attending
___ CXR
Heart size is mild mildly enlarged, similar to ___.
Mediastinum is unremarkable. Lobulations of both hemidiaphragms
are present. No definitive evidence of pleural effusion or
pneumothorax is seen. Linear atelectasis in the right lower lung
is present but no definitive evidence of pneumonia demonstrated.
Brief Hospital Course:
Pt was admitted to neurosurgery floor where an attempted
aspiration of small medial collection was unsuccesful though a
swab cx sent of minimal expressed purulent material was sent.
She was started on Losartan for BP control. A CT of her C-Spine
did not show any fluid collection.
On ___ T spiked to 101.4 WBC 12.2, re-sent blood, urine
cultures. Her CRP and ESR were with in normal range. A CXR
showed concern for right lower lobe pneumonia on ___.
On ___ A ID consult was obtained due to pneumonia versus wound
infection versus superficial wound infection. Given wound
cultures were growing staph auresis they recommended IV
vancomycin while senstivies were pending . Regarding possible
pneumonia, she denies all clinical symptoms of respiratory
infection and the chest x-ray was a portible one. Repeat CXR
with PA/lateral views revealed no definitive evidence of
pneumonia
On ___ Patient continued on IV vancomycin. She remained stable.
Final wound cultures were pending
On ___ ID made final antibiotic recommendations for 14 day
course of moxifloxicin. She was planned for discharge but this
was postponed secondary to transportation issues.
On ___ she was deemed fit for dsicharge and was given
prescriptions for required medications, instructions for
followup, and all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Atenolol 25 mg PO BID
Discharge Medications:
1. Losartan Potassium 50 mg PO DAILY
2. Acetaminophen ___ mg PO Q6H:PRN pain
3. Atenolol 25 mg PO BID
4. moxifloxacin 400 mg oral DAILY Duration: 14 Days
RX *moxifloxacin 400 mg 1 tablet(s) by mouth DAILY Disp #*14
Tablet Refills:*0
5. Outpatient Physical Therapy
Balance training
Discharge Disposition:
Home
Discharge Diagnosis:
Wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a wound infection. You will be discharged
home on oral antibiotics
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
wear your cervical collar as instructed.
You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any medications such as Aspirin unless directed by
your doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19978886-DS-8 | 19,978,886 | 25,887,347 | DS | 8 | 2183-11-11 00:00:00 | 2183-11-11 18:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Condensed history per ED HPI and further discussion with
patient:
___ man with PMH herniated disc s/p L5 through S1
discectomy in ___, hyperlipidemia, HTN who presents ___ of
mildly worsening LBP but ___ experienced excruciating left low
back pain radiating into his L mid-calf when rising from his
car.
He was able to stand upright and "walk it off" but the symptoms
repeated when rising from the dinner table and was debilitating.
He says this is very similar to prior episode when he needed the
discectomy. He presented to an ___ and was transferred to
___ due to multiple prior spinal surgeries performed here.
In the ED, initial vitals were: T 97.2 BP 126/65 HR 96 RR 16
Sat96% RA
Exam notable for:
Neuro:
A&Ox3, CN II-XII intact
___ strength in b/lUE
RLE: ___ strength in hip flexion and extension; ___ knee flexion
and extension; ___ dorsiflexion and plantarflexion with normal
sensation throughout
LLE: ___ strength in hip flexion and extension; ___ knee flexion
and extension; ___ dorsiflexion and plantarflexion with
decreased
sensation on plantar aspect of the L foot with normal sensation
over the legs and thighs
Psych: Normal mentation
Rectal tone: normal with normal perirectal sensation
- Labs notable for:
- Imaging was notable for:
CT Lumbar W&W/O Contrast (myelogram) ******************
- Patient was given:
IV Dilaudid (2.5g total), Ketorolac 15mg, started on Solmedrol
8mg
Upon arrival to the floor, patient reports ongoing stabbing
sharp
backpain that starts in the middle of his back and radiates down
his left leg, also on the side of the leg, and is associated
with
numbness on the top of the left foot. He also experiences left
back and leg pain when he moves his right leg, but does not have
any pain or numbness in right leg. He denies any incontinence of
urine or stool.
Past Medical History:
L5-S1 Disectomy
Cerebral aneurysm with subarachnoid hemorrhage and frontal
contusions, s/p 2 aneurysm clips in brain - ___
HTN
HLD
past smoker
chronic lower back pain
depression (d/t subarachnoid hemorrhage and concussions)
hx of testicular CA s/p orchiectomy
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS:
T 97.2 BP 126/65 HR 96 RR 16 Sat96% RA
GENERAL: well-nourished, pleasant man who appears uncomfortable
HEENT: PERRLA, nystagmus noted with horizontal eye movement
NECK: supple with no LAD
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no wheezes or ronchi
ABDOMEN: soft, NT/ND, BS+
EXTREMITIES: Pulses 2+, ___, ___ strength in UE and ___
bilaterally
NEUROLOGIC: CN2-12 intact, straight-leg positive on left leg;
decreased sensation on dorsal aspect of left foot and mildly
decreased on interior plantar aspect of left foot
SKIN: no rashes, lesions
DISCHARGE PHYSICAL EXAM:
=========================
___ 1227 Temp: 97.3 PO BP: 135/76 HR: 68 RR: 20 O2 sat:
97% O2 delivery: Ra
General: Pleasant, alert, oriented and in no acute distress but
significant amount of pain with movement
HEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI.
No erythema or exudate in posterior pharynx; uvula midline; MMM.
Neck: neck veins flat with full ROM
Resp: Breathing comfortably on RA. No incr WOB, CTAB with no
crackles or wheezes.
CV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral.
Abd: Soft, Nontender, Nondistended with no organomegaly; no
rebound tenderness or guarding.
MSK: ___ without edema bilaterally; paraspinal tenderness to
palpation
Skin: No rash, Warm and dry, No petechiae
Neuro: A&Ox3, CNII-XII intact. Decreased sensation to light
touch
and cold on dorsum of left foot, strength of toe dorsiflexion
slightly limited by pain on left.
Pertinent Results:
___ 02:00PM GLUCOSE-119* UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16
___ 02:00PM estGFR-Using this
___ 02:00PM WBC-7.8 RBC-4.04* HGB-12.8* HCT-39.0* MCV-97
MCH-31.7 MCHC-32.8 RDW-12.5 RDWSD-44.8
___ 02:00PM NEUTS-79.0* LYMPHS-12.6* MONOS-4.5* EOS-2.4
BASOS-1.0 IM ___ AbsNeut-6.12* AbsLymp-0.98* AbsMono-0.35
AbsEos-0.19 AbsBaso-0.08
___ 02:00PM PLT COUNT-261
___ 02:00PM ___ PTT-30.9 ___
Brief Hospital Course:
====================
Summary
====================
___ man with PMH herniated disc s/p L5 through S1
discectomy in ___, hyperlipidemia, HTN who presents ___ of
mildly worsening LBP but ___ experienced excruciating left low
back pain radiating into his L mid-calf when rising from his
car.
He presented to an ___ and was transferred to
___ due to multiple prior spinal surgeries performed here. CT
and
myelogram imaging revealed notable for stable disc bulge at
L4-L5 level; Ortho Spine
determined there was no need for surgical intervention. Pts pain
was
controlled and will be discharged on oral pain control regimen.
===============
ACUTE ISSUES:
===============
#Acute on chronic lower back pain with radiculopathy
Has had multiple lower back procedures including herniated disc
s/p L5 through S1 discectomy in ___, presents with acutely
worsened LBP that radiates down l leg and associated L foot
numbness that started the day prior to discharge while getting
out of his
car at work and became unbearable that evening as he stood up
from
seated position. CT non-contrast and myelogram notable only for:
"At L4-L5, there is a diffuse disc bulge causing mild anterior
thecal sac
deformity and moderate bilateral neural foraminal narrowing,
facet joint
arthropathy and ligamentum flavum hypertrophy. Findings are
relatively stable
when compared with the prior examination in ___ There was no
evidence of
any hardware complications. Per ortho, no surgical intervention
needed. Acute pain episode thought to be caused by bulging or
irritated spinal
disc causing radicular pain and muscle strain with spasms based
on paraspinal muscle tenderness on exam. Initially pain
controlled with IV Dilaudid and IV Ketorolac. Steroids were not
given due to lack of sufficient evidence for their efficacy in
this clinical context. Discharged on Ibuprofen 800mg Q8 hours
for 3 days, capsaicin topical, cyclobenzaprine 10mg QHS PRN, and
prescription for outpatient physical therapy.
#Pain control
Pt is followed by Dr. ___ in ___ for chronic LBP that
is
normally well controlled with home Gabapentin and Duloxetine,
and
PRN Advil. Continued home Gabapentin & Duloxetine. For acute
episode of
LBP, regimen is as stated above.
==================
CHRONIC ISSUES:
==================
#Depression
Patient followed by neuropsychiatrist as outpatient and has
recently been weaned off Eszopiclone (Lunesta) and transitioned
to Mirtazepine QHS for help with sleeping. Subarachnoid
hemorrhage and concussions have contributed to depression since
___. Continued home Duloxetine 90mg QDaily, Mirtazepine 7.5mg
QHS,
and Amantadine 200mg QAM and 100mg QPM.
#Hypertension
Well controlled on home regimen. Continued home atenolol 50mg
Qdaily,
Lisinopril 60mg QDaily, and Chlorthalidone 12.5mg QDaily.
#Hyperlipidmia: Continued atorvastatin 40mg QDaily.
=========================
TRANSITIONAL ISSUES:
=========================
[ ] Of note, the patient's CNS clips are MRI compatible: per the
___ ___, the craniotomy and clipping was performed on ___,
and he then had an MRI Brain on ___, which showed the
residual aneurysm (1mm) below the clips along-- these are MRI
compatible clips per the ___ Notes
the bifurcation. Therefore, if further imaging is needed, MRI
can be done.
[ ] Discharged with prescription for physical therapy. Can
follow up with outpatient PCP regarding need for ongoing ___.
[ ] Patient previously on oxydocone in the past, he received ___
doses of this on this admission but our goal was to discharge
off of opiates so he was sent with ibuprofen instead
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amantadine 200 mg PO QAM
2. Amantadine 100 mg PO LUNCH
3. Atenolol 50 mg PO DAILY
4. Chlorthalidone 12.5 mg PO DAILY
5. DULoxetine 90 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Lisinopril 60 mg PO DAILY
8. Mirtazapine 7.5 mg PO QHS
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Capsaicin 0.025% 1 Appl TP TID
RX *capsaicin [Capzasin-HP] 0.1 % apply cream to lower back up
to three times daily, as needed Refills:*0
3. Cyclobenzaprine 10 mg PO HS:PRN Back pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth evenings before
bed, as needed Disp #*10 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day as
needed Disp #*30 Capsule Refills:*0
5. Ibuprofen 800 mg PO Q8H Duration: 3 Days
RX *ibuprofen [IBU] 800 mg 1 tablet(s) by mouth every 8 hours
Disp #*9 Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM
Alternate the lidocaine patch with the topical capsaicin
ointment.
RX *lidocaine [Lidocaine Pain Relief] 4 % apply patch to
affected area may remain up to 12 hrs in 24-hour period Disp
#*12 Patch Refills:*0
7. Amantadine 200 mg PO QAM
8. Amantadine 100 mg PO LUNCH
9. Atenolol 50 mg PO DAILY
10. Chlorthalidone 12.5 mg PO DAILY
11. DULoxetine 90 mg PO DAILY
12. Gabapentin 300 mg PO BID
13. Lisinopril 60 mg PO DAILY
14. Mirtazapine 7.5 mg PO QHS
15.Outpatient Physical Therapy
Physical therapy to reduce lower back pain, paraspinal muscle
spasms, and treat radiculopathy. ICD10: M54.4 Duration: ongoing
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-----------
Acute left LBP w/ sciatica
Paraspinal muscular spasm
Secondary:
-----------
Depression
Chronic LBP
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had severe lower back pain and there was concern for a
herniated disk or more serious issue due to your prior spine
surgeries.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had CT imaging of your spine, which showed no spinal cord
impingement and no issues with your existing hardware.
- Your back pain is thought to be due to an irritated spinal
disc as well as surrounding muscular spasms.
- Your pain was managed with anti-inflammatory and analgesic
medications.
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:
___
|
19979081-DS-14 | 19,979,081 | 22,763,407 | DS | 14 | 2179-02-05 00:00:00 | 2179-02-05 23:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
simvastatin / lisinopril / Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD w/ EUS and gastric mass bx
History of Present Illness:
Mrs. ___ is an ___ year old woman with a history of colonic
adenoma in ___, and remote TAH/BSO who presents with 1 day of
acute, sudden onset epigastric pain on ___. She
reports feeling generally at her baseline and suddenly after
lunch, she felt acute epigastric pain that radiated down to her
lower abdomen. She also reports ___ years of progressively
worsening early satiety and nausea and vomiting every time she
eats too large of a meal. The vomiting is nonbilious and
nonbloody and occurs once or twice a month, again with eating
too large of a meal (she reports she never mentioned these
symptoms to her physicians because she did feel them to be
abnormal). She does not report any recent vomiting associated
with the pain, however. She also denies fevers, chills, black or
bloody stools,in fact her stools have been normal and brown. She
denies any chest pain, shortness of breath, coughing, dysuria,
calf pain, weight loss (she has remained at her baseline of
about 130 lbs
for the past few years), or night sweats. Of note she was
reminded to follow up with GI for a repeat colonoscopy in ___
___ after adenoma found in ___, per protocol) but she
decided against it because she felt her first one was normal and
she did not need one. Given the severity of her abdominal
symptoms she decided to come to the ED.
In the ED, her vital signs were 97.8 161/68 92 16 99%RA. She
was given morphine 5mg IV once for pain with resolution of her
symptoms. LFTs notable for ALT 230, AST 513, AP 131, TB
1.3,Lipase 83, HCT 30 (baseline mid ___. RUQ U/S showed CBD
dilation (1.1cm) but no stone. Perhepatic GB thickening also
seen. ERCP was consulted and she was admitted to the ___
___ service for further work up.
Past Medical History:
#) Colonic adenoma in ___
#) TAH/BSO
#) Hyperlipidemia
Social History:
___
Family History:
No family history of GI disease or cancer
Physical Exam:
EXAM: VS 98.4 (Tm 99) 130/63 95 18 100%RA
GEN: NAD, well-appearing elderly woman in NAD
EYES: PERRL EOMI conjunctiva clear anicteric
ENT: Dry mucous membranes
NECK: supple
CV: RRR s1s2 no s3 or s4. JVP wnl.
PULM: CTA, no WRR.
GI: normal BS, ND, soft, mild RUQ tenderness, mild lower
abdominal tenderness. No rebound or guarding, negative ___
sign.
EXT: warm, no edema
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands
PSYCH: appropriate
ACCESS: PIV
FOLEY: none present
Pertinent Results:
___ 10:45PM BLOOD WBC-10.7 RBC-4.76 Hgb-9.2* Hct-30.1*
MCV-63* MCH-19.2* MCHC-30.4* RDW-19.5* Plt ___
___ 10:45PM BLOOD Neuts-91.3* Lymphs-4.9* Monos-3.6 Eos-0.1
Baso-0.1
___ 10:45PM BLOOD Plt ___
___ 10:45PM BLOOD Glucose-174* UreaN-18 Creat-0.8 Na-142
K-3.7 Cl-104 HCO3-22 AnGap-20
___ 10:45PM BLOOD ALT-230* AST-513* AlkPhos-131*
TotBili-1.3
___ 10:45PM BLOOD Lipase-83*
___ 07:59AM BLOOD GGT-92*
___ 07:59AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1 Iron-13*
___ 07:59AM BLOOD calTIBC-363 Ferritn-48 TRF-279
RUQ U/S ___
IMPRESSION:
1. Extra-hepatic biliary ductal dilatation, CBD measures 1.1
cm.
2. Asymmetric gallbladder wall thickening on hepatic surface.
Given this patient's elevated LFTs, this may be secondary to
hepatitis.
Colonoscopy report ___ (Atrius):
FINDINGS
Diverticulosis in the left colon
4mm polyp at 30 Polypectomy performed with hot snare.
7mm polyp on a stalk at 20cm. Polypectomy performed with hot
snare
Polyp retrieved. Histology revealed adenoma.
Internal hemorrhoids.
Repeat colonscopy in ___ years.
EKG: NSR, ST depressions are upsloping, diffuse, mild, and
nonspecific. RSR pattern, unchanged per prior report in ___
(Atrius).
___ 07:59AM BLOOD WBC-6.6 RBC-4.56 Hgb-8.8* Hct-29.5*
MCV-65* MCH-19.3* MCHC-30.0* RDW-20.0* Plt ___
___ 06:32AM BLOOD WBC-4.6 RBC-4.29 Hgb-8.4* Hct-28.1*
MCV-65* MCH-19.5* MCHC-29.9* RDW-19.2* Plt ___
___ 07:45AM BLOOD WBC-5.6 RBC-4.89 Hgb-9.2* Hct-31.1*
MCV-64* MCH-18.8* MCHC-29.5* RDW-20.0* Plt ___
___ 07:59AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1 Iron-13*
___ 07:59AM BLOOD calTIBC-363 Ferritn-48 TRF-279
___ 07:59AM BLOOD HCV Ab-NEGATIVE
___ 07:59AM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 09:27AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-PND
___ 06:32AM BLOOD CEA-2.9
___ 07:59AM BLOOD ALT-354* AST-289* AlkPhos-150*
TotBili-1.6*
___ 06:32AM BLOOD ALT-247* AST-134* AlkPhos-151*
TotBili-0.5
___ 07:45AM BLOOD ALT-190* AST-74* AlkPhos-165* TotBili-0.5
___ EBV IgG (+), IgM (-)
___ CMV IgG (+) at 90 AU/ml (normal <4, if >6 considered
positive)
___ MRCP:
1. No biliary dilation. Diffuse, homogeneous gallbladder wall
edema, without evidence of acute cholecystitis. These findings
are likely secondary to the known hepatitis.
2. Multiple subcapsular renal cortical cysts, relate to
glomerular cystic
disease.
___ HIDA SCAN:
IMPRESSION: Essentially normal hepatobiliary scan. There is no
evidence of
acute cholecystitis. Note is made of slow filling of the
gallbladder in the setting of somewhat unusual bilobed
gallbladder anatomy.
___ EGD:
Impression: Mass in the stomach body on the lesser curvature,
just beyond the GE junction. Polyp in the stomach body on the
greater curvature near the antrum. Multiple biopsies taken with
a large capacity biopsy forceps. Otherwise normal EGD to third
part of the duodenum
___ EUS:
Impression:
1.Normal ampulla.
2.Radial EUS of gastric mass: The lesion measured 1.5 cm in
length and 0.3 cm in maximum depth. The lesion was hypoechoic
and heterogenous with well defined borders. The lesion involved
the mucosa and submucosa. There was no evidence of invasion
beyond the submucosa. This was staged as T1b by EUS criteria. No
___ lymphadenopathy was found.
3. Linear EUS of bile duct:
The bile duct was imaged at the level of the porta-hepatis, head
of the pancreas, and ampulla. The maximum diameter of the bile
duct was 8 mm. The bile duct was otherwise normal.
4. Otherwise normal upper EUS to second part of the duodenum.
___ ABD/PELV CT:
IMPRESSION:
1. In this patient with known mass along the lesser curvature
of the stomach,
evaluation for gastric mass is limited due to underdistension.
2. No evidence of metastatic disease otherwise noted.
3. Simple hepatic cysts and multiple sub-cm renal cysts are
again noted.
Brief Hospital Course:
ASSESSMENT & PLAN
___ year old woman with a history of colonic adenoma in ___, and
remote TAH/BSO who presents with 1 day of acute, sudden onset
epigastric pain consistent with cholestatic hepatitis.
#) Cholestatic hepatitis: Unclear cause, but possible
spontaneously passed stone without CBD dilation. No evidence of
cholecystitis. LFTs normalizing dialy prior to discharge. Will
need to be followed as outpatient. PCP ___. Labs indicate
EBV exposure, and chronic CMV, neither of which are likely
culprits here. Her pain dissipated on admission, and patient
tolerated a diet prior to discharge.
#) Gastric Mass: concerning for malignancy, but if so, all
imaging so far would suggest early stage. Surgery ACS team saw
her in house in consultation and will follow up with her in near
future to review pathology, which is pending at discharge.
Patient aware of possibility of cancer and potential need for
surgery.
#) Anemia: HCT to 30, and patient with guiac positive brown
stool in ED. She also has a markedly low MCV, with low iron,
suggesting iron deficiency and perhaps a component of
hemoglobinopathy such as Thallesemia trait. She should receive
oupatient colonoscopy in the future, and especially if the
gastric mass biopsy is benign. She was started on oral iron
therapy.
#) HLP: She was not interested in statin
Transitional issues:
1) Gastric mass biospy results pending -- surgery and PCP aware,
patient to f/u with PCP and outpatient surgery ACS (___)
2) Iron deficiency anemia +/- ___ trait -- recommend
hemoglobin elecrophoresis outpatient, iron therapy and
outpatient colonoscopy
3) LFTS should be repeated at next PCP appointment
___ spoke with PCP coverage on day of discharge with update about
patient's condition.
Medications on Admission:
#) Omeprazole 20mg PO BID (just started on ___
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholestatic hepatitis - ?passed stone?
Gastric mass 1.5cm lesser curvature of stomach
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with RUQ pain and liver test abnormalities
which suggested temporary bile duct obstruction with liver
inflammation Fortunately, your pain quickly improved, as did you
labs. A scan of the gallbladder was normal. A MRCP of the liver
did not demonstrate biliary problems. An endoscopy showed a
1.5cm gastric nodule suspicious for possible cancer. Endoscopic
ultrasound and CT scan of the abdomen/pelvis did not suggested
any spread. A Biopsy of the mass is pending.
Followup Instructions:
___
|
19979239-DS-14 | 19,979,239 | 26,031,061 | DS | 14 | 2117-04-14 00:00:00 | 2117-04-14 10:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ year old female with L4-L5 left disc herniation and LLE
radicular pain.
Major Surgical or Invasive Procedure:
Revision left L4-L5 microdiscectomy by Dr. ___ on ___
History of Present Illness:
___ year old female with Left L4-L5 disc herniation and LLE
radiculopathy who has failed conservative therapies. Patient
had h/o previous L4-L5 microdiscectomy by Dr. ___ in ___.
Past Medical History:
depression
Social History:
___
Family History:
nc
Physical Exam:
NAD, A&Ox4
nl resp effort
RRR
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 09:17PM WBC-6.4 RBC-4.53 HGB-13.5 HCT-40.0 MCV-88
MCH-29.8 MCHC-33.8 RDW-13.0 RDWSD-42.2
___ 09:17PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a IV and PO pain medications. Diet was
advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed
postoperatively without issue. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Please obtain over the counter.
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*1
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*36 Tablet Refills:*0
4. Gabapentin 600 mg PO TID
5. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left L4-L5 disc herniation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have undergone the following operation: Revision
Microdiscectomy
Immediately after the operation:
Activity: You should not lift anything greater than 10 lbs for 2
weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have some constipation
after surgery.
Brace: You do not need a brace.
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home medications.
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Physical Therapy:
No heavy lifting, twisting or bending for 6 weeks.
Treatments Frequency:
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
Followup Instructions:
___
|
19979275-DS-17 | 19,979,275 | 20,033,240 | DS | 17 | 2126-04-24 00:00:00 | 2126-04-24 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Depakote / gabapentin / morphine / naproxen
Attending: ___.
Chief Complaint:
Seizure-Like Episodes
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
Mr. ___ is a ___ with a history of right occipital
gliosarcoma s/p resection with residual left field defect,
non-small cell carcinoma, and chronic dizziness who presented
with seizure like episodes.
He (with help from his family - wife, son, daughter at bedside)
describes the episodes as left arm shaking, which evolves into
to full-body tremulousness. He never loses consciousness and
remembers the events, but he feels poorly for a few minutes
prior. He notices that the events spontaneously happen when he
lifts his left arm, just about every time he lifts it today,
corroborated by his family. He feels like he has no control over
it and that moving the arm exacerbates it.
Per report, he had multiple episodes over the week prior to
admission (1 on ___ and ___, at which time Dr. ___
his lamictal to 125mg twice daily, in addition to Vimpat 100mg
twice daily. This initially resolved the issue for about 1 week.
On ___, he was noted by his wife to have hand clenching and
arching of his back; the episode lasted a minute or so. Based on
this, Dr. ___ increased ___ to 150mg twice daily
and started dexamethasone 2mg daily for concern for progression
of his gliosarcoma. His MRI was moved up. However, he was then
brought into the ED because of ongoing shaking and family
concern for seizures.
He is chronically dizzy with vertigo for which he has been going
to vestibular ___ and getting Epley maneuvers, which he feels
makes things worse. He has nausea with the vertigo but no
vomiting. He reports double vision today but his family was very
surprised by this. His left leg has been colder than the right
for 4 days, but per family this is a baseline and people have
compared pulses before. He has had chronic neck pain on the
right side which is ongoing, perhaps worse over the past few
days. He did have some chest pain on the drive in to the
hospital, left and right sided, difficult to describe which
resolved when he had settled down in the ED.
Notably, his prior seizure episodes were staring episodes, on
EEG found to arise from the right central parasagital region.
In the ED, initial vitals were: 73 | 111/76 | 19 | 97% RA . His
neuro exam was noted to be nonfocal, notable for "some
difficulties with memory and recounting event, tangential
speech, left inferior quadrantanopia, decreased pinprick in the
hands," and his family reportedly felt him to be at his
baseline.
Labs were notable for:
142 | 102 | 24 9.8
---------------< 102 1.9
4.8 | 24 | 1.5 3.7
6.7 > 13.1/41.3 <229
N 75.2
AST 13, ALT 8, AP 89, Tbili 0.2, Alb4.4, Lipase 21
Neg serum tox
Trio 0.01
___ 11.6, PTT 36.4, INR 1.1
UA: Neg
Imaging notable for an MR head with no acute findings. The
patient was given IV lorazepam. Vitals prior to transfer: 98.8 |
68 | 128/79 24 | 96% RA.
Past Medical History:
PAST ONCOLOGIC HISTORY, per primary oncologist note:
(1) blurry vision and headache on ___,
(2) ___ ___ head CT showed intracranial
hemorrhage in the right occipital brain,
(3) started on ___ levetiracetam 500 mg twice daily and
dexamethasone 4 mg TID,
(4) reportedly gross total resection on ___ ___. ___ by
Dr. ___
(4) began ___ IMRT + temozolomide by Dr. ___,
(5) dexamethasone reduced to 2 mg TID for insomnia in ___,
(6) developed strange behavior on ___ with difficulty
buttoning his shirt and word-finding difficulty,
(7) developed right upper extremity tremor on ___,
(8) ___ ED on ___ seizures,
(9) admission to ___ ___ general neurology for seizures
(10) EEG ___ to ___ showed 8 electrographic seizures
in the right central parasagittal region lasting ___ minutes,
(11) lacosamide 100 mg IV BID, fosphenytoin 100 mg IV Q8H added,
(12) EEG ___ to ___ showed bursts of focal slowing at
the right hemisphere,
(13) resumed IMRT + TMZ on ___ at ___ to ___,
(14) monthly TMZ x 11 cycles ended in ___,
(15) both dexamethasone and Bactrim stopped in ___,
916) Pt noted to struggle with low mood in ___, which
seemed to improve.
PAST MEDICAL HISTORY:
- NSCLC: a long standing smoker; developed a chronic cough. PCP
sent him for a chest X-ray which revealed a LUL mass on ___.
Staging scans were negative except for the lung. CT guided
biopsy on ___ revealed non-small cell lung cancer consistent
with squamous cell carcinoma. Power port was inserted ___.
He was treated with chemo-irradiation at ___ Cancer
radiation. Chest irradiation was applied to 6300 cGy and it
ended ___.
- CAD
- HTN
- HLD
- Asthma
- Anxiety
- Degenerative disk disease
PAST SURGICAL HISTORY
- ___ CABG x3 vessel
- ___ AAA repair
Social History:
___
Family History:
Father with alcohol use disorder and lung cancer. Mother with
pancreatitis.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: 98.3 | 131/79 | 58 | 19 | 97%Ra
GENERAL: Appears cachectic and fatigued. Laying in bed, looks
uncomfortable, partially covering face with sheet,
intermittently deferring to his wife
___ mucous membranes. Pupils 4mm and equally reactive
to light (to 2mm).
NECK: No concerning lymphadenopathy. Can turn neck complete to
left, somewhat limited by pain (only about 45* on right)
CV: RRR, no murmurs.
PULM: CTAB without adventitious sounds.
ABD: Scaphoid, soft, nontender, nondistended.
EXT: WWP without edema.
SKIN: No visible rashes.
NEURO: Oriented to year, month; date "___ but knows his
birthday is coming up. Somewhat confused on details of recent
history (per family) and perseverating a bit on older history
(eg, used to be strong enough to lift water buckets for work;
now weaker than that).
Face is grossly symmetric though beard may obscure a slight left
lip droop. Strength and sensation on face are intact and
symmetric. Tongue is midline with some jerking movmements
intermittently. No dysarthria.
Can follow two-step commands: use your left pointer finger to
point at your son.
Can name high and low frequency objects (though does
steth-es-cope by syllables). He has large-amplitude jerking
movement when he moves either his left shoulder or his left
elbow, which can evolve into a whole body jerking movement
during which he is still conscious; however, this can be
suppressed by distraction, or by helping him get into position
(eg, left arm outstretched) and then removing supporting hand.
He has no cogwheel rigditiy. He has no asterixis or jerking on
prolonged finger grip. His strength is grossly ___ in large
muscle groups Sensation to light touch is grossly symmetric in
upper extremities; lower extremities "left feels a little
different." No pronator drift. Gait not assessed.
Pertinent Results:
===============
Admission Labs:
===============
___ 09:37PM BLOOD WBC-6.8 RBC-4.36* Hgb-13.1* Hct-41.3
MCV-95 MCH-30.0 MCHC-31.7* RDW-14.1 RDWSD-48.7* Plt ___
___ 09:37PM BLOOD Neuts-75.2* Lymphs-15.7* Monos-7.3
Eos-0.6* Baso-0.9 Im ___ AbsNeut-5.12 AbsLymp-1.07*
AbsMono-0.50 AbsEos-0.04 AbsBaso-0.06
___ 09:39PM BLOOD ___ PTT-36.4 ___
___ 09:37PM BLOOD Glucose-102* UreaN-24* Creat-1.5* Na-142
K-4.8 Cl-102 HCO3-24 AnGap-16
___ 09:37PM BLOOD ALT-8 AST-13 AlkPhos-89 TotBili-0.2
___ 09:37PM BLOOD Lipase-21
___ 09:37PM BLOOD cTropnT-<0.01
___ 09:37PM BLOOD Albumin-4.4 Calcium-9.8 Phos-3.7 Mg-1.9
___ 09:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:39PM BLOOD Lactate-1.5
========================
Discharge Physical Exam:
========================
___ 06:19AM BLOOD WBC-6.4 RBC-4.38* Hgb-13.2* Hct-41.1
MCV-94 MCH-30.1 MCHC-32.1 RDW-14.0 RDWSD-49.1* Plt ___
___ 06:19AM BLOOD Glucose-91 UreaN-19 Creat-1.2 Na-141
K-4.1 Cl-99 HCO3-31 AnGap-11
___ 06:19AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.1
=============
Microbiology:
=============
___ Urine Culture < 10,000 CFU/mL
========
Imaging:
========
1. Redemonstrated postsurgical changes related to resection of
previously noted right temporoparietal mass.
2. Thin linear enhancement along the inferolateral margin of the
resection cavity appears unchanged.
3. The extent of FLAIR hyperintense signal surrounding the
resection cavity and involving the splenium of the corpus
callosum and white matter along the left occipital horn appears
unchanged.
4. Interval decrease in size of a rounded nonenhancing focus
within the dependent resection cavity, mild measuring 9 mm,
previously measuring 17 mm on ___. Findings likely
reflect clotted blood products with interval partial resorption.
5. No new region of FLAIR signal abnormality or enhancement is
seen.
Brief Hospital Course:
___ with a history of right occipital gliosarcoma s/p resection
with residual left field defect, non-small cell carcinoma, and
chronic dizziness who presented with seizure like episodes of
left arm myoclonus and whole-body jerking, not associated with
an aura or post-ictal state, which is suppressible on exam, but
nonetheless potentially concerning for seizure activity.
# Non-Epileptic Convulsions/Seizures:
# Gliosarcoma: MRI brain was unchanged. Monitored on EEG without
true seizures. He was continued on lamictal (recently increased
as outpatient) and lacosamide. Continued dexamethasone. His
symptoms were improved at discharge. He will follow-up with Dr.
___.
# Acute Kidney Injury: Resolved with fluids.
# Depression: His sertraline was increased to 100mg daily. He
was continued on his other home medications.
# Chronic Back Pain: Continued home oxycodone and oxycontin.
# Hypertension: Continued home metoprolol.
# Hyperlipidemia: Continued home pravastatin.
# BILLING: 35 minutes were spent in preparation of discharge
summary, coordination with outpatient providers, and counseling
with patient/family.
====================
Transitional Issues:
====================
- Sertraline increased to 100mg daily.
- Continued Lamictal 150mg BID and dexamethasone 2mg daily.
- Please follow-up final EEG report from ___ and ___.
- Please ensure follow-up with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 2 mg PO DAILY
2. LACOSamide 100 mg PO BID
3. LamoTRIgine 150 mg PO BID
4. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety
5. Metoprolol Succinate XL 25 mg PO BID
6. Pravastatin 20 mg PO QPM
7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
8. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H
9. Omeprazole 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Sertraline 50 mg PO DAILY
12. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
13. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of
breath/wheezing
14. ALPRAZolam 2 mg PO DAILY
Discharge Medications:
1. Sertraline 100 mg PO DAILY
RX *sertraline 100 mg Take 1 tablet by mouth daily. Disp #*30
Tablet Refills:*2
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
RX *albuterol sulfate 90 mcg Take ___ puffs IH every six (6)
hours Disp #*1 Inhaler Refills:*2
3. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety
4. ALPRAZolam 2 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Dexamethasone 2 mg PO DAILY
RX *dexamethasone 2 mg Take 1 tablet by mouth daily. Disp #*30
Tablet Refills:*0
7. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of
breath/wheezing
8. LACOSamide 100 mg PO BID
9. LamoTRIgine 150 mg PO BID
RX *lamotrigine 150 mg Take 1 tablet by mouth twice daily. Disp
#*60 Tablet Refills:*2
10. Metoprolol Succinate XL 25 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
13. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H
14. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Non-Epileptic Convulsions/Seizures
- Acute Kidney Injury
- Gliosarcoma
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with concern for
seizure. You had a brain MRI that did not show any changes. You
had an EEG that did show any true seizure activity. Your
symptoms improved. Your lamictal and sertraline dose was
increased.
You will follow-up with Dr. ___.
All the best,
Your ___ Team
Followup Instructions:
___
|
19979469-DS-16 | 19,979,469 | 20,045,455 | DS | 16 | 2201-06-09 00:00:00 | 2201-06-09 22:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
EGD, colonoscopy
History of Present Illness:
Mr. ___ is a ___ yo male with history of Hepatitis C c/b
cirrhosis with prior hx varices, & obstructive jaundice s/p ,
unresectable stage IIB ampullary adenocarcinoma s/p operative
resection ___, ERCP and stent placement who presents with
lightheadedness for 2 days in the setting of red diarrhea.
Patient reports 2 day history of diarrhea with reddish color but
no gross blood. Never had GI bleeding before. Diarrhea continued
day of admission w/ some mild, intermittent periumbilical
abdominal pain. On day of admission, patient became lightheaded
and had to lay on floor. Denies LOC or head trauma. Patient then
slept for 2 hours, came down stairs, and was noted by wife to
have 2 separate episodes of sweating, lightheadedness,
hyperventilation while fading out.
Denies chest pain, shortness of breath, nausea, vomiting,
fevers, chills. No recent surgery or prolonged immobilization.
Denies leg swelling, worsening DOE in last couple of days
preceding. No PND/orthopnea.
In the ED, initial VS were: 97.9 94 93/52 16 99%
Patient found to have Hct drop of 10 pts, transfused 2 units,
thought likely LGIB. Started on pantoprazole BID. BP
100s-110s/60s-70s; mentating fine. GI saw patient. Neg NG lavage
per pt.
On arrival to the MICU, patient denies any discomfort.
125/67 87 sat 97% on RA
REVIEW OF SYSTEMS: no chest pain, dyspnea, fevers, chills,
nausea, vomiting, PND or orthopnea.
Past Medical History:
Pancreatic mass as detailed in Oncology notes
Chronic Hep C
Cirrhosis (varices noted in past)
Asthma
ERCP/CBD stent ___
Social History:
___
Family History:
Maternal aunt colon cancer in her ___. Maternal uncles had
cancer NOS in their old age.
Mother: living at age ___ ___VA
Father: living at age ___
Siblings: brother deceased of ___ in ___, 2 other brothers and
1 sister living
Children: healthy
No family history of pancreaticoduodenal cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 125/67 87 sat 97% on RA
General: NAD
HEENT: clear oropharynx
Neck: supple
CV: NR, RR, no murmur
Lungs: CTAB, good air movement
Abdomen: NT, ND, soft, well-healed post-surgical scar on RUQ, no
ascites appreciated
GU: no Foley
Ext: no peripheral edema
Skin: no lesions noted
Neuro: A&O, no gross deficits, moving all ext
Psych: appropriate affect
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 126/73 65 18 97RA
General: alert, oriented x3, NAD
HEENT: clear oropharynx
Neck: supple
CV: NR, RR, no murmur
Lungs: CTAB, good air movement
Abdomen: NT, ND, soft, well-healed post-surgical scar on RUQ, no
ascites appreciated
GU: no Foley
Ext: no peripheral edema
Skin: no lesions noted
Neuro: A&O, no gross deficits, moving all ext
Pertinent Results:
ADMISSION LABS:
___ 05:06PM WBC-5.5 RBC-2.21*# HGB-7.2*# HCT-21.3*#
MCV-96 MCH-32.8* MCHC-34.1 RDW-22.5*
___ 05:06PM NEUTS-78.2* LYMPHS-13.8* MONOS-4.8 EOS-2.9
BASOS-0.3
___ 05:06PM ___ PTT-21.5* ___
___ 05:06PM GLUCOSE-111* UREA N-33* CREAT-0.9 SODIUM-141
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15
___ 05:06PM ALT(SGPT)-32 AST(SGOT)-56* ALK PHOS-62 TOT
BILI-0.3
___ 05:06PM LIPASE-92*
___ 05:06PM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-3.3
MAGNESIUM-2.0
___ 06:03PM LACTATE-1.2
DISCHARGE LABS:
___ 01:00PM BLOOD Hct-26.6*
___ 07:00AM BLOOD WBC-3.8* RBC-2.69* Hgb-8.7* Hct-24.9*
MCV-93 MCH-32.2* MCHC-34.8 RDW-21.8* Plt Ct-94*
IMAGING:
CXR: FINDINGS: Two views were obtained of the chest. Right
Port-A-Cath terminates with tip in the upper right atrium. The
lungs appear well expanded and clear without pleural effusion or
pneumothorax. The heart is normal in size with normal
cardiomediastinal contours. IMPRESSION: No acute intrathoracic
process.
EKG:Sinus rhythm. Left axis deviation. Otherwise, within normal
limits.
No previous tracing available for comparison.
EGD: Distal esophagitis was seen. There were no varices. Antral
gastritis was seen. (biopsy) Duodenal erosions. Medium hiatal
hernia. Otherwise normal EGD to third part of the duodenum
Colonoscopy: Normal colon to cecum.
Brief Hospital Course:
Mr. ___ is a ___ yo male with history of Hepatitis C c/b
cirrhosis with prior hx varices, obstructive jaundice,
unresectable stage IIB ampullary adenocarcinoma s/p operative
resection ___, ERCP and stent placement who presents with
lightheadedness for 2 days in the setting of hematochezia and
significant hematocrit drop.
# GI BLEED: He presented with 2 days of dark bloody stools, and
his Hct dropped from baseline of 30 to 21. This is likely lower
GI given presence of red/maroon colored stools, however source
not entirely clear. Differential included upper source from
local extension of tumor vs. lower source (diverticular, AV
malformation, ischemic). He received 3 units of pRBCs on
admission to the ICU, and his hematocrit remained stable
thereafter. He was treated with IV protonix, and received an
upper endoscopy and colonoscopy which showed esophagitis,
gastritis and duodenitis with duodenal erosions. There were no
active sites of bleeding. At the time of discharge, his
hematocrit was stable at 26.6 and he was started on daily PPI.
There was no need for GI follow-up or further work-up.
# Lightheadedness: He presented with lightheadedness, likely
orthostatic dizziness due to his GIB. His blood pressures
remained stable after his transfusions, however his home
amlodipine was held. At the time of discharge, he did not have
lightheadedness, and his hematocrit was stable. His Amlodipine
was held on discharge, with the instructions that this could be
restarted after being seen by his PCP for HCT check and vitals.
# Ampullary Adenocarcinoma, stage IIB: s/p operative resection
___ however, stage IIB ampullary found intraoperatively to
have unresectable disease secondary to regional lymph node
metastases. Hx obstructive jaundice s/p ERCP and stent
placement. He was previously on capecitabine, however this was
held during this admission given his GI bleed.
# Hepatitis C / Cirrhosis: MELD score 6. Child's ___ class A.
Reported hx of varices, however EGD ___ neg for varices. No
ascites was appreciated on exam, so there was no need for
diuresis or SBP prophylaxis. His mental status was clear and
there was no concern for encephalopathy.
# MOOD: stable, continued his home fluoxetine
TRANSITIONAL ISSUES:
1. Pending labs: biopsy results of gastric mucosa during EGD
2. Hct check: on ___ at Dr. ___ (visit ___/ ___
___ NP.)
3. Amlodipine: was held on discharge as BPs remained well
controlled without this med. Would advise restarting Amlodipine
only if needed after HCT/vitals check
4. For analgesia in the future: please encourage him to use
Tylenol (<3g daily) or low dose oxycodone that he has at home
already. Please remind him to avoid Motrin and aspirin.
5. His chemotherapy (capecitabine) for his ampullary
adenocarcinoma was held during this admission given his GI
bleed. He will follow up with heme-onc on ___ to resume
treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg po Q8H:PRN nausea
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain, headache
hold for sedation or confusion
3. Gabapentin 300 mg PO TID
hold for sedation
4. Fluoxetine 30 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Fluoxetine 30 mg PO DAILY
2. Gabapentin 300 mg PO TID
hold for sedation
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain, headache
hold for sedation or confusion
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Outpatient Lab Work
CBC
ICD-9-CM 578.9
Please fax results to Dr. ___: ___
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
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 with gastrointestinal bleeding and you
received blood transfusions which you tolerated well. You were
also seen by the gastroenterology specialists who performed an
upper endoscopy and colonoscopy. They found areas of
inflammation in the esophagus, stomach and small intestine, but
no sites of active bleeding. At this time, you do not require
further gastrointestional follow-up or imaging studies. It is
important that you stop taking medications that may lead to
bleeding, such as Motrin (ibuprofen) and aspirin. You should
also refrain from ingesting hydrogen peroxide solution as you
were recently doing. You will also need to have blood work done
on ___, to check your hematocrit level (blood level).
If in the future you notice bleeding, weakness/dizziness,
shortness of breath, or chest pain, please call your PCP or come
to the emergency room.
Followup Instructions:
___
|
19979469-DS-21 | 19,979,469 | 23,317,669 | DS | 21 | 2202-08-29 00:00:00 | 2202-08-29 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ h/o recurrent upper GI bleeding in the setting of an
ulcerated stage IIB ampullary adenocarcinoma, ___ ulcer, and
gastric angioectasias s/p recent arterial embolization to
ampulla blood supply presents from clinic for severe anemia. Pt
came to clinic today and was found to be orthostatic and
hypotensive. Pt c/o one day of weakness, fatigue and associated
dark stools. He denies n/v/d/abd pain. He denies fever though
did have an episode of chiils today. Labs in clinic showed Hct
of 22.5 down from 23 on ___ despite having had 2 units prbcs.
He was sent to the ___ and given 1U of prbcs before
transferred to ___ for further management.
.
In the ___: T98.3, bp 104/68, hr 90, 20 98% ra. HCT 22, plt 70.
Admitted to ___ for further management.
.
ROS: as above. otherwise complete ROS negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: developed obstructive jaundice for which he underwent an
ERCP at ___ which was complicated by self-limited
pancreatitis.
___: felt well until developed jaundice. ERCP was again
performed at ___ with stent placement and
his jaundice resolved.
___: EUS revealing enlarged tumor-like ampulla and mass at
the
head of the pancreas. FNA of the mass revealed ampullary
adenocarcinoma.
___: presented to the ___ with fever and obstructive jaundice
and underwent ERCP with previous plastic stent which had
migrated being removed and pigtail biliary stent placed at the
distal CBD stricture.
___: he underwent surgery with Dr. ___ with intention to
perform Whipple, but intraoperatively he was noted to have a
nodule/cirrhotic liver and several hard regional lymph nodes
near
the celiac axis and mesenteric artery/para-aortic region such
that Whipple was abandoned and Pt had cholecystectomy, liver
biopsies and lymph node biopsies. 1 lymph node retro-pancreatic
was positive for adenocarcinoma consistent with ampullary
primary.
___: Gemcitabine started. Dose reduction for C2 by 25%
secondary to neutropenia and thrombocytopenia C1D15 requiring
dose to be held.
___: C2D15 once again held for cytopenias; regimen changed
to
21d cycle with treatment on D1, D8.
___: completed C3 with neulasta support on ___, day 9
___: completed 6.5 cycles of gemcitabine, stopped due to
increasing ___: started capecitabine alone for cycle 1
___: ___ cycle 1 dose reduced oxaliplatin to 100mg/m2
___: ___ 130mg/m2 cycle 2
___: ___ reduced to 100mg/m2 ox. Cycle 6 reduced to
85mg/m2 as had been delayed 2 weeks due to thrombocytopenia.
Cycle
7 was delayed and on ___ he started capecitabine alone. Cycle
9 was postponed 1 week due to borderline platelets and being on
antibiotics.
___ single agent capecitabine was started at 1000mg BID.
___ restaging CT showed stable disease
___ Xeloda held due to hand and foot syndrome.
___ hospitalized due to upper GI bleeding,
replacement
of stent, complicated by sepsis.
___ restaging CT showed local progression of ampullary
cancer.
___ radiation to biliary area with concurrent
Xeloda
___ admitted to medicine service for GI bleed
requiring ___ embolization of arterial supply to ampulla
___ admitted for recurrent GI bleed, no further ___
intervention given risk for necrosis, EGDx2 with APC to areas of
bleeding. continued to have slow bleeding at ___, plan for
palliative transfusions at ___
PAST MEDICAL HISTORY:
# Chronic HCV w/ Class A Cirrhosis:
- Per OMR has had varices in the past but none seen on EGD on
___
- HCV VL 782,757 IU/mL on ___
# Prior GIB, ___: Source unidentified
# Distal esophagitis on EGD ___
# Antral gastritis on EGD ___
# Duodenal erosions on EGD ___
# Medium hiatal hernia on EGD ___
# Asthma - Recent history notable for bronchitis
# HTN
Social History:
___
Family History:
Maternal aunt colon cancer in her ___. Maternal uncles had
cancer (unknown type) in their old age.
Mother: living at age ___ ___VA
Father: living at age ___
Siblings: brother deceased of ___ in ___, 2 other brothers and
1 sister (alcoholic) living
Children: healthy
No family history of pancreaticoduodenal cancer
Physical Exam:
PHYSICAL EXAM:
VITALS: 98.1 106/58 78 18 97%RA
GENERAL: NAD, appears pale
HEENT: MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: clear to ausculation bilaterally, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: moderately distended, positive bowel sounds, non-tender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema bilaterally in lower extremities, warm
and well perfused
NEURO: ___ strength throughout, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==================================
Labs
==================================
___ 12:30PM BLOOD WBC-3.9* RBC-2.31* Hgb-7.1* Hct-21.65*
MCV-94 MCH-30.6 MCHC-32.7 RDW-16.1* Plt Ct-70*
___ 06:50PM BLOOD WBC-3.5* RBC-2.61* Hgb-7.8* Hct-24.6*
MCV-94 MCH-30.0 MCHC-31.8 RDW-16.7* Plt Ct-76*
___ 04:26AM BLOOD WBC-2.8* RBC-2.45* Hgb-7.6* Hct-23.4*
MCV-96 MCH-30.9 MCHC-32.3 RDW-16.2* Plt Ct-69*
___ 06:00AM BLOOD WBC-3.5* RBC-2.39* Hgb-7.4* Hct-22.5*
MCV-94 MCH-31.0 MCHC-32.9 RDW-16.8* Plt Ct-59*
___ 01:00PM BLOOD WBC-3.6* RBC-2.58* Hgb-8.1* Hct-24.3*
MCV-94 MCH-31.5 MCHC-33.5 RDW-16.5* Plt Ct-71*
___ 04:30AM BLOOD ___ PTT-30.3 ___
___ 01:00PM BLOOD Glucose-110* UreaN-17 Creat-0.8 Na-133
K-3.5 Cl-102 HCO3-27 AnGap-8
___ 03:29AM BLOOD ALT-38 AST-100* AlkPhos-326* TotBili-4.6*
___ 06:02AM BLOOD ALT-33 AST-73* AlkPhos-309* TotBili-2.5*
___ 07:29AM BLOOD TotBili-1.4
___ 04:30AM BLOOD TotBili-1.3
___ 04:26AM BLOOD ALT-23 AST-39 AlkPhos-206*
___ 06:00AM BLOOD ALT-10 AST-19 AlkPhos-110 TotBili-0.5
___ 01:00PM BLOOD ALT-20 AST-33 AlkPhos-177* TotBili-1.8*
___ 03:29AM BLOOD Calcium-7.2* Phos-2.9 Mg-2.0
___ 06:00AM BLOOD Albumin-1.1* Calcium-4.3* Phos-2.0*
Mg-1.1*
___ 01:00PM BLOOD Albumin-2.0* Calcium-7.4* Phos-3.8#
Mg-1.8
___ 01:00PM BLOOD Albumin-2.0* Calcium-7.4* Phos-3.8#
Mg-1.8
==================================
Procedures
==================================
EGD ___
Impression:
A medium size paraesophageal hernia was seen.
Grade B esophagitis was seen; no varices were noted
Patchy petechiae and abnormal vascularity of the mucosa
without stigmata of recent bleeding were noted in the antrum
(improved from previous s/p RFA).
Diffuse continuous friability, congestion and abnormal
vascularity of the mucosa with contact bleeding were noted in
the first and second part of the duodenum up until the ampullary
metal stent. There were multiple frank ulcers without high risk
stigmata.
RFA was applied for hemostasis successfully using a flexible
HALO TTS catether in the duodenum (bulb and D1/2 turn).
Overall successful RFA of ongoing/worsening duodenitis.
paracentesis ___
FINDINGS:
Initial four quadrant ultrasound demonstrated a large pocket of
free fluid
consistent with ascites.
PROCEDURE: The procedure, risks, benefits and alternatives were
discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned
procedure,
confirming the patient's identity with 3 identifiers, and
reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the
skin was
prepped and draped in the usual sterile fashion. 1% lidocaine
buffered with
sodium bicarbonate was instilled for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket
in the right
lower quadrant and 4.95 L of clear, straw-fluidwas removed.
The patient tolerated the procedure well without immediate
complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the
critical
portions of the procedure.
IMPRESSION:
Technically successful ultrasound-guided therapeutic
paracentesis with 4.95 L
of ascites removed.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
___ year old man h/o stage IIb ampullary carcinoma and recurrent
GIBs s/p ___ embolization and endoscopy with APC, who presented
with ongoing GI bleeding, requiring maintenance transfusions.
also with symptomatic ascites s/p 5L paracentesis
1. GI Bleed- ongoing issue with several recent hospitalizations.
after last hospitalization DCed with plan for palliative
transfusions which he was getting at ___. s/p 1 unit
___ at ___ and 6 units here over the course of his 1 weeks
stay. He has been evaluated extensively by ___ and GI.
- previously seen by ___, no plan for further intervention given
risk for necrosis
- endoscopy with GI shows similar findings of some oozing
angioectasias and friable mucosa. may be related to radiation to
the area. despite multiple attempts with APC and RFA he
continues to lose blood and is requiring blood transfusions
every ___ days. He was transfused to a goal hct >24. plt goal
was >50 though he did not require platelet transfusion.
2. Ascites: malignant versus related to liver cirrhosis. s/p
paracentesis ___, approx 5L removed, with improvement in
discomfort and hiccups. started on lasix and aldactone. will
need f/u electrolytes in the next few days. repeat paracentesis
will be based on reaccumulation and development of symptoms.
outpatient paracentesis can be arranged through Dr. ___
___ if needed.
3. Stage IIb Ampullary Carcinoma - Deemed not a surgical
candidate. Cannot have further chemotherapy at this point due to
his continued GI bleeds and thrombocytopenia. CT abd/pelvis on
last admission suggests slight increase in tumor burden. given
his ongoing bleeding and cytopenias he will likely not be able
to get any further tumor directed therapy. pt and his wife are
aware of this, and of the fact that his tumor will likely
progress over the next few weeks to months and eventually cause
some kind of new medical problem.
4. Depression - he continued his home dose of Prozac
5. Pain - controlled on home regimen:
- Continue OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
- OxycoDONE (Immediate Release) 10 mg PO/NG Q4H:PRN pain
6. Pancytopenia -likely ___ malignancy and
cirrhosis/splenomegaly. stable, no intervention was required.
FEN: regular diet
ACCESS: PIV, port-a-cath
PROPHYLAXIS:
- DVT ppx with compression stockings, holding anticoagulation
given bleeding concerns
-Pain management with Oxycodone, Oxycontin
-Bowel regimen with colace, senna
CODE: Full code
EMERGENCY CONTACT: ___ ___
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Dronabinol 2.5 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Gabapentin 300 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
8. Senna 8.6 mg PO BID:PRN constipation
9. Ascorbic Acid ___ mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Ondansetron 4 mg PO Q8H:PRN n/v
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Dronabinol 2.5 mg PO DAILY
4. Fluoxetine 40 mg PO DAILY
5. Gabapentin 300 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN n/v
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. Baclofen 15 mg PO TID hiccups
12. Omeprazole 20 mg PO BID
13. Furosemide 20 mg PO DAILY
14. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ampullary carcinoma
GI bleed
ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you were having persistent GI
bleeding. You had a repeat endoscopy and some small areas of
bleeding were stopped, but you continue to have persistent
oozing and are requiring blood transfusions every ___ days. It
was noticed that your abdomen was getting more and more
distended. Therefore, a paracentesis was performed to remove
fluid from your abdomen. You were then discharged to ___
___ where you will continue being monitored.
Followup Instructions:
___
|
19979529-DS-14 | 19,979,529 | 27,918,561 | DS | 14 | 2167-09-20 00:00:00 | 2167-09-20 16:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benzocaine
Attending: ___.
Chief Complaint:
PCP: ___
GI: ___
CC: ___ pain x 2 months
Major Surgical or Invasive Procedure:
EGD/colonoscopy
History of Present Illness:
HPI(4): Ms. ___ is a ___ female with a PMH of
multinodular goiter (euthyroid), dysphonia, anxiety, and
multiple orthopedic surgeries after an escalator accident who
presents with two months of constant abdominal pain. She was
referred here by her gastroenterologist, Dr. ___ expedited
workup.
The abdominal pain is diffuse, difficult to localize and feels
like an gnawing pain. It is aggravated by having an empty
stomach and sometimes wakes her up at night from sleep.
Sometimes drinking hot tea with milk alleviates the pain.
Tensing her abdomen does not make the pain worse. She denies
associated nausea/vomiting and has not had any bladder or bowel
issues. History of a cholecystectomy years ago but no other
abdominal surgeries. Has had a lot of recent stressors including
interpersonal issues with people at her group home and a stalled
lawsuit over an escalator accident.
On ___, patient called Dr. ___ at ___ with with
persistent severe abdominal pain. Passing gas and having BMs. No
nausea and vomiting. No fever. Patient very irritable and unable
to provide further details of character of pain. Given severity
they advised her to come to ED for expedited CT scan.
However she did not want to come to ER and hung up. She did not
want to try any medications such as tylenol/Bentyl. Per Dr.
___, pain seemed c/w some kind of ulcer or gastritis or
possibly Gerd and may require egd, omeprazole and h pylori
testing.
ED Course: VS, PE, belly labs and CT unremarkable. GI consulted.
Admitted for expedited workup.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
MULTINODULAR GOITER -
euthyroid, has recent benign biopsy for a nodule
HYPERTENSION
DYSPHONIA
PSYCHIATRIC ILLNESS, ? TYPE -see ___ social service note-
living
in group home, no primary care, in process of changing- no
records yet available - not sure who gave her her anti anxiety
meds originally or who other than pcp is regulating
SURGICAL HISTORY
KNEE SURGERY - bilat tkr last ___
CHOLECYSTECTOMY
? when
MULTIPLE ORTHOPEDIC OPERATIONS ON KNEES AND L SHOULDER
escalator accident ___ unavailable
Social History:
___
Family History:
Father died of MI and had ulcers
Physical 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: nondistended, tender in focal areas in mid ax line
lug and mid rectus to l and slightly below umbilicus, both
hardly
tender when pt relaxed or tenses. Negative ___.
no lumps or masses appreciated. No rebound
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
Pertinent Results:
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
___ 06:15AM BLOOD WBC: 7.5 Hgb: 13.___*
___ 06:15AM BLOOD Glucose: 98 UreaN: 20 Creat: 1.1 Na: 141
K: 5.1 Cl: 103 HCO3: 27 AnGap: 11
___ 06:15AM BLOOD Lipase: 34 GGT: 13
___ 06:15AM BLOOD 25VitD: 15*
___ 06:15AM BLOOD Hpy IgG: Pending
___ 06:20AM BLOOD Lactate: 1.0
___ 10:00AM URINE Blood: NEG Nitrite: NEG Protein: NEG
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.0
Leuks:
LG*
___ 10:00 am URINE
URINE CULTURE (Pending):
___ 6:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
# Abd CT (___): 1. Mild intrahepatic biliary dilation and
slightly increased CBD diameters are new since ___. No
evidence of stones on CT however choledocholithiasis cannot be
excluded. Correlation with hepatic function is recommended. 2.
No bowel obstruction or ascites.
# EGD/colonoscopy (___): prelim read. EGD showed nodular
inflammation of the antrum. Mult biopsies taken. Colonoscopy
was negative.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ F h/o goiter, anxiety and multiple
orthopedic injuries who presents from her group home with poorly
localized abd pain of unclear etiology x 2 mos. Pain worse when
tensing abd at ___ clinic, concerning for abdominal wall pain.
ACUTE/ACTIVE PROBLEMS:
#Abdominal pain.
Ms. ___ was admitted with abdominal pain over the past 2
months. Extensive tests here were performed - including HPylori
serologies, LFTS, and abd/pelvic CT scan were unremarkable. The
thought was that this most c/w gastritis. She underwent
EGD/colonoscopy which showed evidence of nodular inflammation of
the antrum - c/w gastritis but could not rule out cancer.
Multiple biopsies were taken.
PPI was increased to 40 mg BID and sucralfate was added to
her regimen. Colonoscopy was negative. Of note, her
symptoms/complaints were out of proportion from objective
markers and she was noted to be sleeping well, not tachycardic,
fully mobile, and without distress otherwise. She was seen by
her gastroenterologist - who will follow up with the results and
follow up as outpt.
#Anxiety- pt has had behavioral issues in the past and gotten
agitated with staff. will work on getting social work involved
to both get some history, figure out prior care, and to work
with patient get old records from prior ___ care environment
CHRONIC/STABLE PROBLEMS:
#Anx: CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth
three times a day - (Prescribed by Other Provider)
#HTN: LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth
daily - (Prescribed by Other Provider)
#GERD: OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth at 4 pm
#Urinary retention: OXYBUTYNIN CHLORIDE - oxybutynin chloride ER
5 mg tablet,extended release 24 hr. 1 tablet(s) by mouth twice a
day - (Prescribed by Other Provider)
GENERAL/SUPPORTIVE CARE:
# Nutrition/Hydration: clears tomorrow, moviprep.
# Functional status: can complete ADLs
# Bowel Function: miralax, moviprep
# Lines/Tubes/Drains: PIV
# Precautions: none
# VTE prophylaxis: HSQ
# Consulting Services: GI
# Code: presumed full
# Disposition:
- Anticipate discharge to: assisted living home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Oxybutynin 5 mg PO BID
3. ClonazePAM 1 mg PO TID
4. Omeprazole 20 mg PO DAILY gerd
Discharge Medications:
1. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1 ml by mouth four times a day Disp
#*1 Bottle Refills:*2
2. Omeprazole 40 mg PO BID gerd
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. ClonazePAM 1 mg PO TID
RX *clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp
#*6 Tablet Refills:*0
4. Lisinopril 40 mg PO DAILY
5. Oxybutynin 5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain -- gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
As you know, you were admitted with abdominal pain.
Extensive workup here was performed - including CT scan, blood
tests, and endoscopy (EGD and colonoscopy). These studies
revealed showed gastritis which is likely to respond to the acid
suppressant medication, Prilosec and sucralfate (which coats the
stomach). We anticipate that your pain will improve over time
with this medication. There were biopsies taken of the stomach
which will be followed up by Dr. ___.
Please continue to take these 2 medications until your visit
with Dr. ___.
Your other medications otherwise remain unchanged.
We wish you good health.
Your ___ team
Followup Instructions:
___
|
19979532-DS-21 | 19,979,532 | 26,713,659 | DS | 21 | 2116-11-05 00:00:00 | 2116-11-05 18:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending: ___.
Chief Complaint:
Tachycardia and malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man
with a past medical history of IVDU, hypertension, asthma, and
PTSD, who presents for the evaluation of flu-like symptoms,
cough, abdominal pain, nausea and vomiting.
The patient is homeless, and states that for about the past ___
days, he has felt chills and muscle aches. A few days ago, he
developed a cough without hemoptysis. He also notes RUQ
abdominal
discomfort over the last few days associated with nausea and
vomiting, and inability to keep anything down for the last ___
days. He also states that about 4 days ago, he developed a rash
spreading over his whole body. He states he has been feeling
like he is having a panic attack "all day." As a result, he was
having shortness of breath and chest pain during this attack. He
states he normally sees a psychiatrist, but lost this provider
as
result of missing too many appointments. He states he has
anxiety
and PTSD from childhood trauma.
Of note the patient was admitted to ___ for MSSA bacteremia
about
___ year ago. He has been sober from IV drug use for about 2
months.
ED Course notable for:
Initial vital signs: T 97.1, HR 145, BP 156/99, RR 24, O2 sat
99%
RA
Exam notable for: Appears anxious and slightly diaphoretic.
HEENT
exam unremarkable. Cardiac exam with regular tachycardia; no
murmurs, rubs, or gallops. Lungs are clear to auscultation
bilaterally. Abdomen is mildly tender to palpation in the
periumbilical and right lower quadrant regions. Lower
extremities
are warm well perfused. The patient has a faint blanching
petechial rash over his torso and extremities.
Labs notable for: WBC 12.9, AST 85, ALT 133, Cr 1.1, lactate
2.6,
utox positive for amphetamines
Imaging notable for: CT A/P- No acute findings in the abdomen or
pelvis to explain the patient's abdominal pain, nausea or
vomiting. Specifically, the appendix is normal.
EKG: Sinus rhythm 131. Normal PR, QRS, and QTc intervals. Normal
axis. No clear ST segment deviation or T-wave inversion to
suggest ischemia. Peaked T waves in the lateral precordial leads
V3-V5 are new from his prior exam.
The patient received 3L IVF, lorazepam, and was started on
vancomycin and Zosyn for concern for endocarditis prior to
transfer to the MICU.
Vital signs prior to transfer: HR 135, BP 129/66, RR 19, O2 sat
98% RA
On arrival to the MICU, the patient confirmed the above history.
He states that he is beginning to feel better. He currently does
not report fevers, chills, chest pain, shortness of breath,
nausea, and vomiting. He still notes RUQ abdominal pain.
Past Medical History:
HTN
Asthma
PTSD
IVDU
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: T 97.7 BP 108 / 64 HR 94 RR 19 O2 Sat 96 RA
GENERAL: Alert, oriented, no acute distress, appears anxious,
pacing around the room
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, RUQ tenderness on palpation, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: red macular lesions on face and abdomen
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
==========================
VS: T 97.4 BP 150 / 76 HR 81 RR 16 O2 Sat 93 Ra
GENERAL: Well-appearing, eyes closed, in NAD
HEENT: NC/AT, EOMI, MMM
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, normal S1/S2, no murmurs
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing
SKIN: no rashes appreciated, no diaphoresis
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
================
___ 02:10AM WBC-12.9* RBC-4.97 HGB-15.4 HCT-45.2 MCV-91
MCH-31.0 MCHC-34.1 RDW-13.7 RDWSD-45.4
___ 02:10AM NEUTS-73.3* LYMPHS-18.4* MONOS-7.3 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-9.44* AbsLymp-2.37 AbsMono-0.94*
AbsEos-0.01* AbsBaso-0.05
___ 02:10AM cTropnT-<0.01
___ 02:10AM LIPASE-19
___ 02:10AM ALT(SGPT)-133* AST(SGOT)-85* ALK PHOS-81 TOT
BILI-0.5
___ 02:17AM LACTATE-2.6*
PERTINENT LABS:
================
___ Trend:
___ 04:40AM BLOOD WBC-9.7 Hgb-12.7* Hct-38.8* Plt ___
___ 08:15AM BLOOD WBC-7.1 Hgb-13.7 Hct-41.8 Plt ___
___ 09:54AM BLOOD WBC-6.6 Hgb-14.0 Hct-41.1 Plt ___
___ 04:40AM BLOOD Neuts-59.9 ___ Monos-5.6 Eos-2.6
Baso-0.6 Im ___ AbsNeut-5.80 AbsLymp-2.99 AbsMono-0.54
AbsEos-0.25 AbsBaso-0.06
LFTs:
___ 04:40AM BLOOD ALT-90* AST-60* LD(LDH)-261* AlkPhos-66
TotBili-0.7
___ 08:15AM BLOOD ALT-88* AST-56* AlkPhos-64 TotBili-0.3
___ 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 04:40AM BLOOD HCV Ab-POS*
___ 04:40AM BLOOD HCV VL-PND
___ 04:40AM BLOOD TSH-3.3
___ 04:40AM BLOOD Free T4-1.3
___ 04:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 10:48AM BLOOD Lactate-1.5
DISCHARGE LABS:
================
___ 06:30AM BLOOD WBC-7.5 Hgb-13.6* Hct-40.6 Plt ___
___ 06:30AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-140
K-4.4 Cl-102 HCO3-24 AnGap-14
IMAGING/STUDIES:
=================
CXR ___
No focal consolidation or other acute cardiopulmonary
abnormality.
CT A/P ___
No acute findings in the abdomen or pelvis to explain the
patient's abdominal pain, nausea or vomiting. Normal appendix.
TTE ___
Normal biventricular cavity sizes, regional/global systolic
function. No valvular pathology or pathologic flow identified.
Normal estimated pulmonary artery systolic pressure. No 2D
echocardiographic evidence for endocarditis.
MICROBIOLOGY:
==============
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 1:50 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date (as of
___ at 6PM)
Brief Hospital Course:
Mr. ___ is a ___ man with a past medical history of
IVDU, hypertension, asthma, and PTSD, who presents for the
evaluation of flu-like symptoms, cough, abdominal pain, nausea
and vomiting, initially admitted to the MICU for sinus
tachycardia to 140's, now with resolution of tachycardia and
improvement in presenting symptoms.
ACTIVE ISSUES:
==============
# Tachycardia, resolved
The etiology of his tachycardia was unclear but likely related
to dehydration or viral infection. Other infection was ruled
out, and although his lactate at presentation was 2.6, this
resolved with fluids. He was briefly maintained on
broad-spectrum antibiotics from ___. Of note, the patient
had been missing a couple of dose of his psychiatric
medications, so he may have had withdrawal sympathetic response.
He did have a skin rash on presentation but this is likely a
viral exanthema.
# Abdominal pain/malaise
# Transaminitis
The etiology of his transaminases unclear but could be related
to hepatitis C infection versus viral gastroenteritis. His
hepatitis C viral load was pending at discharge. His liver labs
trended down. LFTs at discharge: ALT 106 AST 68 LDH 226 Alk Phos
67 Tbili 0.2.
# Homelessness: Importantly, the patient has been homeless for
months. He has had multiple admissions to and from ___ and has
not had good follow-up. Social worker helped with resources as
inpatient, and patient decided to go to shelter today upon
discharge. He continues to be on an expedited waiting list for
___. Patient is unable to
return home to stay with his parents.
# Normocytic anemia: Unclear etiology. Hgb fluctuating between
13 and 15 over past few days. No evidence of active bleeding on
exam. No reason to suspect hemolysis and tbili normal. Concern
for nutritional deficiency given history vs. anemia of
inflammation. Discharge Hgb 13.6.
CHRONIC ISSUES:
==============
# Hx of IVDU: Reportedly sober for past 2 months. Serum tox
positive only for amphetamines (on Adderall which was
discontinud on discharge). He was continued on his Suboxone.
# PTSD
Continued home meds as confirmed by psychiatry. He was
maintained on buspirone, gabapentin, Benadryl, clonidine as
needed, Vistaril as needed, Effexor and Suboxone as above. He
should follow-up with Bridge clinic at ___.
TRANSITIONAL ISSUES:
===============
[] HELD MEDICATION: Adderall given sinus tachycardia. Patient
did well without Adderall while in-house. Restart as clinically
indicated.
[] Patient is willing to go to ___ today for ongoing
assistance seeking substance use treatment. ___ will assign
clinician work with him to identify appropriate treatment
programs.
___
[] Please follow-up with LFTs at discharge. They were elevated,
and HCV viral load was also pending at discharge. Patient will
like to discuss hepatitis C treatment, but he should require
close follow-up with his PCP prior to initiating HCV treatment.
We set up an appointment with a PCP that he has not seen in
years, Dr. ___.
[] Patient should continue to follow up with Dr. ___ at the
___ clinic. Phone number for Dr. ___ is ___.
[] No new medications or antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.1 mg PO BID:PRN anxiety
2. Amphetamine-Dextroamphetamine 30 mg PO BID
3. Gabapentin 800 mg PO TID
4. BusPIRone 10 mg PO BID
5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
6. DiphenhydrAMINE 50 mg PO QHS
7. HydrOXYzine 50 mg PO BID:PRN anxiety
8. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. BusPIRone 10 mg PO BID
3. CloNIDine 0.1 mg PO BID:PRN anxiety
4. DiphenhydrAMINE 50 mg PO QHS
5. Gabapentin 800 mg PO TID
6. HydrOXYzine 50 mg PO BID:PRN anxiety
7. Venlafaxine XR 75 mg PO DAILY
8. HELD- Amphetamine-Dextroamphetamine 30 mg PO BID This
medication was held. Do not restart
Amphetamine-Dextroamphetamine until your doctor tells you to
Discharge Disposition:
Home
Discharge Diagnosis:
Sinus tachycardia related to dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
Thank you for coming to ___!
WHY WERE YOU ADMITTED?
- You were admitted with a fast heart rate and were looking very
sick
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were briefly in the ICU (Intensive Care Unit) to control
your heart rate. Your heart rate improved with IV fluids
- We gave you antibiotics for 2 days due to concern for
infection. We did not find any infection so we stopped your
antibiotics
- We had our social worker see you. They offered some resources
for addiction as well as shelters.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- It is important for you to follow up with a doctor. We set up
an appointment with ___ MD for follow-up. They can also
talk to you about hepatitis C treatment.
- It is also important for you to follow up with your
psychiatrist.
- For housing, you agreed to go to a shelter today. We believe
that this is very important for you, and if you should any other
resources, please see below for other shelters that you can go
to.
- It is important for you to continue refraining from using any
IV drugs.
You can ask for a Homeless Outreach Team (HOT) when you stay at
any emergency shelter in ___. They will continue to work with
you to identify stable housing in the community.
You can also walk in to the below clinics for psychiatric and
substance use treatment:
___ for the Homeless Program (___)
Address: ___
Phone: ___
Walk in hours: M-F 7a-11p
Or ___ has a clinic at ___ (___):
___ at ___ offers primary care each weekday in the
Medical Walk-in Unit, and coordinates and assists with care and
discharge planning for homeless patients throughout ___.
___
You can walk in to ___ if you want help getting placement
for
substance use treatment
Providing Access to Addictions Treatment, Hope and Support
Address: ___
Walk in M-F 7:30AM-6PM
Walk in S/S: 8AM-3PM
Phone: ___re located at the Dr. ___
___ ___ at ___
___ Floor,
___
Or at the ___ ___.
___ Floor
___
Homeless Support Services
___
___
___
___
___
___
___ Floor
___
Walk-ins are welcome for enrollment (no appointment needed)
Intakes: ___. ___., 9:00am 3:00pm (note: ___ until
1:00pm).
Programs: ___. ___., 8:00am 4:00pm (note: ___ until
2:00pm).
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
19979651-DS-9 | 19,979,651 | 27,852,917 | DS | 9 | 2187-08-01 00:00:00 | 2187-08-02 17:34:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L wrist pain
Major Surgical or Invasive Procedure:
L wrist ORIF
History of Present Illness:
___ RHD woman was leaving the ___ at ___
this evening and tripped on the sidewalk, landed on outstretched
left hand. Had immediate pain and obvious deformity. Presented
with husband to ___. ED staff performed hematoma block and
closed reduction, sugartong splinting and consulted Orthopedic
surgery for evaluation of reduction acceptability. Patient
denies any numbness, tingling, head strike, LOC, syncope,
previous osteoporotic fracture.
Past Medical History:
Osteoporosis (recent diagnosis), no surgical hx
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION:
General: NAD, AOx3
RRR on peripheral vascular exam
Regular WOB, Symmetric chest rise bilaterally, no audible
wheezing
Vitals: AVSS
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Splint c//di
- Soft, non-tender arm and forearm
- Full AROM/PROM of shoulder, elbow, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, BCR distally all digits
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 02:30AM GLUCOSE-117* UREA N-22* CREAT-0.5 SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ 02:30AM estGFR-Using this
___ 02:30AM WBC-9.2# RBC-4.51 HGB-13.9 HCT-42.0 MCV-93
MCH-30.8 MCHC-33.1 RDW-12.6 RDWSD-42.9
___ 02:30AM NEUTS-83.9* LYMPHS-9.1* MONOS-5.9 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-7.73* AbsLymp-0.84* AbsMono-0.54
AbsEos-0.04 AbsBaso-0.03
___ 02:30AM PLT COUNT-255
___ 02:30AM ___ PTT-29.0 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L wrist fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for L wrist 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 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, and will be
discharged on aspirin 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:
Nasacort, Fosamax
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours as needed for pain Disp #*120 Tablet
Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth
daily as needed for constipation Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day as needed for constipation Disp #*60 Capsule Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4 hours
as needed for pain Disp #*70 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
left volar bartons fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - independent
Discharge Instructions:
Ms. ___,
- ___ 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:
- Nonweight bearing in the left upper extremity
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 ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325 mg at bedtime daily for two weeks
WOUND CARE:
- ___ may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
___ will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
19979849-DS-10 | 19,979,849 | 21,842,247 | DS | 10 | 2135-02-05 00:00:00 | 2135-08-11 14:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
pitted fruit
Attending: ___.
Chief Complaint:
2 obstructing right distal ureteral stones, acute kidney injury
Major Surgical or Invasive Procedure:
___ Cystoscopy, right ureteroscopy, laser lithotripsy, right
ureteral stent placement
History of Present Illness:
HPI: Patient is a ___ male who known to urology for a small right
renal mass and nephrolithiasis s/p R PCNL by Dr. ___ in
___, who presents with right sided flank pain since ___.
He
has had nausea but no vomiting, no fevers or chills. He
presented
to the ER overnight a CT showed 2 distal right ureteral stones
with hydronephrosis. His Cr was 1.8 from 0.9, and he was
observed
overnight. His Cr only improved to 1.6 with fluids and he
required more morphine overnight.
Past Medical History:
PMH/PSH:
- nephrolithiasis
- renal mass
Social History:
Country of Origin: ___
Marital status: Significant Other
Name of ___
___:
Children: Yes: 1 son and 1 daughter
Work: ___
Sexual Abuse: Denies
Domestic violence: Denies
Tobacco use: Never smoker
Alcohol use: Present
Alcohol use rarely
comments:
Recreational drugs Past
(marijuana, heroin,
crack pills or
other):
Recreational drugs marijuna up to ___
comments:
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: None
Diet: not always healthy
Family History:
Father ___ ___ HEART DISEASE
ALCOHOL ABUSE
Brother ___ ___ DIABETES MELLITUS
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 05:40AM BLOOD WBC-12.5* RBC-4.55* Hgb-13.3* Hct-41.0
MCV-90 MCH-29.2 MCHC-32.4 RDW-14.0 RDWSD-46.3 Plt ___
___ 07:15PM BLOOD WBC-13.5* RBC-4.75 Hgb-13.9 Hct-42.5
MCV-90 MCH-29.3 MCHC-32.7 RDW-14.3 RDWSD-46.5* Plt ___
___ 07:15PM BLOOD Neuts-74.3* Lymphs-13.8* Monos-10.2
Eos-1.0 Baso-0.3 Im ___ AbsNeut-10.05* AbsLymp-1.87
AbsMono-1.38* AbsEos-0.13 AbsBaso-0.04
___ 07:15PM BLOOD ___ PTT-26.7 ___
___ 05:40AM BLOOD Glucose-95 UreaN-23* Creat-1.6* Na-140
K-4.7 Cl-103 HCO3-24 AnGap-13
___ 07:15PM BLOOD Glucose-83 UreaN-29* Creat-1.8* Na-140
K-4.6 Cl-100 HCO3-26 AnGap-14
___ 07:15PM BLOOD ALT-51* AST-35 AlkPhos-83 TotBili-0.6
___ URINE URINE CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
Brief Hospital Course:
___ was admitted to Dr. ___ for
nephrolithiasis management with a known obstructing stone, from
the ED. He was given pain control and Flomax
and consented for urgent cystoscopy with right ureteral stent
insertion. He underwent cystoscopy, right ureteroscopy, laser
lithotripsy, right ureteral stent placement for known right
ureteral stones, right renal stone and acute kidney injury.
See the dictated operative note for full details. Overnight, the
patient was hydrated with intravenous fluids and received
appropriate perioperative prophylactic antibiotics. On POD1,
catheter was removed and he was prepped for discharge home. At
discharge on POD1, patients pain was controlled with oral pain
medications, tolerating regular diet, ambulating without
assistance, and voiding without difficulty. Patient was
explicitly advised to follow up as directed as the indwelling
ureteral stent must be removed and or exchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phenazopyridine 100 mg PO Q8H:PRN pain
2. potassium citrate 15 mEq oral TID W/MEALS
3. Tamsulosin 0.4 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Cephalexin 500 mg PO ONCE Duration: 1 Dose
RX *cephalexin 500 mg 1 capsule(s) by mouth once Disp #*1
Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg one capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain -
Severe
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every four hours Disp #*20 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily
Disp #*30 Capsule Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. potassium citrate 15 mEq oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Nephrolithiasis, right distal ureteral
Acute kidney injury (creat to 1.6)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent .
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
Followup Instructions:
___
|
19980241-DS-9 | 19,980,241 | 23,739,999 | DS | 9 | 2137-12-21 00:00:00 | 2137-12-25 07:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
NEPHROLITHIASIS, ACUTE KIDNEY INJURY, BACTEREMIA
Major Surgical or Invasive Procedure:
___: LEFT PERCUTANEOUS NEPHROSTOMY by Interventional
Radiology
___: MIDLINE placed for IV Antibiotics
History of Present Illness:
___ with no significant PMH who presents from an OSH with left
flank pain, fevers, and evidence of an obstructing left UPJ
stone. Labs are remarkable for WBC 20.4 and Cr 2.5. The patient
is currently afebrile, hemodynamically stable, and comfortable.
The patient proceeded from the ED to ___ for L PCN placement,
which was uncomplicated.
Past Medical History:
Mr ___ reports that he has had no medical care for over ___
years and since his last known PCP ___. He reports no
medical problems or use of medications.
Morbid obesity
Social History:
___
Family History:
No family history of kidney stones
Maternal uncle with DM and kidney disease. Mother with DM and
afib. Paternal grandfather with HTN. No family hx of renal
stones.
Physical Exam:
WDWN
Caucasian male
obese
NT/ND
LEFT PCN w/ clear yellow UOP
lower extremities w/out edema, pitting, pain
Pertinent Results:
___ 06:05AM BLOOD WBC-10.4 RBC-4.67 Hgb-13.6* Hct-41.8
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.5 Plt ___
___ 05:50AM BLOOD WBC-12.9* RBC-4.27* Hgb-12.5* Hct-37.3*
MCV-87 MCH-29.3 MCHC-33.5 RDW-14.3 Plt ___
___ 02:35AM BLOOD WBC-20.4* RBC-4.18* Hgb-12.6* Hct-35.6*
MCV-85 MCH-30.2 MCHC-35.5* RDW-15.0 Plt ___
___ 02:35AM BLOOD Neuts-89.0* Lymphs-5.5* Monos-5.1 Eos-0.2
Baso-0.2
___ 06:05AM BLOOD Plt ___
___ 02:35AM BLOOD Plt ___
___ 02:35AM BLOOD ___ PTT-34.2 ___
___ 06:05AM BLOOD Glucose-128* UreaN-39* Creat-2.5* Na-141
K-3.6 Cl-104 HCO3-22 AnGap-19
___ 05:50AM BLOOD Glucose-128* UreaN-36* Creat-2.8* Na-138
K-3.7 Cl-103 HCO3-21* AnGap-18
___ 04:58PM BLOOD Glucose-155* UreaN-33* Creat-2.7* Na-135
K-4.4 Cl-102 HCO3-17* AnGap-20
___ 02:00AM BLOOD Glucose-181* UreaN-29* Creat-2.5* Na-134
K-3.8 Cl-98 HCO3-21* AnGap-19
___ 02:00AM BLOOD ALT-34 AST-61* AlkPhos-89 TotBili-1.5
___ 06:05AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.3
___ 05:50AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.1
___ 02:00AM BLOOD Albumin-3.3*
___ 05:50AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:50AM BLOOD TSH-5.2*
___ 05:50AM BLOOD PTH-157*
___ 02:44AM BLOOD Lactate-2.1*
___ 05:50AM BLOOD VITAMIN D ___ DIHYDROXY-PND
___ 02:24PM URINE Hours-RANDOM Creat-89 Na-37 K-23 Cl-42
TotProt-148 Prot/Cr-1.7*
___ 02:24PM URINE Osmolal-340
___ 2:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0204 ON ___
- ___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 2:00 am 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.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ @
8:12 ___.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 5:20 am URINE CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
Brief Hospital Course:
Mr. ___ is a ___ obese male with no significant past
medical or surgical history who presented from an OSH with
fevers, left flank pain, and evidence of an obstructing left UPJ
stone. He had previously been in his usual state of health when
he experienced left flank pain radiating to his LUQ. He also
reported fevers to 104.9. He took Tylenol for the fevers and
pain. He denied dysuria, hematuria, nausea, and vomiting. He
presented to an OSH, where a CT scan showed a 9mm obstructing
left UPJ stone with associated hydronephrosis. He had a temp of
104, WBC 18.5, Cr 2.2, Lactate 5.6, UA c/w infection and was
subsequently transferred to ___ ED as there was no urology at
the OSH.
Mr. ___ was admitted and urgently taken to the
interventional radiology theater for urgent decompression. A
left percutaneous nephrostomy was placed and he was recovered
and transferred to the general surgical floor. He was placed on
telemetry for monitoring for hypotension/sepsis. Empiric
intravenous antibiotics were continued pending cultures and his
diet was advanced as tolerated.
Mr. ___ remained inpatient until preliminary culture data
was available and until he was afebrile for over 24 hours and
there was noted trend improvement in his acute kidney injury.
His creatinine had been elevated since admission and at the OSH
on ___ his creatinine was 2.1. It uptrended to 2.8 even after
the placement of the PCN so consult services were provided by
nephrology for this acute kidney injury (presumed acute tubular
necrosis).
At discharge Mr. ___ pain was controlled with oral pain
medications, he was tolerating a regular diet, ambulating
without assistance, and voiding without difficulty.
Mr. ___ was explicitly advised to follow up with nephrology
as an outpatient and to report back to ___ daily for his
intravenous antibiotics. Appointments and follow up appointments
were secured and documented on his Discharge Worksheet. He was
given explicit instructions to return to urology for follow up
and for definitive stone management. Supplies and instructions
for percutaneous nephrostomy care were provided by nursing and
detailed on the Discharge Worksheet. All of his questions were
answered in detail.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain, headache, fever
2. CeftriaXONE 1 gm IV Q24H
RX *ceftriaxone 1 gram ONE gram IV Q24hrs Disp #*11 Vial
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*1
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #*40 Tablet
Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [Senokot] 8.6 mg ONE tablet by mouth QD - BID
Disp #*60 Tablet Refills:*0
6. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home
Discharge Diagnosis:
acute kidney injury, flank pain, urinary tract infection, left
obstructing nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You will be discharged home with the PERCUTANEOUS NEPHROSTOMY
(PCN)
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-PCNs/Ureteral stents MUST be removed or exchanged and therefore
it is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
PCN is in place. You should NOT drive while taking narcotic
pain medication and while the PCN is in place.
-Please refer to the provided nursing instructions and handout
on PCN care, waste elimination, dressing changes.
PERCUTANEOUS NEPHROSTOMY (PCN) TUBE INSTRUCTIONS FOR CARE---FOR
FAMILY:
Please leave PCN tube to external gravity drainage.
Catheter flushing: If there are excessive blood clots or debris
or thick urine within the connecting tubing, this can be gently
flushed as needed to promote clearing. Use normal saline filled
syringes provided by nursing.
Change every 3 days, if soiled/saturated, as needed: Gently
cleanse around the skin entry site of the catheter with gentle
soap w/ warm water. Dry and apply gauze dressing.
Catheter security: a) EVERYDAY you must check to be sure the
catheter, the connecting tubing and the drainage bag are
securely attached to the patient and are not kinked. b) If the
catheter appears to be pulling "out", please notify
Interventional Radiology.
c) If the catheter pulls out, please notify Interventional
Radiology within 8 hours. SAVE THE CATHETER for inspection--DO
NOT throw
it away.
Call Interventional Radiology/Angio for ANY catheter related
questions or problems. ___ or Fellow/Resident (pager#
___
Followup Instructions:
___
|
19980545-DS-14 | 19,980,545 | 21,585,596 | DS | 14 | 2179-01-04 00:00:00 | 2179-01-08 17:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sprintec (___)
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female recently admitted with bilateral pulmonary embolism
(s/p dx and hospitalization ___ on coumadin who presents
w/ acute onset CP. Reports awoke from sleep with left sideded
CP, ___, pleuritic and constant. + difficulty taking deep
breath, dry cough. No hemoptysis, no syncope. Took dilaudid 2 mg
PO x2 and came to ED. Of note, had INR checked on ___ which was
7.4 and was instructed by PCP to discontinue lovenox and
coumadin until ___ recheck. Has been off OCP since diagnosis.
Only other med is ativan which was started recently for anxiety.
The patient's PE was diagnosed at OSH, and patient had normal
LENIs, and IVC was clean. No evidence of elevated BNP or
Troponin. ECG was concerning for strain. Pt's lovenox and
coumadin did overlap for greater than 5 days before
discontinuation.
.
In the ED, initial vs were 98.1 115 130/85 19 99% 2L (100% on
RA) Pt was found to be sinus tachy at 113. Bedside echo was
performed and was w/o pericardial effusion or septal deviation;
RV function appeared grossly normal. The patient was given 1 L
NS
.
On arrival to the floor, patient reports feeling well with
minimal pain after dilaudid, but still anxious.
Past Medical History:
Asthma
GERD
Bilateral pulmonary emboli without evidence of DVT in lower
extremities or IVC treated with anticoagulation.
Social History:
___
Family History:
No family history of blood clots, or young relatives with
unexplained early deaths.
Physical Exam:
Admission:
Vitals: 98.2, 118/76, 76, 16, 100% RA
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no loud or wide split S2, ___ systolic
murmur at the RUSB and LUSB, non harsh, non radiating
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM, +aortic abdominal bruit
EXT: warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal, gait intact
Discharge:
VSS, on ambulation O2 sat remained 100%, BP after exertion
102/60s
No change in exam
Pertinent Results:
___ 08:30AM WBC-5.5 RBC-5.38 HGB-15.3 HCT-45.1 MCV-84
MCH-28.5 MCHC-34.0 RDW-12.2
___ 08:30AM NEUTS-56.8 ___ MONOS-6.7 EOS-2.5
BASOS-1.3
___ 08:30AM PLT COUNT-372
___ 08:30AM ___ PTT-55.1* ___
___ 08:30AM GLUCOSE-95 UREA N-14 CREAT-0.7 SODIUM-141
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
___ 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:15AM URINE UCG-NEGATIVE
___ 08:30AM cTropnT-<0.01
___ 08:30AM proBNP-20
___ 08:30AM TSH-3.7
Discharge Labs:
___ 08:30AM BLOOD ___ PTT-49.6* ___
Imaging:
___ CXRay:
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
___ yo female with bilateral PE found two weeks ago in setting of
OCP use but no other known risk factors who presents with severe
pleuritic chest pain this morning with improvement with
dilaudid.
# Chest pain s/p PE: The patient was stable throughout her stay.
On the floor, she had 100% O2 sat on room air with exertion and
stable blood pressures with SBP>100. She had a normal appearing
ECG on the floor aside from incomplete RBBB which is typically a
normal variant in young healthy athletes, no evidence of right
heart strain on informal echo in ED, normal trop and BNP.
Notably, in the ED, the patient did have an abnormal ECG with
sinus tachycardia and diffuse ST segment depression which was
similar to her ECG on her initial presentation of PE about 1.5
weeks ago but this resolved on subsequent ECG as noted above.
The patient had a normal appearing chest x ray. The etiology of
the patient's pain is unclear, but could be from distal
embolization of clot with possible infarct of small area of lung
as severe pleuritic pain in PE is typical of an embolus that
lodges peripherally near the innervation of pleural nerves, or
the pain may be secondary to an inflammatory response as the
body is resorbing her lung clot. Given the patient's stability
lack of evidence of massive PE (no hemodynamic instability) or
submassive PE (no elevated trop, BNP, or evidence of right heart
strain), it was thought that continued anticoagulation would be
the preferred approach over embolectomy or thrombolysis. It
could be argued that in this otherwise healthy female with
bilateral PEs, that thrombolysis would be reasonable to reduce
the patient's chances of future pulmonary hypertension; however
given how well and asymptomatic she appeared after the one
episode of pain, it was thought best to manage conservatively.
The patient's anticoagulation was held for supratherapeutic INR
and she was scheduled to follow up with her PCP with
instructions to recheck her INR. Given the clear reversible
risk factor for her PE (OCPs) and lack of FHx of blood clots, no
hypercoagulability workup was performed. The patient had been
undergoing appropriate anticoagulation with >5 days of lovenox
and discontinuation of LMWH only after therapeutic INR>24 hours.
# Pain and Anxiety: Pt with significant anxiety regarding her
pulmonary embolism. She was maintained on her outpatient regimen
of dilaudid and ativan as needed.
CODE: full
COMMUNICATION Patient
EMERGENCY CONTACT ___ (___) HCP? Y/N
TRANSITIONAL:
1) Follow up INR with PCP for continued anticoagulation for at
least 3 months
2) Counsel on safe sex practices as she will likely not use OCPs
again
Medications on Admission:
1. lorazepam 1 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours)
as needed for anxiety.
2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Warfarin as directed
Discharge Medications:
1. lorazepam 1 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours)
as needed for anxiety.
2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. Outpatient Lab Work
Please have your INR drawn on ___ and faxed to ___,
Dr. ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Chest pain
Secondary: Bilateral pulmonary embolism
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. You were admitted for
chest pain after your pulmonary embolism a couple of weeks ago.
Your chest pain resolved after taking pain pills and your vital
signs remained stable. Your ecg and lab tests were normal.
Please
STOP taking warfarin and lovenox until you see Dr. ___ on
___.
Your last INR here on ___ was 4.0. It is likely that Dr.
___ like you to have your INR drawn again on ___.
START Docusate sodium 100 mg BID for constipation
Followup Instructions:
___
|
19981190-DS-6 | 19,981,190 | 24,364,972 | DS | 6 | 2111-07-31 00:00:00 | 2111-07-31 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
amoxicillin / Penicillins
Attending: ___.
Chief Complaint:
Left thigh pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left periprosthetic femur
fracture
History of Present Illness:
___ y/o female residing in ___ Place w/ history
of dementia, CKD, lymphoma s/ chemotherapy, parkinsons disease
with worsening balance problems and frequent falls over the last
year, left hip hemiarthroplasty in ___ for a fall at ___ by Dr. ___ admission to ___ for subdural
hematoma
in ___ here by transfer from ___ after a
mechanical fall and left periprosthetic spiral femoral neck
fracture. Patient is unable to provide collateral history.
Past Medical History:
___ Disease
CKD
Peripheral Neuropathy
Anemia
Lymphoma
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals:
___ 0408 Temp: 98.3 PO BP: 133/74 R Lying HR: 101 RR: 16 O2
sat: 93% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: Sleeping
General: Well-appearing, breathing comfortably
MSK:
LLE:
Primary dressing to left lateral thigh in place
Mild warmth and erythema without marked ecchymosis, stable from
serial exams
Patient did not participate in motor/sensory exam
WWP
Pertinent Results:
___ 06:30AM BLOOD WBC-8.3 RBC-2.84* Hgb-8.7* Hct-26.5*
MCV-93 MCH-30.6 MCHC-32.8 RDW-16.2* RDWSD-54.9* Plt ___
___ 06:15AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.2* Hct-25.4*
MCV-96 MCH-30.8 MCHC-32.3 RDW-15.8* RDWSD-54.7* Plt ___
___ 06:15AM BLOOD Glucose-92 UreaN-18 Creat-1.1 Na-143
K-4.1 Cl-106 HCO3-25 AnGap-12
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 periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of left periprosthetic femur fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
remarkable for transfusion of 2 units of packed red blood cells,
but her hemoglobin had stabilized and the patient did not
demonstrate signs of symptomatic anemia on discharge.
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 left lower extremity, and will be
discharged on heparin 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:
acetaminophen 325 mg capsule oral
2 capsule(s) Twice Daily
amlodipine 5 mg tablet oral
1 tablet(s) Once Daily
aspirin 81 mg tablet oral
1 tablet(s) Once Daily
carbidopa ER 25 mg-levodopa 100 mg tablet,extended release oral
1 tablet extended release(s) Four times daily (9a, 12p, 1600,
___
metoprolol succinate ER 25 mg tablet,extended release 24 hr
oral
1 tablet extended release 24 hr(s) Once Daily
nitroglycerin 0.4 mg sublingual tablet sublingual
1 tablet, sublingual(s) Q5mins x3 doses)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth q6hr Disp #*80
Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
3. Calcium Carbonate 1250 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Heparin 5000 UNIT SC BID
RX *heparin (porcine) 5,000 unit/mL 5000 units subcutaneous
twice a day Disp #*56 Syringe Refills:*0
6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q6hr Disp
#*30 Tablet Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
9. amLODIPine 5 mg PO DAILY
10. Carbidopa-Levodopa (___) 1 TAB PO QID
11. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing to left lower extremity
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 heparin twice 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.
-___ change the dressing to the thigh as needed.
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. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Touchdown weightbearing to the left lower extremity
Treatments Frequency:
Staples will remain in place for at least 2 weeks
postoperatively. Incision may be left open to air unless
actively draining. If draining, you may apply a gauze dressing
secured with paper tape. You may shower and allow water to run
over the wound, but please refrain from bathing for at least 4
weeks postoperatively
Followup Instructions:
___
|
19981210-DS-27 | 19,981,210 | 27,159,051 | DS | 27 | 2146-11-30 00:00:00 | 2146-12-01 12:31:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast
Media
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
___ w CAD s/p 2 vessel CABG (LIMA-LAD, SVG-LPL) in ___, s/p
ramus intermedius stent placement in ___, s/p AVR in ___, s/p
pacemaker placement in ___, s/p PCI with BMS to LCx and
angioplasty to ___ on ___, now presents with recurrent
anginal chest pain.
The patient reports that ___ chest pain started this afternoon
when he was at home and at rest. It is left-sided and radiates
to his neck. This is his typical anginal pain. He denies
associated dyspnea, nausea, vomiting, and diaphoresis. He used
nitro SL x3 at home without resolution and decided to return to
the hospital for evaluation given his recent stent placement.
Prior to this afternoon, he has felt in his normal state of
health since discharge. He noted some minor chest irritation on
___ afternoon, and has seen no improvement or worsening of
his dyspnea on exertion.
In the ED, initial vitals were 97.5 62 150/70 22 97% 4LNC. He
received 2 nitroglycerin SL tablets and morphine IV 5mg x4 for
chest pain and dyspnea with eventual resolution. EKG showed
more upright T-waves in V2-3 compared to prior on ___. Initial
troponin was negative, although was only ___ hours after
initiation of chest pain. Of note, at the time of his
catheterization on ___, the patient had a thrombus that
extended into the large ramus vessel requiring POBA with 30%
residual occlusion. It was therefore thought likely that the
patient's current chest pain was due to residual ramus disease.
The cardiologist in the ED recommended admission for repeat PCI
tomorrow.
On the floor, the patient denies chest pain or dyspnea. He is
breathing comfortably on room air. On review of systems he
notes that he had an episode of indigestion (not chest pain) on
___ evening after dinner. He also is experiencing some cough
and wheeze secondary to allergies. He sleeps with 2 pillows.
He notes dyspnea on exertion when climbing a flight of stairs
rapidly, but is able to tolerate working out regularly. He runs
on a treadmill 30 minutes several times a week and does strength
training.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. Cardiac review of
systems is notable for absence of paroxysmal nocturnal dyspnea,
ankle edema, palpitations, syncope or presyncope. All of the
other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (Borderline), Dyslipidemia,
Hypertension
2. CARDIAC HISTORY:
- AVR ___ (St ___ for bicuspid aortic valve, on coumadin
- CABG: ___ (2 vessel: LIMA-LAD, SVG-LPL)
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ Tetra stent placed
in ramus intermedius; ___ BMS to LCX and balloon
angioplasty to the ramus
- Tachy-brady syndrome s/p dual chamber PPM ___. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation and atrial flutter previously on
clonidine, dofetilide, dronedarone and now amiodarone. Warfarin
for thromboembolic prophylaxis. S/P DCCV ___.
- Mild diastolic dysfunction (EF 70% from ___
- GERD
- Gout (reports had ankle swelling 3mos previously that he
attributed to gout, not taking medications currently)
- T2DM
- GERD
- asthma
- MGUS IgM
- iron-deficiency anemia
- macular degeneration
- s/p right cataract repair
- osteopenia
- tremor
- trigger finger
- erectile dysfunction
- cervical radiculopathy
Social History:
___
Family History:
Father with MI at age ___
No h/o arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
Admission exam:
VS: 98.1 177/70 61 18 97% RA
GENERAL: NAD. Alert and oriented x3. Mood, affect appropriate.
HEENT: NC/AT. PERRL, EOMI, OP clear, MMM.
NECK: Supple with no JVD.
CARDIAC: RRR, nl S1, mechanical S2. ___ crescendo early systolic
murmur best heard at the USB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no rales, wheezes
or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No HSM.
EXTREMITIES: No cyanosis or clubbing. Trace pedal edema b/l. DP
and ___ 2+
SKIN: Well healed scar over sternum. No stasis dermatitis,
ulcers, scars, or xanthomas.
Discharge exam:
VS 133/64; 60; 18; 97%RA
CARDIAC: RRR, nl S1, mechanical S2. ___ crescendo early systolic
murmur best heard at the USB. No thrills, lifts. No S3 or S4.
LUNGS: CTAB, no rales, wheezes or rhonchi.
EXTREMITIES: Left wrist radial access without bleeding or
hematoma
Pertinent Results:
ADMISSION LABS:
___ 04:47PM BLOOD WBC-11.9* RBC-4.79 Hgb-12.4* Hct-40.3
MCV-84 MCH-25.9* MCHC-30.8* RDW-17.5* Plt ___
___ 04:47PM BLOOD Neuts-81.6* Lymphs-8.3* Monos-5.5
Eos-4.2* Baso-0.4
___ 04:47PM BLOOD ___ PTT-33.8 ___
___ 04:47PM BLOOD Glucose-205* UreaN-25* Creat-0.9 Na-138
K-4.3 Cl-104 HCO3-22 AnGap-16
CARDIAC ENZYMES:
___ 07:40AM BLOOD CK-MB-4 cTropnT-0.04*
___ 11:48PM BLOOD CK-MB-4 cTropnT-0.03*
___ 04:47PM BLOOD cTropnT-0.03*
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-9.4 RBC-4.23* Hgb-10.9* Hct-35.5*
MCV-84 MCH-25.8* MCHC-30.8* RDW-17.4* Plt ___
___ 08:26AM BLOOD ___ PTT-34.2 ___
___ 07:40AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.0
IMAGING:
___ CXR:
IMPRESSION: No acute intrathoracic process.
Cardiac cath ___:
COMMENTS:
1. Selective coronary angiography of the left coronary artery
was
obtained via access through the left radial artery with a ___ Fr
Glidesheath, using a ___ Fr XB 3.5 guide catheter. The LAD was
known to be
occluded from prior studies. The stent in the proximal
circumflex was
widely patent with a 30% distal stepdown. The mid-circumflex had
a 40%
stenosis. The ramus intermedius had a 30% stenosis at its
origin.
2. The LIMA-LAD was known to be widely patent from the recent
study, and
hence was not engaged. The SVG-OM is known to be occluded, and
partial
filling of the distal segment of the vein graft could be seen in
the
images. The RCA is known to be non-dominant and was not engaged
during
the present study.
3. In view of the patient's symptoms we decided to interrogate
the
lesions in both circumflex, as well as in ramus branch by FFR
study.
This was performed using a Certus pressure wire with IV infusion
of
Adenosine. At maximal hyperemia the FFR value in Ramus was 0.88
(baseline 0.95), and in the circumflex was 0.87 (baseline 0.95).
The
values obtained indicated that none of the stenoses visualized
in the
circumflex and the ramus branches were hemodynamuically
significant, and
thus, failed to account for the patient's symptoms.
FINAL DIAGNOSIS:
1. Patent stent in proximal circumflex and widely patent ramus
intermedius (non-obstructive plaques only).
2. FFR interrogation of both ramus intermedius and circumflex
coronary
artery revealed no hemodynamically significant lesion.
3. Continuation of medical therapy.
Brief Hospital Course:
___ y/o M w CAD s/p 2 vessel CABG (LIMA-LAD, SVG-LPL) in ___,
s/p ramus intermedius stent placement in ___, s/p AVR in ___,
s/p pacemaker placement in ___, s/p PCI with BMS to LCx and
angioplasty to ramus on ___, now presents with recurrent
chest pain.
# Chest pain: The patient has known extensive CAD with multiple
interventions including 2V CABG and several stent placements.
The ramus intermedius was stented in ___, and during ___
PCI a thrombus was noted to partially occlude this large vessel.
Balloon angioplasty of the ramus was performed but no new stent
placed. Patient reports exertional chest pain relieved with SL
nitroglycerin prior to ___ PCI. After ___ PCI, he started
having chest pain at rest not relieved by SL nitroglycerin after
___ PCI, but sometimes no pain with exertion. EKG unchanged,
CKMB 4, trop 0.03-0.04. Given his high risk, there was initial
concern chest pain is angina due to ramus lesion. Initially
started on nitroglycerin drip, morphine prn, and heparin drip
(despite INR 2.3). Continued ASA, statin, Plavix. Repeat
cardiac catheterization showed patent ramus and circumflex with
FFR >0.8, so no intervention was indicated. Chest pain is
unlikely cardiac in origin. Uptitrated Imdur from 60mg to 90mg
daily as tolerated by BP. Plan to follow up with Dr. ___
on ___ as previously scheduled.
# RHYTHM: Chronic atrial fibrillation and atrial flutter, s/p
DCCV in ___ and pacemaker placement. Rhythm paced at 60
throughout hospitalization. Continued amiodarone and coumadin
(see below).
# PUMP: Mild symmetric left ventricular hypertrophy with mild
diastolic dysfunction but preserved systolic function seen on
last echo.
# Anticoagulation: Currently anti-coagulated on coumadin for h/o
AVR and atrial fibrillation. INR goal 2.5-3.5. INR on
presentation on ___ was 2.3. Warfarin held on ___ due to plan
for cardiac catheterization. INR on ___ was 2.4. Warfarin
restarted on ___ post cath. Plan to recheck with Dr. ___
(___) on ___.
# HTN: Well-controlled on home regimen. Continue diltiazem and
Diovan. Uptitrated Imdur from 60mg to 90mg daily.
# DM: No recent A1c in our system. Held metformin ___.
Plan to restart on ___.
# GERD: Continued omeprazole.
# Asthma: Continue albuterol, mometasone, and Singulair.
# BPH: ContinueD tamsulosin
# Anemia: Continued ferrous sulfate
# Macular degeneration: Continued olopatadine gtt, Preservision
vitamins
# Transitional issues:
- code status: full
- follow up with:
- Dr. ___ ___
- INR check with Dr. ___ ___
- Medication changes:
- restart Metformin on ___
- increase Imdur from 60mg to 90mg daily
Medications on Admission:
ALBUTEROL SULFATE 90 mcg 2 puff Q6H PRN SOB, wheeze
AMIODARONE 100 mg daily
ATORVASTATIN 40 mg daily
CLOPIDOGREL 75 mg daily
DILTIAZEM XL 120 mg BID
ISOSORBIDE MONONITRATE 60 mg daily
METFORMIN 500 mg daily
MOMETASONE 110 mcg 2 puffs daily
MONTELUKAST 10 mg daily
NITROGLYCERIN 0.4 mg SL PRN chest pain
OLOPATADINE 0.1 % 1 gtt per eye daily
OMEPRAZOLE 20 mg BID
TAMSULOSIN 0.4 mg daily
TRIAZOLAM 0.125 mg QHS PRN sleep
VALSARTAN 60 mg BID
WARFARIN 5 mg daily
ASPIRIN 81 mg daily
CALCIUM CARBONATE-VITAMIN D3 500 mg-200 unit BID
COENZYME Q10 50 mg daily
FERROUS SULFATE 140 mg (45 mg iron) daily
MULTIVITAMIN 1 tablet daily
VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] 226 mg-200 unit-5
mg-0.8 mg-34.8 mg 1 capsule daily
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO BID (2 times a day).
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*0*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. mometasone 110 mcg (30 doses) Aerosol Powdr Breath Activated
Sig: Two (2) puffs Inhalation once a day.
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed as needed for chest pain: repeat every 5
minutes up to three times.
11. olopatadine 0.1 % Drops Sig: One (1) Ophthalmic daily ().
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
14. triazolam 0.25 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for sleep.
15. valsartan 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
18. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
19. ferrous sulfate 140 mg (45 mg iron) Tablet Extended Release
Sig: One (1) Tablet Extended Release PO once a day.
20. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1)
Capsule PO once a day.
22. Outpatient Lab Work
___ on ___
Attention: Dr. ___.
___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted because you had chest and neck pain. You underwent
cardiac catheterization, which showed that your heart vessels
are not blocked. Your blood work and electrocardiogram also
showed that you did not have a heart attack.
We made the following changes to your medications:
INCREASED Imdur from 60mg daily to 90mg daily
HOLD Metformin till ___
Followup Instructions:
___
|
19981210-DS-29 | 19,981,210 | 26,790,133 | DS | 29 | 2148-07-10 00:00:00 | 2148-07-10 20:27:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast
Media
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
Cardiac catheterization ___
History of Present Illness:
___ with h/o CAD s/p 2v CABG (LIMA-LAD, SVG-LPL) in ___ and
multiple stents, bicuspid aortic valve s/p AVR ___, atrial
fibrillation/flutter, and tachy-brady syndrome s/p PPM placement
in ___ presents with intermittent substernal chest pain since
this morning. Pt. had been in his usual state of health until
06:00 in the monring of presentation (___). Pt. notes at
that time his typical anginal chest pain at rest, specifically
left sided chest pain with radiation to the left shoulder and
jaw. Pt. also describes associated nausea and palpitations.
Pt. took 3 sublingual nitro with minimal improvement in
symptoms. He went back to sleep and woke up around 11:00 with
substernal chest pressure that is new compared to typical CP.
He took 3 more nitros with minimal improvement. Pt. then
attended a ___ dinner at ___ and returned
home. At 16:00, for continued pain, pt. took 3 more nitros and
Dilt 60mg PO x1 with no improvement in pain. At this time, pt.
called ambulance. En route, pt. reports no relief with 2
nitroglycerin sprays. He had 3 additional chewed baby aspirin
for total of 325mg on day of presentation. Pt. denies any
associated SOB/lightheadedness/dizzinessNo radiation to back. No
shortness of breath.
In the ED, initial vitals were: 97.6 74 132/68 18 99% 2L NC.
EKG: AF @ 86, NA, NI, TWI v2-4 are c/w prior, new ST dep in
v3-4. No STE. Rear leads w/o STE. Labs were notable for WBC 14.3
(85%N), INR 2.8, trop 0.32. Pt given morphine total of 4mg.
Patient's presentation is concerning NSTEMI given his extensive
history and ongoing pain. Pt continues have pain despite nitro
gtt and dose of morphine. Pt given further morphine and nitro
gtt uptitrate. His pain continuted but decreased to ___ and
then ___. Spoke with patient's cardiologist and the cardiology
fellow. Pt. received plavix-load (600mg) and start heparin gtt.
Vitals on transfer: 64 137/59 20 96% RA. Pt.'s nitro drip was
uptitrated and his CP resolved.
On arrival to the floor, pt reports no ongoing chest pain at
this time. Overall, he feels well. Continues to deny any
palpitations/SOB/Cough/lightheadedhess/dizziness/orthopnea/PND.
Past Medical History:
1. Coronary artery disease status post coronary artery bypass
grafting in ___ (2-vessel: LIMA-LAD, SVG-LPL), PERCUTANEOUS
CORONARY INTERVENTIONS ___ Tetra stent placed in ramus
intermedius; ___ Bare metal stent to LCx and balloon
angioplasty to ramus; ___ drug eluding stent placement x2 to
ramus and LCx (bifurcation stenting), ___ POBA to ramus);
ACS: NSTEMI ___
2. Bicuspid aortic valve status ___ mechanical
bileaflet prosthesis in ___ on warfarin
3. Tachy-brady syndrome status post dual chamber permanent
pacemaker placement in ___
- Atrial fibrillation and atrial flutter on amiodarone DC
cardioversion ___
- Diastolic dysfunction (LVEF 70% in ___
- Diabetes
- Dyslipidemia
- Hypertension
- Gastroesophageal reflux disease
- IgM kappa monoclonal gammopathy
- Asthma
- Iron deficiency anemia
- Macular degeneration
- Osteopenia
- Erectile Dysfunction
- Tremor
- Trigger finger
- Cervical radiculopathy
- Status post right cataract repair
Social History:
___
Family History:
Father with myocardial infarction at age ___. Mother died of
natural causes at ___. No h/o arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission physical
VS: 98.1, 70, 138/61, 18, Sat 97% on RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD 8cm at 45 degrees
CV: regular rhythm, early systolic decrescendo murmur heard best
at ___ increased on expiration
Lungs: Mild bibasilar crackles bilaterally, otherwise lungs are
clear
Abdomen: protuberant, soft, NT/ND, BS+
Ext: WWP, trace to 1+ ___ pitting edema bilaterally, no
clubinb/cyanosis, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Discharge physical
Tmax: 36.9 °C (98.5 °F)
Tcurrent: 36.8 °C (98.2 °F)
HR: 64 (64 - 81) bpm
BP: 137/59(79) {120/51(69) - 156/79(89)} mmHg
RR: 14 (10 - 26) insp/min
SpO2: 97%
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD 8cm at 45 degrees
CV: regular rhythm, early systolic ejection murmur heard best at
___ increased on expiration
Lungs: CTAB, no wheezes, rales, rhonci, or egophany
Abdomen: protuberant, soft, NT/ND, BS+
Ext: WWP, no ___ edema, no clubbing/cyanosis, 2+ distal pulses
bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
___ 05:35AM BLOOD WBC-15.7* RBC-4.35* Hgb-12.4* Hct-39.1*
MCV-90 MCH-28.4 MCHC-31.6 RDW-14.7 Plt ___
___ 05:45PM BLOOD Neuts-85.1* Lymphs-5.9* Monos-6.4 Eos-2.1
Baso-0.4
___ 05:35AM BLOOD ___ PTT-35.5 ___
___ 05:35AM BLOOD Glucose-166* UreaN-23* Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
___ 05:35AM BLOOD CK-MB-126* MB Indx-11.6* cTropnT-1.94*
___ 05:35AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
NOTABLE LABS:
___ 05:35AM BLOOD WBC-15.7* RBC-4.35* Hgb-12.4* Hct-39.1*
MCV-90 MCH-28.4 MCHC-31.6 RDW-14.7 Plt ___
___ 08:15PM BLOOD Hct-39.1* Plt ___
___ 02:05AM BLOOD WBC-20.5* RBC-4.21* Hgb-12.0* Hct-37.6*
MCV-89 MCH-28.4 MCHC-31.8 RDW-14.5 Plt ___
___ 05:15AM BLOOD WBC-28.1* RBC-4.15* Hgb-11.8* Hct-37.2*
MCV-90 MCH-28.4 MCHC-31.6 RDW-14.5 Plt ___
___ 05:15AM BLOOD Neuts-94.6* Lymphs-1.6* Monos-3.2 Eos-0.3
Baso-0.3
___ 05:35AM BLOOD ___ PTT-35.5 ___
___ 02:05AM BLOOD ___ PTT-33.2 ___
___ 05:15AM BLOOD ___ PTT-31.9 ___
___ 05:35AM BLOOD Glucose-166* UreaN-23* Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
___ 02:05AM BLOOD Glucose-199* UreaN-21* Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-25 AnGap-13
___ 05:15AM BLOOD Glucose-187* UreaN-20 Creat-0.8 Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
___ 11:55PM BLOOD CK(CPK)-1156*
___ 05:35AM BLOOD CK(CPK)-1082*
___ 08:15PM BLOOD CK(CPK)-718*
___ 05:45PM BLOOD CK-MB-79* MB Indx-12.2*
___ 05:45PM BLOOD cTropnT-0.32*
___ 11:55PM BLOOD CK-MB-151* MB Indx-13.1* cTropnT-1.56*
___ 05:35AM BLOOD CK-MB-126* MB Indx-11.6* cTropnT-1.94*
___ 08:15PM BLOOD CK-MB-62* MB Indx-8.6* cTropnT-1.82*
___ 02:05AM BLOOD CK-MB-39* MB Indx-8.4* cTropnT-1.27*
___ 11:18AM BLOOD CK-MB-28* cTropnT-0.91*
___ 05:35AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
___ 02:05AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0
___ 05:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
DISCHARGE LABS:
___ 04:58AM BLOOD WBC-22.9* RBC-3.99* Hgb-11.2* Hct-35.4*
MCV-89 MCH-28.0 MCHC-31.6 RDW-14.7 Plt ___
___ 04:58AM BLOOD ___
___ 04:58AM BLOOD Glucose-128* UreaN-24* Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
___ 04:58AM BLOOD Calcium-8.6 Phos-2.8 ___
Micro: None
IMAGING:
___ CXR - IMPRESSION: No acute cardiopulmonary process.
EKG: afib, 82, Q in III, TW flattening in precordial leads and
inferior leads; compared to ___ EKGs voltage differs in V3-V5
and previous TWI are no longer seen in these leads
2D-ECHOCARDIOGRAM:
___: The left atrium is elongated. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF = 50%) secondary to hypokinesis of the posterior and
lateral walls. Right ventricular chamber size and free wall
motion are normal. A bileaflet aortic valve prosthesis is
present. The transaortic gradient is higher than expected for
this type of prosthesis. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
resting posterior and lateral wall hypokinesis is now present.
TTE ___: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. A bileaflet aortic
valve prosthesis is present. The transaortic gradient is higher
than expected for this type of prosthesis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
ETT with Stress TTE ___:
TTE - Average functional exercise capacity. Ischemic ECG changes
with 2D echocardiographic evidence of regional wall motion
abnormalities at rest as detailed above. Worsening in wall
motion abnormalities (akinesis rather than hypokinesis) of the
same segments at achieved workload. Hypotensive response to
stress. Mild aortic regurgitation, mild to moderate mitral
regurgitation, and mild to moderate tricuspid regurgitation at
rest. Well seated mechanic aortic prosthesis with slightly
increased gradients (19mm valve). Moderate pulmonary artery
systolic hypertension.
Stress report - Marked significant EKG changes with ST elevation
in aVR in the setting of baseline AV pacing and IVCD at peak
exercise. Probable anginal type symptoms with a significant drop
in systolic blood pressure. Average functional capacity. Echo
report sent separately.
CARDIAC CATH:
___: 1. Selective coronary angiography of this right
dominant system revealed LAD, Ramus intermedius, SVG-OM
occlusions. The site of the previous LMCA stent and the previous
LCx stent was found to have no angiographically apparent flow
limiting stenoses. Please see interventional addendum for full
details. In shoft, the ramus intermedius was found to be
occluded and was crossed with some difficulty. Angioplasty was
performed with 2.0, 2.5, and 2.75 mm balloons and there was a
residual 20% stenosis
with normal flow. 2. Limited resting hemodynamics revealed
normal systemic arterial pressure at 117/60.
FINAL DIAGNOSIS:
1. Occlusion of the previously stented Ramus branch (ISR vs
thrombosis)
of undetermined age.
2. Successful POBA.
3. If recurrent symptoms, stenting would be possible from the
femoral
approach. Evidence of viability in this territory would be ideal
prior
to re-intervention.
4. DAPT minimum 1 month, ideally ___ year.
Repeat Cath ___: Coronary angiography: right dominant
LMCA: Widely patent. LAD: Occluded proximally LCX: There
was a 20% stenosis in the proximal LCx at the prior stent sites.
There was a ___ stenosis in the ramus branch at the site of
POBA yesterday. There were two layers of prior
stents in this region and incomplete balloon expansion
consistent
with vessel rigidity. RCA: Co-dominant/non dominant by prior
cath SVG-LPL: Occluded on prior angiography LIMA-LAD: Widely
patent. There was a 50-60% stenosis in the LAD just after the
touchdown of the LIMA-LAD that is essentially unchanged from
prior examination. The mid to distal LAD was a
small-medium sized vessel. Interventional details There were
no culprits for rest pain or EKG changes which would be
consistent with small vessel disease. Maximal medical therapy
will be pursued.
Assessment & Recommendations
1.Three vessel coronary artery disease
2.Patent LIMA to the LAD with intermediate disease in the LAD
3.Patent ramus at the prior POBA site performed for in-stent
restenosis
4.Occluded SVG to LPL by prior examination
Previous Cath ___:
Coronary angiography: right dominant
LMCA: Distal 40% into Ramus and OM.
LAD: Occluded ostially. Mild luminal irregularities after LIMA
touchdown with serial 40% lesions.
LCX: Ostial and proximal restenosis with 70% disease involving
bifurcation with Ramus.
RCA: Known small and nondominant. Not injected.
LIMA-LAD: Widely patent.
Ramus: Ostial 70% stenosis into previously placed stent.
--> drug eluding stent placement x2 to ramus and LCx
(bifurcation stenting)
Brief Hospital Course:
BRIEF SUMMARY STATEMENT:
___ w/ CAD s/p 2v CABG (LIMA-LAD, SVG-LPL) in ___ and multiple
stents ___ Tetra stent ramus intermedius; ___ BMS to LCx
and
balloon angioplasty to ramus; ___ DES x2 to ramus and LCx
(bifurcation stenting)), bicuspid aortic valve s/p ___
___ AVR ___ on coumadin, atrial fibrillation/flutter on
amiodarone, and tachy-brady syndrome s/p PPM placement in ___
presents with intermittent substernal chest pain x1d, trop leak
of 0.32, and EKG w/ t-wave inversions V2-V4 with 1mm ST
depressions V3-V4 c/w NSTEMI. The patient was placed on a nitro
gtt for chest pain and BP control. Cath on ___ showed patent
LMCA, LAD w/ proximal occlusion, occluded SVG->LPL (seen
previously), and LCX Ramus w/ occlusion. Pt. had LCx Ramus
balloon angioplasty performed for in-stent re-stenosis vs.
thrombosis. Patient was sent back to the cath lab on ___ for
persistent chest pain; no new culprit lesions were demonstrated,
LIMA-LAD SVG remained patent. The patient did well post-cath
and was continued on Plavix (no stents placed). Medical
optimiziation was pursued, his Imdur was uptitrated from 60 to
120 mg PO QD. Because he is now on triple anticoagulant
therapy, his goal INR for his mechanical valve should be
2.5-3.0.
ACTIVE ISSUES:
# NSTEMI: Pt presented with intermittent substernal CP
associated with a troponin leak of 0.32 and EKG changes
including t-wave inversions V2-V4 with 1mm ST depressions V3-V4
meeting criteria for NSTEMI. Pt's admission TIMI risk score of
6 placed the pt. in the high-risk category estimating his risk
of all-cause mortality, new or recurrent MI, or severe recurrent
ischemia requiring urgent revascularization in the next ___ days
at 41%. Pt. received 600mg plavix load in the ED and was placed
on a nitro drip. Heparin and coumadin were held in preparation
for cath (INR 2.8). Pt. had TTE which revealed LVEF 50%
secondary to hypokinesis of the posterior and lateral walls (new
compared to prior TTE on ___ int he region of the rams
with preserved function in the LAD territory) with a higher than
expected transaortic gradient higher than expected for his type
of prosthesis (chronic and stable). Pt. underwent cath on
___ which revealed showed patent LMCA, LAD w/ proximal
occlusion, occluded SVG->LPL (seen previously), and LCX Ramus w/
occlusion. Pt. had LCx Ramus balloon angioplasty performed for
in-stent re-stenosis vs. thrombosis. Patient was sent back to
the cath lab on ___ for persistent chest pain; no new culprit
lesions were demonstrated, LIMA-LAD SVG remained patent. Pt.
remained chest pain free 24 hours prior to discharge. His
medical regimen was continued with an increase of his imdur to
120mg Daily.
# Leukocytosis: WBC count 14 on admission with neutrophil
predominance thought to be ___ stress response to NSTEMI. His
WBC count continued to increase in the setting of receiving
methylprednisone for pre-allergy treatment of anticipated
contrast for cath. WBC was downtrending at time of discharge.
Throughout the hospital course, the pt. had no signs or symptoms
of infection.
CHRONIC ISSUES:
# Afib/Aflutter: Stable. Continued on coumadin for goal INR
2.5-3.0, diltiazem, and amiodarone.
# HTN: Stable. Pt's anti-hypertensives were initially held
given titration of blood pressure with nitro drip. His imdur
was increased at time of discharge while other home meds were
continued at their previous doses.
# T2DM: Stable. Placed on insulin sliding scale while in
hospital. Discharged on home dose of metformin.
# Asthma: Stable. Continued on regimen of memetasone inhaler
and singulair.
# GERD: Stable. Continued pantoprazole.
# BPH: Stable. Continued tamsulosin.
# Iron Deficiency Anemia: Stable. Continued ferrous sulfate.
TRANSITIONAL ISSUES:
# INR: At discharge, pt. with INR of 3.7 (up from 3.2 the day
previous). Pt. will be taking 5mg coumadin ___, 6mg on
___, and will be rechecking his INR on ___.
# Goal INR: Pt. with AVR with hx. afib/aflutter. Given this
history and given that pt. is on triple anticoagulation therapy
his optimal INR range should be between 2.5 to 3.0 (full
therapeutic range 2.5 to 3.5)
# Beta Blocker: Pt. had stated that he had not tolerated beta
blockage in the past. As such, one was not initiated on this
admission.
# Leukocytosis: Pt. had significant leukocytosis in the setting
of NSTEMI and pre-treatment with methylprednisone for contrast
allergy prior to cath. Pt. WBC downtrending at discharge.
Repeat CBC should be done to ensure return of normal WBC ___
days prior to discharge.
# Atorvastatin: Pt's atorva was increased from 40mg to 80mg on
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
3. Valsartan 60 mg PO BID
4. Amiodarone 100 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. coenzyme Q10 50 mg oral daily
9. Montelukast Sodium 10 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Atorvastatin 40 mg PO HS
13. Tamsulosin 0.4 mg PO HS
14. MetFORMIN (Glucophage) 500 mg PO DAILY
15. Warfarin 6 mg PO 5X/WEEK (___)
16. Warfarin 7 mg PO 2X/WEEK (MO,WE)
Discharge Medications:
1. Amiodarone 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO HS
4. Clopidogrel 75 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg 1 tablet extended release 24
hr(s) by mouth Daily Disp #*90 Tablet Refills:*3
7. Montelukast Sodium 10 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Tamsulosin 0.4 mg PO HS
10. Valsartan 60 mg PO BID
11. Warfarin 6 mg PO DAILY16
Starting ___
12. Warfarin 5 mg PO ONCE Duration: 1 Dose
For ___
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
14. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral BID
15. coenzyme Q10 50 mg ORAL DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Non-ST-segment elevation myocardial infarction (NSTEMI)
Secondary Diagnsoes:
1. Coronary artery disease status post coronary artery bypass
grafting in ___ (2-vessel: LIMA-LAD, SVG-LPL), PERCUTANEOUS
CORONARY INTERVENTIONS ___ Tetra stent placed in ramus
intermedius; ___ Bare metal stent to LCx and balloon
angioplasty to ramus; ___ drug eluding stent placement x2 to
ramus and LCx (bifurcation stenting), ___ POBA to ramus)
2. Bicuspid aortic valve status ___ mechanical
bileaflet prosthesis in ___ on warfarin
3. Tachy-brady syndrome status post dual chamber permanent
pacemaker placement in ___. Atrial fibrillation and atrial flutter on amiodarone
5. Diastolic dysfunction (LVEF 70% in ___
6. Diabetes
7. Dyslipidemia
8. Hypertension
9. Gastroesophageal reflux disease
10. IgM kappa monoclonal gammopathy
11. Asthma
12. Iron deficiency anemia
13. Macular degeneration
14. Osteopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to ___ with chest
pain and found to have a heart attack (NSTEMI). You underwent
cardiac catherization, which found an occluded artery. We
opened this artery with a balloon (no stents were placed). We
then treated you with medications. You had some persistent
chest pain after this and had a repeat catheterization which
showed no new or additional blockages. You had one episode of
mild chest pain following this procedure but no additional chest
pain. We continued you on a blood thinner medication that you
will go home on (Plavix). We also increased increased your
Imdur from 60 mg to 120 mg per day. Because you were started on
a new blood thinner, you will need to have your INR monitored
closely after discharge to make sure your blood is not too thin.
You remained stable and were discharged home. Please follow-up
with your PCP and your cardiologist.
Thank you for allowing us to participate in your care.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
19981210-DS-31 | 19,981,210 | 25,095,273 | DS | 31 | 2149-01-17 00:00:00 | 2149-02-06 01:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast
Media
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
-___: Right heart catheterization
-___: Cardioversion
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a past medical
history significant for AVR, CAD s/p CABG and PCI with stent
placement in proximal LCx and ramus, and asthma who presented to
the ED with complaint of dyspnea. He was recently admitted in
___ for shortness of breath which was attributed to pneumonia.
Since that hospitalization, he felt that his breathing never
returned to baseline. Previously, he was able to do
approximately 45 minutes of exercise on the treadmill however
after his recent discharge he has only been able to get up to
___ minutes.
His dyspnea on exertion failed to improve, and over the past
several days he noted increasing shortness of breath and even
some SOB at rest. He also endorses orthopnea (having to sleep on
several pillows at night), abdominal distension, peripheral
edema, and very slight weight gain (approximately 2lbs).
___ also notes that he had a failed cardioversion
approximately 2 weeks ago as an outpatient and hasn't felt well
since.Last echo in ___ showed mild global LV systolic
dysfunction, 1+ MR. ___ does not wear O2 at home, reports
compliance with medications. Denies any recent diet changes or
salty meals. Started on lasix 2 weeks ago.
In the ED, labs were notable for elevated BNP, supratherapeutic
INR, and troponin 0.06. Exam with mild respiratory distress,
+JVD, irregularly irregular. Crackles at bases bilaterally. ___
Pitting edema and ___ was admitted to the heart failure
service.
On the floor, ___ is comfortable. Not currently short of
breath. ___ no chest pain, no current complaints. Pt does
endorse a productive cough which is baseline for him with his
asthma.
Past Medical History:
1. CAD s/p CABG in ___ (2-vessel: LIMA-LAD, SVG-LPL), PCIs
___ Tetra stent placed in ramus intermedius; ___ Bare
metal stent to LCx and balloon angioplasty to ramus; ___ ___
___ x2 to ramus and LCx (bifurcation stenting), ___
POBA to ramus); ACS: NSTEMI ___.
2. Bicuspid aortic valve status ___ mechanical
bileaflet prosthesis in ___ on warfarin
3. Tachy-brady syndrome status post dual chamber permanent
pacemaker placement in ___
- Atrial fibrillation and atrial flutter on amiodarone s/p
cardioversion ___, failed cardioversion ___
- Diastolic dysfunction (LVEF 70% in ___
- Diabetes
- Dyslipidemia
- Hypertension
- Gastroesophageal reflux disease
- IgM kappa monoclonal gammopathy
- Asthma
- Iron deficiency anemia
- Macular degeneration
- Osteopenia
- Erectile Dysfunction
- Tremor
- Trigger finger
- Cervical radiculopathy
- Status post right cataract repair
Social History:
___
Family History:
Father with myocardial infarction at age ___. Mother died of
natural causes at ___. No h/o arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
General: friendly gentleman, conversant, resting comfortably in
no acute distress
HEENT: NC/AT, PERRL, MMM
Neck: +JVD, supple full ROM
CV: Regular rate, irregularly irregular rhythm. Nl S1, S2. soft
systolic murmur. No rubs or gallops.
Lungs: crackles at bases bilaterally, no wheezes
Abdomen: Soft, moderately distended, non-TTP, bowel sounds
present
GU: No foley
Ext: bilateral ___ pitting edema R>L
Neuro: CN ___ intact. Motor function grossly normal, alert and
oriented x3
Skin: no rashes
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T 98.1, HR 76, BP 113/59, RR 16, 02 sat 95% RA
Weight: 62.8<--69.3
General: sitting up in bed eating breakfast, NAD
HEENT: MMM, OP clear
Neck: JVD 8cm
CV: RRR, +systolic murmur, mechanical valve
Lungs: CTA b/l, no crackles or wheezes
Abdomen: Soft, non-tender
GU: No foley
Ext: trace edema in ___ b/l
Pertinent Results:
ADMISSION LABS
==============
___ 11:32AM BLOOD WBC-10.3 RBC-3.64* Hgb-9.6* Hct-31.0*
MCV-85 MCH-26.4* MCHC-31.0 RDW-16.0* Plt ___
___ 11:32AM BLOOD Neuts-84.6* Lymphs-5.1* Monos-7.9 Eos-2.2
Baso-0.2
___ 11:32AM BLOOD ___ PTT-35.4 ___
___ 11:32AM BLOOD Plt ___
___ 11:32AM BLOOD Glucose-181* UreaN-24* Creat-0.9 Na-143
K-3.8 Cl-108 HCO3-26 AnGap-13
___ 11:32AM BLOOD proBNP-2420*
___ 11:32AM BLOOD cTropnT-0.06*
___ 11:32AM BLOOD Calcium-9.2 Phos-2.1* Mg-1.9
DISCHARGE LABS
==============
___ 07:05AM BLOOD WBC-11.9* RBC-4.28* Hgb-11.0* Hct-35.7*
MCV-83 MCH-25.7* MCHC-30.8* RDW-15.3 Plt ___
___ 07:05AM BLOOD ___
___ 07:05AM BLOOD Glucose-123* UreaN-38* Creat-1.3* Na-140
K-4.1 Cl-99 HCO3-32 AnGap-13
___ 07:05AM BLOOD Calcium-9.9 Phos-3.8 Mg-2.1
OTHER PERTINENT LABS
====================
___ 11:12PM BLOOD CK-MB-4 cTropnT-0.10*
___ 06:40AM BLOOD CK-MB-5 cTropnT-0.07*
___ 06:40AM BLOOD TSH-<0.02*
REPORTS
=======
___ CXR: Stable cardiomegaly, increased b/l pleural
effusion, insterstitial pulmonary edema.
___ TTE: The left atrium is mildly dilated. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed, with regional variation (LVEF = 35 %). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. The mitral valve leaflets are mildly thickened.
Moderate to severe (3+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function is worse; mitral and tricuspid
regurgitation is also worse.
___ REST THALLIUM STRESS: Moderate size, moderate severity
defect seen in the left circumflex territory
with some partial redistribution seen on 4 and 24 hour images.
___ Right heart cath: Hemodynamics: elevated filling
pressures with moderate pulmonary hypertension
Assessment & Recommendations
1. Elevated filling pressures with moderate pulmonary
hypertension and hypoxemia.
2. Continue diuresis as per CHF team.
Brief Hospital Course:
___ with h/o CAD s/p 2v CABG (LIMA-LAD, SVG-LPL) in ___ and
multiple stents, bicuspid aortic valve s/p AVR ___, atrial
fibrillation/flutter, and tachy-brady syndrome s/p PPM placement
in ___ presented w/SOB found to have CHF exacerbation, now s/p
successful cardioversion and diuresis. Has been in NSR since
cardioversion.
ACTIVE ISSUES
=============
# Systolic and Diastolic HF: Pt reported increasing SOB in the
setting of abdomen and ___ edema and slight weight gain. CXR
showed pulmonary edema and bilateral pleural effusions which are
increased from prior. Elevated BNP. Repeat TTE ___ with
decreased EF from ___ (50% -> 35%), worsened TR and MR. ___
suspicion for low gradient low flow AS based on Dr. ___
___. Right heart cath ___ significant for elevated filling
pressures, with further diuresis recommended. Ddx for CHF
includes CAD (Stress test with new defect with LCx territory),
amiodarone toxicity. Afib also may have contributed; now in
sinus s/p cardioversion. Pt remained volume overloaded so
diuresis was continued and prior to discharge ___ was
transtioned to PO torsemide (had been on lasix 20mg PO daily at
home).
# CAD: Last TTE showed left ventricular systolic function as low
normal (LVEF = 50%) with mild global hypokinesis. Troponin 0.06
on admission labs, up to 0.10, down to ___ AM. Likely
secondary to CHF exacerbation and not ACS. ___ did have an
episode of chest discomfort ___ AM which he attributes to his
afib/anxiety. Similar to his chronic episodes at home, and EKG
unchanged. Likely represent chronic angina, pt reports episodes
when HR>100. Repeat TTE with EF worsened to 35%. Restarted
beta-blocker ___. Stress test ___ showed for moderate size,
moderate severity defect seen in the left circumflex territory.
Will hold off on cardiac cath for now, may reconsider
outpatient. ___ was discharged on increased valsartan dose
from 60mg (home) to 80mg. He was continued on home ASA/plavix,
atorvastatin, imdur, and metoprolol as below.
# Afib/Aflutter: CHADS 2 = 3 (HTN, age, DM). ___ on coumadin
5mg qd at home however INR supratherapeutic on admission so
intially held. Of note, pt had recent cardioversion which failed
to convert back to sinus rhythm. Pacer interrogation ___
significant for persistent AF since ___ with average V rates
<100bpm, max V rate 137 bpm, and 34% V pacing since ___. Per
EP recs, considering re-attempt at cardioversion now that he has
received higher dose amiodarone x 1 month. INR down to 2.7 on
___ labs and warfarin restarted at home dose. Metoprolol
restarted ___ at 12.5 qd (had been on previously then
discontinued by ___ outpatient secondary to worsening
asthma/COPD so had not been taking prior to admission), then
uptitrated to 25mg qd ___. Now s/p successful cardioversion ___
AM. Rhythm remains regular. Home diltiazem discontinued ___.
Metoprolol increased to 50mg qd on ___. On discharge,
amiodarone dose decreased to 200mg qd.
# Leukocytosis: pt with persistent leukocytosis, up to 13 on AM
labs ___, ___ elevated at 12.6 ___. UA ___ without evidence
for UTI. Pt without any symptoms or clinical signs of infection,
likely a stress response.
# Abdominal distension: Also present on ___ recent
admission where he was fluid overloaded; attributed to volume
overload at that time and reduced with diuresis. Now resolved
with diuresis.
CHRONIC ISSUES
==============
# HTN: continued home regimen as above, with newly increased
valsartan dose, and added metoprolol on this admission.
# T2DM: held home metformin while inpatient, and ___
received sliding scale insulin.
# Asthma: on home symbicort, albuterol PRN. Pt received Advair
in house as symbicort not formulary and pt did not have his
inhaler with him.
# GERD: continued home pantoprazole
# BPH: continued home tamsulosin
TRANSITIONAL ISSUES
===================
-___ being discharged home with ___ to help with medication
changes, heart failure teaching
-Will have labs drawn ___: INR, electrolytes that should
be followed-up
-TTE with significantly decreased EF since 6 weeks prior
-Consider repeat TTE on an outpatient basis now that pt is
diuresed
-Multiple cardiac medication changes: please refer to sheet
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, sob
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Diltiazem Extended-Release 120 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Tamsulosin 0.4 mg PO HS
12. TRIAzolam 0.125 mg PO HS:PRN insomnia
13. Valsartan 60 mg PO BID
14. coenzyme Q10 50 mg oral daily
15. MetFORMIN (Glucophage) 500 mg PO QHS
16. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral daily
17. Amiodarone 300 mg PO DAILY
18. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs BID
19. Furosemide 20 mg PO DAILY
20. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
BID
21. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, sob
2. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet by mouth once a day Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Tamsulosin 0.4 mg PO HS
11. TRIAzolam 0.125 mg PO HS:PRN insomnia
12. Valsartan 80 mg PO BID
RX *valsartan [Diovan] 80 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Warfarin 5 mg PO DAILY16
14. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet by mouth once a day Disp
#*30 Tablet Refills:*0
15. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet by mouth once a
day Disp #*15 Tablet Refills:*0
16. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablets by mouth once a day Disp #*60
Tablet Refills:*0
17. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
BID
18. coenzyme Q10 50 mg ORAL DAILY
19. MetFORMIN (Glucophage) 500 mg PO QHS
20. Nitroglycerin SL 0.4 mg SL PRN chest pain
21. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral daily
22. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
23. Outpatient Lab Work
Lab draw ___
-INR
-Complete electrolyte panel
Please fax results to: Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
-Systolic and diastolic heart failure
SECONDARY DIAGNOSES
===================
-Coronary artery disease
-Mitral regurgitation
-Atrial fibrillation
-Hypertension
-Hyperlipidemia
-Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you were having shortness of breath
and leg and abdomen swelling consistent with heart failure
exacerbation. You were also in atrial fibrillation.
While here, you had an echocardiogram which showed decreased
ejection fraction. You also had a right heart catheterization
which confirmed fluid overload.
You underwent cardioversion which successfully converted you out
of atrial fibrillation, and you have been in normal sinus rhythm
since.
Now that the extra fluid has been diuresed off and you have been
transitioned to oral diuretic medication you are ready to be
discharged to continue your recovery at home with home visiting
nurse service. You will need to have labs drawn on ___. This
can be done either by the visiting nurse or at a lab.
It is important that you continue to weigh yourself every
morning, call MD if weight goes up more than 3 lbs. Continue to
eat a sodium restricted (<2000mg) diet and take your medications
as directed below.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19981210-DS-33 | 19,981,210 | 27,919,282 | DS | 33 | 2152-01-03 00:00:00 | 2152-01-03 16:35:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast
Media
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a past medical history of CAD with a very
complex course including multiple stents, CHF, DM who presents
with substernal chest pain. Chest pain occurred last night at
rest. Took nitro and was able to sleep and then woke up with
worsened chest pain and mild SOB. The pain improved after 3
nitroglycerin from a 6 out of 10 to 3 out of 10 and decided to
go to ___. Trop neg there and CXR neg, received NTG and
then xfer to ___ for further eval given complex cardiac
history. Trop here negative. CP is now ___, attributes to
taking his home medicines. Took full dose aspirin this morning.
In the ___ initial vitals were:
98.0 76 131/76 14 96% RA
EKG: paced
Labs/studies notable for: trop < 0.01
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
1. Coronary artery disease s/p t CABG & PCI.
- NSTEMI ___ s/p cath and POBA to Ramus stent,
- recath showing patent stent.
- extremely complicated anatomy unamenable to complete
revascularization
2. Bicuspid aortic valve s/p aortic valve replacement ___
3. Atrial fibrillation and atrial flutter
- dronedarone and warfarin
- amiodarone
- PPM
4. Amiodarone therapy complicated with thyroiditis managed by
endocrine service.
5. Mild diastolic dysfunction.
6. Cath for positive stress test in ___: 3 vessel cad
- 60-70% proximal lesion in the LCx.
- 30% in-stent restenosis of the ramus.
- Patent LIMA->LAD. Totally occluded SVG->OM1.
USA ___ CTO PCI of Ramus with PTCA alone
7. EF - 50%-55%.
3. OTHER PAST MEDICAL HISTORY
- Diabetes mellitus.
- Hypertension.
- Dyslipidemia.
- Iron deficiency anemia (previously on iron supplementation,
discontinued ___.
- History of a colon polyp.
- Asthma.
- Macular degeneration.
- Osteopenia.
Social History:
___
Family History:
Father with myocardial infarction at age ___. Mother died of
natural causes at ___. No h/o arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
VS: afebrile BP 133/72 HR 75 RR 18 O2 SAT 97 RA
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP non elevated
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, systolic murmur, (+) click
LUNGS:Resp were unlabored, no accessory muscle use. No crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses dopplerable
DISCHARGE EXAM:
- VITALS: 119 / 54R Lying 76 20 96 RA
- I/Os: even
- WEIGHT: 67.7 kg
- WEIGHT ON ADMISSION: 67.1
- TELEMETRY: paced
GENERAL: WDWN M comfortable in bed. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP non elevated
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, systolic murmur, (+) click
LUNGS:Resp were unlabored, no accessory muscle use. Mild basilar
crackles L>R
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
Pertinent Results:
ADMISSION LABS:
___ 12:55PM cTropnT-<0.01
___ 05:24PM WBC-10.6* RBC-3.87* HGB-9.4* HCT-30.3*
MCV-78* MCH-24.3* MCHC-31.0* RDW-18.6* RDWSD-51.9*
___ 05:24PM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.1
___ 05:24PM CK-MB-3 cTropnT-<0.01
___ 05:24PM GLUCOSE-100 UREA N-26* CREAT-1.4* SODIUM-139
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
ECHO ___
The left atrial volume index is moderately increased. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF = 50%) secondary to focal
inferior posterior hypokinesis. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
The right ventricular free wall thickness is normal. The right
ventricular cavity is mildly dilated with normal free wall
contractility. A bileaflet aortic valve prosthesis is present.
The transaortic gradient is higher than expected for this type
of prosthesis. Trace aortic regurgitation is seen. [The amount
of regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
no major change.
___ CXR
IMPRESSION:
1. Obscured right heart border may be secondary to atelectasis
versus a
consolidation. Recommend lateral view to further evaluate for a
right middle
lobe pneumonia.
2. Mild fluid overload new since the prior study.
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-11.1* RBC-4.62 Hgb-12.1* Hct-37.4*
MCV-81* MCH-26.2 MCHC-32.4 RDW-20.2* RDWSD-56.4* Plt ___
___ 08:20AM BLOOD Neuts-76* Bands-1 Lymphs-9* Monos-6 Eos-6
Baso-0 ___ Myelos-2* AbsNeut-8.78* AbsLymp-1.03*
AbsMono-0.68 AbsEos-0.68* AbsBaso-0.00*
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD Glucose-109* UreaN-31* Creat-1.6* Na-138
K-3.7 Cl-102 HCO3-23 AnGap-17
___ 07:55AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.3
___ 08:40AM BLOOD TSH-12*
Brief Hospital Course:
___ h/o CAD, HFpEF, AF s/p PPM, DM p/w chest pain and negative
trops, ecg at baseline.
- CORONARIES: s/p CTO of ramus stent
- PUMP: 50
- RHYTHM: paced
ACTIVE ISSUES:
==================================
#Chest Pain/CAD: c/f unstable angina improves with nitrates.
Given known inoperable CAD, attempted medical optimization. This
was complicated by HAP that developed on ___. After hemodynamic
stabilization and antibiotics, his discharge regimen was metop
37.5 mg daily, imdur 30 daily, ASA/Plavix, atorva 80, spirono
12.5, and torsemide 20 mg daily. TSH elevate to 12, likely from
nonadherence. Should have recheck in 4 weeks and titrate as
outpt
#HAP: ___ with new URI symptoms congestion. CXR on ___ c/f RML
PNA given new obscuring of R heart border. Hypotension on ___
out of proportion to patient's medication regimen c/f septic
shock requiring approx. 12 hours of pressor support. He was
fluid resuscitated and transfused 1u prbc for downtrending Hb
and outpt provider goal of ___ 10. Micro data was unrevealing
though MRSA swab negative. Vanc/cefepime started ___ and
stopped on ___. Transitioned to Levofloxacin 750 mg po q48hrs
based on renal clearance on ___. Will have last dose ___.
Should be monitored closely for COPD exacerbation, which did not
occur while inpt.
#CHF/HTN: meds as above. euvolemic on discharge. DC weight 67.7
#Afib, PPM: CHADS-5 cont amio 100 mg daily, daily dose warfarin.
INR on dc was 2.5. Given levoflox, ___ w/ 4 mg daily. Needs
INR check ___
#Iron Deficiency Anemia: Patient with history of MUGS, iron
deficient anemia with MCV 78 ferritin <20. Patient with history
of colon polyps. Per outpatient PCP, concern for GI bleed, plan
outpatient was EGD +/- colonoscopy; patient has negative guiaiac
stools card from PCP and no bloody bowel movements while
inpatient. In terms of MGUS, patient follows with Dr. ___,
___ visit ___ noted stability of IgM kappa MGUS. Per GI
will do outpt scope given better outcomes and intermittent CP in
house and no urgency to scope at this time. ___ with po iron
and bid ppi
CHRONIC/STABLE ISSUES:
==================================
#COPD: stable on RA. cont inhalers - symbicort not on formulary
will use advair, cont singulair. Patient refused advair
throughout admission for throat irritation.
#CKD: developed ___ after septic shock. improving and stable by
discharge.
#DM: appears no long on metformin. ISS
#Hypothyroid: cont home synthroid 88mcg ___ 132 mcg). TSH
12, needs outpt med titration and f/u
#GERD: cont ppi
#BPH: cont Flomax
#MGUS: stable, outpt f/u.
#insomnia: hold benzo, offer ramelteon
TRANSITIONAL ISSUES:
- Please ensure outpt GI workup
- Please titrate anti-angina and anti-hypertensives. Discharged
on metop 37.5 mg daily, imdur 30 mg daily, spironolactone 12.5
mg daily, torsemide 20 mg daily
- Please restart ___ when able
- HAP: ___ on levoflox 750mg q48 hrs. QTC 476. Last dose ___
- INR: 2.5 on dc. 4 mg daily given levoflox. please recheck ___
and adjust prn
- Please get BMP at next visit to assess renal function
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___)
7. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___)
8. Metoprolol Succinate XL 50 mg PO BID
9. Montelukast 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. Tamsulosin 0.4 mg PO QHS
14. TRIAzolam 0.125 mg PO QHS:PRN insomnia
15. Valsartan 80 mg PO DAILY
16. Warfarin 5 mg PO DAILY16
17. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
18. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
19. Spironolactone 12.5 mg PO DAILY
20. Torsemide 30 mg PO DAILY
21. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
RX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5
mg-7.5 mg ___ lozenge(s) by mouth four times a day Disp #*32
Lozenge Refills:*0
3. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 ml by mouth four times a day
Refills:*0
4. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*3 Tablet Refills:*0
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Metoprolol Succinate XL 37.5 mg PO DAILY
RX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
8. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
10. Amiodarone 100 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
14. Clopidogrel 75 mg PO DAILY
15. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___)
16. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___)
17. Montelukast 10 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. Spironolactone 12.5 mg PO DAILY
21. Tamsulosin 0.4 mg PO QHS
22. TRIAzolam 0.125 mg PO QHS:PRN insomnia
23. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral
DAILY
24. Warfarin 5 mg PO DAILY16
25. HELD- Valsartan 80 mg PO DAILY This medication was held. Do
not restart Valsartan until you see your doctor in clinic for
blood pressure check
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Unstable angina
HAP
Secondary diagnoses:
Iron deficiency anemia
CAD
Atrial fibrillation
HTN
COPD
Diabetes
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 at ___.
WHY DID I HAVE TO STAY IN THE HOSPITAL?
You had to stay in the hospital because of chest pain.
You also had to stay in the hospital because of a pneumonia, aka
lung infection.
WHAT WAS DONE FOR ME?
Your medications were adjusted for your chest pain.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
You should take your medications as prescribed.
Please take your antibiotics (levofloxacin) at 8 pm on ___,
___, and ___
Please do not take valsartan until you see your regular doctors
in ___ and discuss it with them.
Please check your blood pressure every day and call your doctor
if the systolic blood pressure (the top number) is LESS THAN 90.
Please have an INR check on ___.
Please follow up with your regular doctors.
___ yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your Medical Team
Followup Instructions:
___
|
19982305-DS-10 | 19,982,305 | 28,629,030 | DS | 10 | 2161-05-14 00:00:00 | 2161-05-14 10:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
Left hemiarthroplasty
History of Present Illness:
___ year old female with history of hypertension (untreated)
presents after slip and fall on the stairs with immediate right
hip pain and inability to ambulate. Denies HS, LOC, pain
elsewhere. Denies dizziness, SOB, CP or other syncopal symptoms.
Patient is a community ambulatory and lives with daughter and
other family. She is able to walk for grocery shopping and
getting up and stairs on her own at baseline.
Past Medical History:
Hypertension
Social History:
___
Family History:
NC
Physical Exam:
LLE:
Dressing intact
Fires ___
SILT DPN/SPN
Foot perfused, palp DP pulse
Pertinent Results:
___ 01:29PM K+-4.0
___ 12:40PM URINE HOURS-RANDOM
___ 12:40PM URINE UHOLD-HOLD
___ 12:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 12:40PM URINE RBC-19* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-6
___ 10:45AM GLUCOSE-126* UREA N-23* CREAT-0.8 SODIUM-137
POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21*
___ 10:45AM estGFR-Using this
___ 10:45AM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9
___ 10:45AM WBC-11.2* RBC-4.41 HGB-14.3 HCT-42.8 MCV-97
MCH-32.4* MCHC-33.4 RDW-14.7 RDWSD-52.0*
___ 10:45AM NEUTS-81.7* LYMPHS-12.1* MONOS-5.4 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-9.16*# AbsLymp-1.36 AbsMono-0.61
AbsEos-0.01* AbsBaso-0.02
___ 10:45AM PLT COUNT-175
___ 10:45AM ___ PTT-28.2 ___
Brief Hospital Course:
Hospitalization Summary
The patient presented to the emergency left femoral neck
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ after being
preoperatively cleared by medical service, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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:
- Weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. Please do not bathe or soak for 4 weeks.
- Please change dressing every ___ days or more frequently if
needed for drainage.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with ___ in the Orthopaedic
Trauma Clinic ___ days post-operation for evaluation. Please
call ___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
19982483-DS-11 | 19,982,483 | 28,983,948 | DS | 11 | 2184-03-26 00:00:00 | 2184-03-28 12:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R Shoulder pain
Major Surgical or Invasive Procedure:
ORIF R proximal humerus fracture
History of Present Illness:
___ s/p mechanical fall this AM onto Right side in home
bathroom hitting Right shoulder on toilet with immediate pain
and swelling. Developed gradual onset of RUE parasthesias and
later wrist extension weakness at ___, ___, transferred to
___ for evaluation. No loss of pulses or cool distal
extremity, no open injuries. Endorses head strike without LOC,
no neck/back pain, mild headache relieved with Tylenol.
Past Medical History:
Hypothyroid, hyperlipidemia. s/p hysterectomy, cholecystectomy,
breast mass removal, abdominal lysis of adhesions
Social History:
___
Family History:
NC
Physical Exam:
98.0 95 137/67 16 98%
NAD, AAOx3
RUE - shoulder moderately swollen, tender, skin intact
WWP distally, 2+ radial pulse
Sensation diminished radial nerve distribution compared to left,
median/ulnar/axillary intact
Motor: shoulder exam limited by pain, triceps/biceps fire, ___+/5
wrist flexion, ___ finger flexion, ___ finger abduction.
Pertinent Results:
LABS:
11.6 > 37 < 292
INR 0.9
Electrolytes WNL
U/A negative
IMAGING:
Xrays Right shoulder reviewed supine and standing films, notable
for 3-part proximal humerus fracture with articular surface
humeral head moderately intact, metaphyseal fracture, glenoid
appears intact. Shaft medially displaced, Greater tuberosity
superiorly displaced. Moderate reduction of angulation with
gravity films.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with a R proximal humerus fracture. Patient was taken
to the operating room and underwent ORIF R proximal humerus
fracture. Patient tolerated the procedure without difficulty
and was transferred to the PACU, then the floor in stable
condition. Please see operative report for full details.
Musculoskeletal: prior to operation, patient was ___.
After procedure, patient's weight-bearing status was
transitioned to ___ RUE, in sling at all times and orthoplast
splint at all times. Throughout the hospitalization, patient
worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
morphine IV and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's HCT was stable and she did not
require any blood transfusions during this hospitalization.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received aspirin during this stay, and
was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on aspirin for
DVT prophylaxis for 4 weeks post-operatively. All questions
were answered prior to discharge and the patient expressed
readiness for discharge.
Medications on Admission:
levothyroxine 100mcg, pravastatin, Vit D, MVI
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Senna 1 TAB PO BID
7. Pravastatin 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
9. Multivitamins 1 CAP PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R proximal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 will be taken out at your
2-week follow up appointment. No dressing is needed if wound
continues to be non-draining.
******WEIGHT-BEARING*******
- Non weight bearing R upper extremity w/sling at all times,
orthoplast cock-up wrist splint on at all times
- No right shoulder Range of Motion, elbow/wrist/finger ROM ok
******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 Aspirin 325mg PO daily for 4 weeks to prevent blood clots
Physical Therapy:
- NWB RUE w/sling at all times, orthoplast cock-up wrist splint
at all times
- no right shoulder ROM, elbow/wrist/finger ROM ok
Treatments Frequency:
Daily dressing change - dry sterile dressing overlay
Followup Instructions:
___
|
19982539-DS-17 | 19,982,539 | 23,136,520 | DS | 17 | 2175-06-04 00:00:00 | 2175-06-04 12:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R sided weakness, language difficulties
Major Surgical or Invasive Procedure:
___ - Thrombectomy TICI IIb reperfusion
___ - Left hemicraniectomy for decompression
___ - PEG placement
___ - Right frontal EVD placement in OR
___ - Left wound washout and revision
___ - Removal of right frontal EVD
___ - Right VPS placement, ___ Strata
History of Present Illness:
Mr. ___ is a ___ yo man with history of poorly controlled HTN
who
presents as transfer from ___ with change
in speech and right-sided weakness.
Mr. ___ was LKW at 2300 ___ ___ when he was seen by his
mother before going to bed. She heard a 'thump' at approx. 0200
and found him in the kitchen 'fumbling' in the sink. He said "I
think I need some help, Mom". When she asked what was wrong, he
said 'oatmeal' indicating he had dropped a bowl of oatmeal,
leading to the thump. She helped him get dressed, and noted that
he was dropping things out of his right hand.
He was then taken to ___ at ___, where
CTA
reportedly showed M2 cutoff. Blood pressure on presentation was
208/101, HR 79. He was treated with IV labetalol 10 mg x3 then
nicardipine gtt. He received ASA 325 at 0322. He was
subsequently
transferred for consideration of thrombectomy.
Regarding his history, his mother states that he has known
hypertension. He was recently experiencing severe headaches,
went
to his PCP, and was started on BP medications.
Past Medical History:
Hypertension
Social History:
___
Family History:
Father with hypertension and three strokes, CEA
Mother with atrial myxoma and valve replacement
Physical Exam:
ADMISSION EXAM:
==============
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: RRR. Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert. No speech, occasional nonsyllabic
vocalizations. Does not repeat even monosyllabic words. Follows
some very simple commands (open/close eyes, look up) but opens
mouth when asked to stick out tongue and holds up forefinger
when
asked to show thumbs up. Some perseveration.
-Cranial Nerves: Gaze conjugate. Gaze rests to the left, crosses
midline with VOR. R facial droop.
- Motor: Normal bulk. Decreased tone R hemibody. RUE 2 at
bi/tri, no movement distally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 0 ___ 0 0 0 4 5 3 0
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 2 2 2 1
R 0 2 2+ 2
Plantar response was flexor on the left, extensor on the right.
-Sensory: Grimace to noxious R hemibody. Withdraws RLE from
noxious.
- Coordination: No dysmetria with finger to nose testing LUE.
- Gait: unable to ambulate.
DISCHARGE EXAM:
==============
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Nonverbal, patient with expressive aphasia,
grunts
Follows commands: [x]Simple [ ]Complex [ ]None
Pupils: PERRL 4-3mm bilaterally
EOM: Full throughout
Speech Fluent: [ ]Yes [x]No - Expressive Aphasia
Comprehension intact [x]Yes [ ]No
Motor:
LUE/LLE follows commands and moves purposely with ___ strength
strength.
RUE with no movement to noxious.
RLE withdraws to noxious.
Incision: Clean, dry and intact; closed with sutures and
staples.
Pertinent Results:
Please see OMR for pertinent results
Brief Hospital Course:
#MCA infarct
Pt presented w/ CTA showing L M2 cutoff. Underwent thrombectomy
w/ TICI IIb reperfusion. He initially was transferred from PACU
to ___ where he was found to have increased somnolence. Pt
underwent stat CT which appeared stable and was transferred to
NeuroICU. Upon arrival, pt's mentation appeared to improve. EEG
was placed and was without seizure activity. On hospital day 2,
he developed anisacoria secondary to cerebral edema and uncal
herniation. Mannitol was started and his mental status improved.
Mannitol was discontinued on ___ (within 48hrs) after Na >155
and sOsm>320. On ___, he developed an acute change with
increasing somnulence and minimal responsiveness. STAT non-con
head CT was obtained and he was found to have progression of
cerebral edema with herniation. He was taken for STAT
hemicraniectomy without complications. JP drain was removed on
POD#2. He was extubated on ___. Once he was stable and
transferred to to the ___.
#Dyspgagia
His swallowing was periodically evaluated and did not improve,
therefore, a PEG tube was placed. He tolerated tube feeds. On
___, trials of nectar were initiated which the patient
tolerated.
#Seizure
He had left arm seizure following hemicraniectomy and was
started on Keppra 1g PO BID which should be taken as prescribed.
#MRSA infection/External Hydrocephalus
Hemicraniectomy incision had small amount of serous drainage and
was closely monitored. Additional suture and staple was placed
with improvement, however on ___ he was noted to have
significant purulent, yellow drainage from craniectomy incision.
Decision was made to place EVD for persistent CSF leak. He was
taken to the OR for placement and given 1 unit platetes prior
for recent Aspirin use. R frontal EVD was placed and wound was
washed out. Pus was seen intraoperatively and cultures were
sent. Please see operative report by Dr. ___ full
details. He was transferred to the ___ for recovery and EVD
was open to 10. Postop head CT showed expected surgical changes.
Infectious disease was consulted and he was empirically started
on Vancomycin and Cefepime ___. He was transferred to the ___
on Neurosurgery service. CSF culture grew MRSA and Cefepime was
discontinued. Vanco was continued and adjusted per ID for
therapeutic trough. He continued to have yellow drainage from
incision. EVD height was lowered and tight head wrap was placed
in attempt to divert flow. Unfortunately he continued to leak,
and he was taken back to the OR on ___ for wound washout and
revision with Dr. ___. Procedure was uncomplicated. For
further procedure details, please see separately dictated
operative report by Dr. ___ was extubated in the operating
room and transported to the PACU for recovery. Once stable, he
was transferred to the ___ for close neurological monitoring.
Cultures were taken and eventually grew out MRSA. He was
continued on Vancomycin per ID with dose adjusted according to
trough. He underwent trial to wean EVD and incision began
leaking. Patient was brought to the OR on ___ for VPS
placement. The VPS was set to 1.0. He was extubated in the
operating room and transferred to the PACU for recovery. He was
later transferred to the ___ for close neurologic monitoring.
Shunt adjusted to 2.0 on ___. Final ID plan is continue
vancomycin until ___ then transition to doxycycline 100mg
BID PO. Patient will follow up with ID outpatient.
#Urinary Retention
The patient's foley catheter was discontinued on ___.
#Dispo
Although physical therapy recommended rehab, his placement was
complicated by the lack of a HCP. His mother elected to be the
HCP but his placement required a guardian to be assigned.
Guardianship was obtained and it was determined he would be
medically ready for rehabilitation on ___. He was
discharged to rehab on ___ in good condition with instructions
for follow up.
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 = 114) - () 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: held given bleeding risk
[ ] Statin medication allergy
[x ] 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? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - x() No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist -->
bleeding risk
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: (x)
Antiplatelet - Aspirin 325() Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. amLODIPine 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Bisacodyl 10 mg PO/PR DAILY Constipation
6. Docusate Sodium 100 mg PO BID
7. FLUoxetine 20 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Heparin 5000 UNIT SC BID
10. Hydrochlorothiazide 50 mg PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing
12. Labetalol 300 mg PO Q6H
13. LevETIRAcetam 1000 mg PO Q12H
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Nicotine Patch 21 mg TD DAILY
16. Nystatin Oral Suspension 5 mL PO QID oral thrush
17. OLANZapine (Disintegrating Tablet) 2.5 mg PO TID:PRN
agitation
18. Thiamine 100 mg PO DAILY
19. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
20. Vancomycin 1000 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left MCA Infarct
Uncal Herniation
Hydrocephalus
Wound Infection
Dysphagia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Surgery
You underwent a surgery called placement of a right VP shunt
which is a ___ Strata Valve set to 2.0.
You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You must
wear a helmet when out of bed at all times.
Please keep your sutures and staples along your incision dry
until they are removed.
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 have been discharged on Keppra (Levetiracetam) as you
experienced a seizure during this hospitalization. This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
Infectious Disease Recommendations
You have been discharged on Vancomycin 1000 mg IV Q12H which
will be continued through ___. At that time, you will
need to be transitioned to Doxycycline 100mg PO BID.
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 ___ 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:
___
|
19982541-DS-12 | 19,982,541 | 20,860,014 | DS | 12 | 2148-12-02 00:00:00 | 2148-12-02 17:08:00 |
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:
___: Successful US-guided placement of ___ pigtail
catheter into the gallbladder.
History of Present Illness:
Patient is a ___ male with a history of hypertension,
stroke in ___, hyperlipidemia, question of MI in 1980s, who
presents with several weeks of intermittent right upper quadrant
abdominal pain. He reports he first had an episode of pain
lasting 2 or 3 hours 3 weeks ago which resolved with Tylenol.
He had a second episode of pain about a week ago, and today
started having severe pain worse than his previous episodes that
did not go away so he presented to ___ where
he was found to have cholecystitis and a hepatic abscess. He was
transferred to ___ for further management. He reports that
since he received morphine he does not have any right upper
quadrant abdominal pain, he denies fever/chills,
nausea/vomiting, dyspnea or chest pain. He reports that he is
lost approximately 40 pounds intentionally over the past 10
months. His last colonoscopy was ___ years ago and normal. He
denies any blood in the stool. He has never had any abdominal
surgeries.
Past Medical History:
Hypertension
MI
Hyperlipidemia
Stroke
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Physical Exam on Admission ___:
Vitals: 101.3 86 130/62 16 99% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Breathing comfortably on room air
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Physical Exam on Discharge ___:
VS: Temp 98.7 Oral BP 165/79 HR 76 RR 18 O2 Sat 94% RA
GEN: NAD. A+Ox3.
CV: Regular rate and rhythm
Pulm: Lung sounds clear bilaterally
Abd: Soft, large, non-tender. +BS. RLQ perc chole tube in place
with bilious drainage. Dsg C/D/I. No erythema or hematoma noted.
Ext: Warm, well-perfused. No pain or edema.
Pertinent Results:
Lab Values:
___ 05:30AM BLOOD WBC-6.5 RBC-3.83* Hgb-11.1* Hct-34.9*
MCV-91 MCH-29.0 MCHC-31.8* RDW-13.8 RDWSD-46.2 Plt ___
___ 06:02PM BLOOD Neuts-74.6* Lymphs-13.5* Monos-10.0
Eos-0.8* Baso-0.2 Im ___ AbsNeut-6.92* AbsLymp-1.25
AbsMono-0.93* AbsEos-0.07 AbsBaso-0.02
___ 04:25AM BLOOD ___
___ 05:30AM BLOOD Glucose-113* UreaN-12 Creat-1.4* Na-140
K-4.1 Cl-101 HCO3-26 AnGap-13
___ 04:25AM BLOOD ALT-22 AST-15 AlkPhos-83 TotBili-0.4
___ 05:30AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1
___ 06:21PM BLOOD Lactate-0.7
Brief Hospital Course:
Mr. ___ is a ___ year old male with a PMH significant for
HTN, HLD, MI, and stroke (___), who presented to OSH and had CT
imaging which showed acute cholecystitis and a hepatic abscess.
He was transferred to ___ on ___ for further management.
He was admitted to the Acute Care Surgery service and made NPO
and started on IV fluids and IV antibiotics. The Interventional
Radiology service was consulted for a percutaneous
cholecystostomy, which was done on ___. Upon return to the
floor, the patient was started on a clear liquid diet. The next
day on HD1, he was advanced to a regular diet, which he was
tolerating well. He was transitioned from IV antibiotics to PO
antibiotics (Augmentin) on HD1 to finish a 10 day course. His
abdominal pain had resolved. He was having bilious drainage from
the percutaneous cholecystostomy tube.
During this hospitalization, the patient voided without
difficulty and was ambulating. The patient received subcutaneous
heparin and venodyne boots were used during this stay. Nursing
performed teaching with the patient on drain care and the
patient verbalized understanding. At the time of discharge on
___, the patient was doing well. He was afebrile and vital
signs were stable. The patient was discharged home with ___
services set up. Discharge teaching was completed and follow-up
instructions were reviewed with reported understanding and
agreement. He will follow up in the Acute Care Surgery clinic
and with his PCP.
Medications on Admission:
1. amLODIPine 5 mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Labetalol 300 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Please do not exceed 3gm in a 24 hour period.
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
End date ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*18 Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. Labetalol 300 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Intrahepatic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were transferred to ___ on
___ for evaluation of abdominal pain and were found to have
acute cholecystitis (inflammation of your gallbladder) with an
abscess in your liver. You were evaluated by the acute care
surgery team and interventional radiology. You subsequently
underwent placement of a percutaneous cholecystostomy tube. You
tolerated this procedure well. You have since been tolerating a
regular diet, ambulating, and your pain has resolved. You are
now ready for discharge home with ___ services. 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.
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.
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:
___
|
19982872-DS-22 | 19,982,872 | 22,448,158 | DS | 22 | 2156-12-13 00:00:00 | 2156-12-14 06:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ year-old Female with a PMH significant for
hypertension, GERD, osteoarthritis and recurrent pharyngitis
(scheduled for tonsillectomy next week) who presents with
acute-onset abdominal pain for 3-days.
.
The patient notes the acute onset of sharp and stabbing
abdominal pain in the umbilical region that began 3-days prior
and was non-radiating and non-positional, but worse with
movement. The pain is not relieved with Tylenol, Tums or
Mylanta. She associates the pain with some loose, non-bloody and
formed stools with nausea, but without emesis. She has had
increased stool frequency in the last few days. She continues to
pass flatus and is having BMs. She has no fevers or chills or
back pain. She notes decreased interest in food over several
days without significant unintentional weight loss. She denies
dysuria or hematuria. No cough or URI symptoms. No sick
contacts. She had a colonoscopy many years prior at ___.
___ which documented some internal hemorrhoids.
.
In the ED, initial VS 98.7 128 148/87 16 100% RA. Her exam was
notable for diffuse abdominal pain, worse in the RUQ. Her
laboratory studies were remarkable for a WBC 11.3 with
neutrophilia of 78.4% without bandemia. Her LFTs and creatinine
were normal. Lactate 1.8. She had a CT abdomen and pelvis that
demonstrated 1.6-cm high density rounded structure along the
transverse mesocolon with significant inflammatory changes (new
since ___, concerning for a colonic diverticulum that appeared
inflamed with concern for microperforation. She was evaluated by
___ surgery who felt there were no acute surgical indications.
She received Zofran 4 mg IV x 1 and Morphine 4 mg IV x 1 for
relief.
.
On arrival to the floor, she appears comfortable without
complaints.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Hypertension
2. Reflux esophagitis, GERD
3. Osteoarthritis
4. Recurrent pharyngitis (scheduled for tonsillectomy)
5. Fibromyalgia
6. Unexplained chronic anemia (likely iron deficiency anemia;
work-up by Dr. ___ in ___
7. s/p appendectomy ___ years prior)
8. s/p tubal ligation
9. s/p Cesarean section
Social History:
___
Family History:
Her mother had hypertension and died of a stroke. Her father
also had hypertension. No malignancy history of note.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 98.6 80 130/80 18 99% RA
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, tender in the RLQ and epigastrum, non-distended, with
normoactive bowel sounds. No palpable masses or peritoneal
signs. No rebound tenderness or guarding. No CVA tenderness.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength ___ bilaterally, sensation grossly intact. Gait
deferred.
.
DISCHARGE EXAM:
.
VITALS: 100.6 99.7 ___ 18 99% RA weight: 79.9 kg
I/Os: 1160 / 300 | 700
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, minimally tender in the epigastrum to deep palpation,
non-distended, with normoactive bowel sounds. No palpable masses
or peritoneal signs. No rebound tenderness or guarding. No CVA
tenderness.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength ___ bilaterally, sensation grossly intact. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
.
___ 05:45AM BLOOD WBC-11.3* RBC-4.07* Hgb-12.1 Hct-33.4*
MCV-82 MCH-29.6 MCHC-36.2* RDW-12.7 Plt ___
___ 05:45AM BLOOD Neuts-78.4* Lymphs-17.7* Monos-3.1
Eos-0.4 Baso-0.3
___ 05:45AM BLOOD Glucose-108* UreaN-15 Creat-0.9 Na-134
K-3.8 Cl-99 HCO3-23 AnGap-16
___ 05:45AM BLOOD ALT-15 AST-16 AlkPhos-65 TotBili-0.6
___ 05:45AM BLOOD Lipase-23
___ 05:45AM BLOOD Albumin-4.4 Calcium-10.0 Phos-3.8 Mg-1.8
___ 05:53AM BLOOD Lactate-1.8
.
DISCHARGE LABS:
.
___ 08:00AM BLOOD WBC-12.3* RBC-4.13* Hgb-12.3 Hct-34.6*
MCV-84 MCH-29.8 MCHC-35.6* RDW-12.8 Plt ___
___ 08:00AM BLOOD Glucose-104* UreaN-16 Creat-1.1 Na-135
K-3.7 Cl-98 HCO3-24 AnGap-17
___ 08:00AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0
.
URINALYSIS: None
.
MICROBIOLOGY DATA:
___ Blood cultures (x 2) - pending
.
IMAGING:
___ CT ABD & PELVIS WITH CO - 1.6 cm high-density rounded
structure along transverse mesocolon with significant
surrounding inflammatory changes, new since ___, in
similar location to a previously seen transverse colonic
diverticulum, suggestive of diverticulitis or appendagitis with
an eroding fecalith with
possible microperforation. An enhancing mass is felt less likely
but cannot be excluded on this contrast-enhanced study, and
could be further assessed with a limited non-contrast CT through
this region in a few hours. Cholelithiasis without evidence to
suggest cholecystitis.
.
___ CT LIMITED ___ SCANS - Again demonstrated is a 1.6 cm
high-density rounded structure along the transverse mesocolon
with significant associated inflammatory changes, stable
compared to prior study from 6:53 am the same day and new since
___. This mass is in a similar location to a previously
seen transverse colon diverticulum and suggests diverticulitis
or appendigitis with an eroding fecolith with microperforation.
Brief Hospital Course:
IMPRESSION: ___ with a PMH significant for HTN, GERD,
osteoarthritis and recurrent pharyngitis who presents with
3-days of acute onset right upper quadrant abdominal pain found
to have 1.6-cm diverticulum of the transverse mesocolon with
inflammatory changes and concern for microperforation.
.
# TRANSVERSE MESOCOLON DIVERTICULITIS WITH ABDOMINAL PAIN - The
patient presents with only a history of presumed gastritis
associated with epigastric pain in ___ with CT imaging at that
time that was reassuring. She now presented with 3 days of acute
RUQ abdominal pain and a mild leukocytosis with shaking chills
but fevers. A CT abdomen and pelvis demonstrated evidence of a
transverse mesocolon diverticulum with surrounding inflammation.
She was without clinical evidence of obstruction. After
reviewing the imaging study, it was felt that a large 1.6-cm
fecalith had impacted in the transverse colonic diverticulum
resulting in inflammation and microperforation. We treated her
with IV Ciprofloxacin and Flagyl and transitioned her to PO
antibiotics once her pain improved. She was seen by
Gastroenterology who felt she would require a colonoscopy as an
outpatient once the inflammation subsides, with possible
intervention. If this proves difficult, she will see Dr.
___ ___ surgery and discuss possible surgical
intervention at a later time. Surgery felt there were no acute
surgical indications on admission. Her exam improved with
antibiotics, bowel rest and pain medication and she was
discharged in stable condition. She was tolerating a liquid
diet. She will remain on oral antibiotics for a total of
1-month.
.
# HYPERTENSION - Diagnosis of essential hypertension with
outpatient blood pressures ranging from 120-140 mmHg systolic on
recent clinic visits in late ___. Has been maintained on
beta-blocker only. We continued her Atenolol 25 mg PO daily
without issue.
.
# REFLUX ESOPHAGITIS, GERD - History of intermittent epigastric
complaints with negative work-up. She has been utilizing a PPI
and we continued Omeprazole 20 mg EC PO BID on admission.
.
TRANSITION OF CARE ISSUES:
1. Patient will continue on 1-month of oral antibiotics to be
completed as an outpatient; Ciprofloxacin and Flagyl starting
___ and ending ___.
2. At the time of discharge, blood cultures from admission were
without growth, but were still pending.
3. She has outpatient Gastroenterology and primary care
physician ___ scheduled and will likely undergo
colonoscopy following improvement in her symptoms and resolution
of her inflammation, in the next ___ weeks. If there is
unsuccessful endoscopic intervention to remove the impacted
fecalith, she may require surgical consultation (which will need
to be scheduled) as an outpatient to discuss possible partial
colonic resection.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Atenolol 25 mg PO daily
2. Clobetasol 0.05% ointment applied to affected area at night
3. Fluticasone 50 mcg ___ sprays INH QHS
4. Omeprazole 20 mg EC PO BID
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clobetasol 0.05 % Ointment Sig: One (1) application Topical
at bedtime: applied to affected areas.
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: ___
sprays Nasal at bedtime.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 30 days: starting ___, ending ___.
Disp:*90 Tablet(s)* Refills:*0*
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 30 days: starting ___, ending ___.
Disp:*60 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain: AVOID taking this medication if you anticipate
driving or if you are consuming alcohol.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Acute uncomplicated transverse colonic divericulitis
.
Secondary Diagnoses:
1. Hypertension
2. Reflux esophagitis, GERD
3. Osteoarthritis
4. Recurrent pharyngitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your abdominal pain. On CT imaging you were found to have a
small outpouching or diverticulum of your transverse colon which
was inflamed and likely infected. The Gastroenterology team felt
you would best be managed with oral antibiotics and then you
would undergo an outpatient colonoscopy following discharge. If
they are unable to handle the issue via endoscopy, you will
___ with surgery for possible operative intervention in
the future. Once your clinical exam improved, your pain was
controlled and you were tolerating PO intake, you were
discharged with oral antibiotics for 1-month.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Ciprofloxacin 500 mg by mouth twice daily for 30-days
(started ___, ending ___
START: Flagyl (Metronidazole) 500 mg by mouth three times daily
for 30-days (started ___, ending ___
START: Oxycodone 5 mg ___ tablets) by mouth every ___ hours, as
needed for pain. AVOID taking this medication if you anticipate
driving or if you are consuming alcohol.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
___
|
19982896-DS-22 | 19,982,896 | 23,285,325 | DS | 22 | 2157-07-27 00:00:00 | 2157-07-27 20:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old female with a history of
cholecystectomy who presents to the ED from home with abdominal
pain.
In early ___ she first developed RUQ/epigastric pain. She was
found to have an elevated alkaline phosphatase and subsequent
MRCP showed a small fluid-filled structure in the porta hepatis
and a dilated cystic duct remnant. On ___ she underwent
ERCP with sphincterotomy and spyglass cholangioscopy where
filling defects were noted in the gallbladder neck although
scope could not traverse a valve so not amenable to therapy.
Following the procedure she was observed overnight and
discharged home with minimal pain.
The day prior to admission she developed severe epigastric pain.
This was associated with nausea but no vomiting. No fevers or
chills, no blood in stool, no jaundice.
In the ED, initial vitals were:98.4 55 149/85 18 98% RA. Patient
was given morphine and zofran. Currently abdominal pain is ___.
Past Medical History:
hypothyroid
depression
hypo-vitamin d
esophagitis
prior knee meniscal tear
Social History:
___
Family History:
Father with skin cancer
Mother in good health in ___
Physical Exam:
Vitals: T: 98.4 BP: 154/80 HR: 84 RR: 18 O2: 99%RA
General: lying on left side, awake and alert, mild
uncomfortable
HEENT: dry mucus membranes
Neck: no cervical LAD appreciated
CV: S1, S2 regular rhythm, normal rate
Lungs: CTA bilaterally, unlabored respirations
Abdomen: soft, mild TTP epigastric, no rebound, no guarding
GU: no foley
Ext: no edema
Neuro: alert, oriented to self, hospital, date, speech fluent,
tongue midline
Pertinent Results:
___ 04:40PM BLOOD WBC-8.3# RBC-4.69 Hgb-13.8 Hct-41.1
MCV-88 MCH-29.4 MCHC-33.5 RDW-13.0 Plt ___
___ 04:40PM BLOOD Neuts-64.6 ___ Monos-6.4 Eos-1.0
Baso-0.6
___ 04:40PM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-25 AnGap-16
___ 04:40PM BLOOD ALT-14 AST-18 AlkPhos-144* TotBili-0.5
___ 04:40PM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.7 Mg-1.9
___ 04:40PM BLOOD Lipase-17
Final Report
INDICATION: Cholecystectomy ___ years ago, abdominal pain, found
to have stone
in the cystic duct remnant/gallbladder neck.
COMPARISON: Abdominal ultrasound on ___.
TECHNIQUE: MDCT images were obtained through the abdomen first
without IV
contrast, and subsequently following the administration of IV
contrast in the
arterial and portal venous phases. Coronal and sagittal
reformats were
performed.
FINDINGS: There is mild bibasilar dependent atelectasis.
Visualized heart
and pericardium are unremarkable.
The liver is normal in contour and there are no focal hepatic
lesions. There
is no intrahepatic biliary duct dilatation. A clip is seen
either within a
seroma in the gallbladder fossa or in the remnant cystic duct
which would be
dilated. There is mild fat stranding adjacent to the
gallbladder fossa. The
pancreas is normal. The spleen is normal. The adrenal glands
are normal.
The kidneys are normal. No hydronephrosis. The visualized
portions of the
small and large bowel are unremarkable. The appendix is
visualized and
unremarkable. There is no free air. There is no mesenteric or
retroperitoneal lymphadenopathy.
CTA: The celiac artery and its major branches are patent. The
SMA and its
major branches are patent. The origin of the ___ is patent.
The portal vein
is patent. The aorta is normal in caliber.
BONES: There is a hemangioma in the T12 vertebral body. There
are
mild-to-moderate degenerative changes of thoracolumbar spine.
No suspicious
osseous lesions.
IMPRESSION: Findings consistent with inflammation of either a
chronic seroma
or remnant cystic duct with a surgical clip within the lumen of
the structure.
No stones are identified in the CBD.
Brief Hospital Course:
___ year old female with a history of cholecystectomy who
presents to the ED from home with abdominal pain found to have
inlammatory changes consistent with cholecystitis of the
remanant portion of her cystic duct. She had cholecysectomy
performed ___ years ago. Earlier in ___ she underwent ERCP
with sphincterotomy and spyglass evaluation of cystic duct but
her pain recurred prompting this admission. Imaging during this
admission included RUQ ultrasound and abdominal CT. The
ultrasound showed 13mm stone in the cystic duct but I reviewed
her abdominal CT with radiology and the finding on ultrasound
more likely represents a prior surgical clip rather than stone
based on appearance on CT. This area was deemed to be too small
to target with ___ drainage. The pancreaetico-biliary surgery
service consulted and with input from the ERCP team, we agreed
that she will be treated with antibiotics for 10 days, have
outpatient follow up with surgery and then elective
cholecystectomy when her inflammation improves. Oral
cipro/flagyl were started on ___ and should be continued for 10
days. She has follow up with Dr. ___ on ___. She was given
instructions to take ibuprofen or percocet for RUQ pain. She
was tolerating POs and had no pain prior to discharge.
.
#HYPOTHYROID:
-continue dhome levothyroxine
.
#DEPRESSION:
-continued home fluoxetine
.
#GERD:
-continued home PPI
Discharge Medications:
1. Fluoxetine 60 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*24 Tablet Refills:*0
6. Vitamin D 800 UNIT PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
8. Docusate Sodium 100 mg PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Ibuprofen 600 mg PO Q8H:PRN pain
over the counter
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were hospitalized with abdominal pain. CT of your abdomen
showed cholecystitis of the remaining portion of your gall
bladder. you will benefit from discussing removing the
remaining portion of the gallbladder with Dr. ___. For now we
recommend antibiotic treatment until you are ready for surgery.
You will take two antibiotics for the next ___ days
Followup Instructions:
___
|
19982989-DS-16 | 19,982,989 | 28,630,229 | DS | 16 | 2150-12-22 00:00:00 | 2150-12-22 13:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
dyspnea, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
============================
This is an ___ ___ gentleman with a history
notable for HFpEF (EF 50% in ___, ?COPD, dementia, T2DM and
BPH
who presents from nursing home with dyspnea and hypoxia.
Per the patient's daughter, Mr. ___ was diagnosed with a
UTI at his nursing home one week prior to admission and was
treated with antibiotics (cefpodoxime?). He also endorsed
shortness of breath and cough during this week. On ___ his
lasix
was changed from 40 mg PO QD to 20 mg PO TID, and on ___ he
received 40 mg PO BID. On ___ he became more short of breath
and
was noted to be sating 77-83% on RA. He received 3 stacked nebs
without improvement in his oxygenation. EMS was called and they
placed him on CPAP with improvement in his O2 sat and he was
taken to the ___ ED.
In the ED,
- Initial Vitals: T 103.8, HR 83, BP 151/78, RR 20, 99% on CPAP
- Exam:
General: On a BiPAP, alert and oriented
HEENT: Normal oropharynx, no exudates/erythema
Cardiac: RRR , no chest tenderness
Pulmonary: Diffuse crackles bilaterally.
Abdominal/GI: Normal bowel sounds, no tenderness or masses
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted.
3+ pitting edema up to the knees
Neuro: Sensation intact upper and lower extremities, strength
___
upper and lower, no focal deficits noted, moving all extremities
- Labs:
- WBC 14.8 (90% N), Hgb 11.3, Plt 248
- AST 26, ALT 21, AP 169, Tbili 1.2, Alb 3.3
- Na 142, K 4.6, Cl 102, HCO3 19, BUN 34, Cr 1.8, Gluc 152,
AGap 21
- proBNP 2263, trop <0.01
- Lactate 3.5
- VBG: pH 7.38, pCO2 48
- UA: Large Leuk, Nitr Pos, >182 WBC, Mod Bact
- Imaging:
- CXR: Lungs are low volume with increase in volume of
bilateral pleural effusions right greater than left. Pulmonary
edema has worsened. Consolidative opacities in both lower lobes
right greater than left have also worsened. No pneumothorax.
There is worsening pulmonary vascular congestion
- Consults: N/A
- Interventions: Placed on BiPAP ___ FiO2 50%, cefepime 2g,
metronidazole 500 mg, 40mg IV Lasix
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
-BPH
-Hypercholesterolemia.
-Hypertension.
-Head lesion after falling off a horse many years ago
-Shoulder surgery status post motor vehicle accident
-h/o prostate surgery
-Olfactory groove Meningioma
-T2DM
-L hip replacement
Social History:
___
Family History:
Heart disease and lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: Reviewed in ___
GENERAL: Elderly man, agitated and picking at IV lines.
HEENT: NCAT. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
LUNGS: Bilateral expiratory wheezes, bilateral crackles at lung
bases.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
palpation
EXTREMITIES: Warm, 2+ edema in b/l lower extremities
NEUROLOGIC: Moving all extremities spontaneously
DISCHARGE PHYSICAL EXAM
========================
VS: WNL
GENERAL: Alert, smiling sitting up in bed with no conversational
dyspnea, very animated this AM
EYES: Anicteric, PERRL
ENT: Ears and nose without visible erythema, masses, or trauma.
MMM
CV: RRR, +S1, +S2, no S3/S4, no murmurs, unable to assess JVD
given large neck radius
RESP: B/L crackles tracking to lower lung fields. Breathing is
non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: Condom cath in place draining clear yellow urine. No
suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, No ___ edema B/L
SKIN: No rashes or ulcerations noted
NEURO: A+O x 1.5 (identified hospital, his doctor and named
family members not present, chronically unable to identify
year/month/president) face symmetric, gaze conjugate with EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:24PM ___ PO2-33* PCO2-43 PH-7.42 TOTAL CO2-29
BASE XS-2
___ 05:24PM LACTATE-3.7*
___ 02:40PM LACTATE-5.8*
___ 10:09AM URINE HOURS-RANDOM CREAT-24 SODIUM-101
___ 10:09AM URINE OSMOLAL-334
___ 10:09AM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 10:09AM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 10:09AM URINE RBC-6* WBC->182* BACTERIA-MOD*
YEAST-NONE EPI-0
___ 10:05AM ___ PO2-32* PCO2-48* PH-7.38 TOTAL
CO2-29 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-PERIPHERAL
___ 10:05AM LACTATE-3.5*
___ 09:50AM GLUCOSE-152* UREA N-34* CREAT-1.8* SODIUM-142
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-21*
___ 09:50AM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-169* TOT
BILI-1.2
___ 09:50AM LIPASE-12
___ 09:50AM cTropnT-<0.01
___ 09:50AM proBNP-2263*
___ 09:50AM ALBUMIN-3.3* CALCIUM-9.1 PHOSPHATE-4.2
MAGNESIUM-1.8
___ 09:50AM WBC-14.8* RBC-3.91* HGB-11.3* HCT-38.4*
MCV-98 MCH-28.9 MCHC-29.4* RDW-14.6 RDWSD-51.8*
___ 09:50AM NEUTS-89.7* LYMPHS-5.3* MONOS-3.8* EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-13.31* AbsLymp-0.78* AbsMono-0.57
AbsEos-0.03* AbsBaso-0.04
___ 09:50AM PLT COUNT-248
IMAGING
=======
CXR ___
Lungs are low volume with increase in volume of bilateral
pleural effusions right greater than left. Pulmonary edema has
worsened. Consolidative opacities in both lower lobes right
greater than left have also worsened. No pneumothorax. There
is worsening pulmonary vascular congestion
Renal US ___. No evidence of stones or hydronephrosis.
2. Complex cystic structure at the left upper renal pole
measuring 1.9 cm
without evidence of internal vascularity, possibly representing
a complex cyst but cannot exclude the possibility of an abscess.
Reccomend follow-up with dedicated CT or MRI with contrast for
further characterization.
TTE ___
There is mild regional left
ventricular systolic dysfunction with basal to mid infeiror wall
hypokinesis (see schematic) and preserved/normal contractility
of the remaining segments. The visually estimated left
ventricular
ejection fraction is 55%. Mild symmetric left ventricular
hypertrophy with mild regional systolic dysfunction most
consistent with single vessel coronary artery disease (PDA
distribution). Moderate pulmonary hypertension.
CXR (___)
Bilateral pulmonary edema is mildly decreased. The pleural
effusion with associated bibasilar atelectasis is unchanged, a
superimposed focal consolidation cannot be excluded.
Cardiomediastinal silhouette is stable. There is no
pneumothorax.
WBC: 8.5 <-- 11.3 <-- 14 <-- 20.7
Cr: 2.2 <-- 2.4 <-- 2.5 <-- 2.3 (B/L 1.8)
HCO3: 31 <-- 28 <-- 29 <-- 30 <-- 22
Mg: 2.3
K: 4.0
Lac: 1.4
BNP: 2263 on admission
VBG: pH 7.37, pCO2 55
UA: >182 WBC, Mod bacteria, +Nitrite, ___
BCx: Pending
UCx: E Coli
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
No prior positive UCx
Brief Hospital Course:
This is an ___ gentleman with a history notable for
HFpEF
(EF 50% in ___, ?COPD, dementia, T2DM and BPH who presents
from
nursing home with 1 week of dyspnea found to have crackles and
edema on exam, CXR with pulmonary edema and elevated proBNP all
consistent with a heart failure exacerbation and pneumonia. In
addition, he has
a dirty UA, leukocytosis, and fever suggestive of acute
complicated UTI.
ACUTE ISSUES
=======================
# HFpEF exacerbation
# Hypercarbic respiratory failure
Patient presented with dyspnea (sating 77-83% on RA at nursing
home) which improved on non-invasive ventilation. Was treated
with BiPAP in MICU and improved rapidly with diuresis and
antibiotics. Time course of improvement (<24 hours) c/w diuresis
and not PNA treatment. Furthermore, denies any cough and no
focal
consolidation on CXR (obscured by pulm edema and effusions).
Treating for HF exacerbation. TTE shows LVEF 55%
with mild inferior wall hypokinesis, elevated PCWP (>18),
moderate pulmonary artery systolic hypertension. Concern that
home Lasix dose (40mg QD) was recently changed to 20mg TID which
may be contributing to HF Exac. Likely trigger is UTI (treatment
below)
Pump
- C/w Lasix 40mg PO QD with goal Net even. Given that patient
is on RA and improving ___ c/w home 40mg PO Lasix QD
- Chem should be checked at facility on ___ to ensure
improvement of creatinine. If Cr > 2.3, then hold Lasix and
hydrate orally for 48 hours. If Cr equal to 2.3, then decrease
Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg
PO QD and resume home Metop Succ XL 200mg PO BID.
- C/w home Isosorbide Mononitrate ER 30mg PO QD given SBP
150-170
- C/w home amlodipine 10mg PO QD
- Incentive spirometry to stent open atelectatic alveoli in
lower
lung field due to shallow breathing
Rhythm: NSR on ECG
Ischemia: C/f CAD on TTE given mild inferior wall hypokinesis.
Given neg trop and ECG w/o ischemic features, no concern for ACS
event. Will empirically start atherosclerotic therapy
- ASA 81mg QD
- ___ year ASCVD risk 17.4%, started Atorva 40mg PO QD
- Will need outpatient coronary angiogram pending patient/family
preference
# Acute complicated UTI
# Leukocytosis
Acute complicated E. Coli UTI sensitive to Bactrim and
Macrobid. Given age > ___ and CrCl < ___, Macrobid is relatively
contraindicated. Will start Bactrim knowing that this may
artificially elevated serum Cr without changing CrCl. Given lack
of productive cough, improving hypoxemia with diuresis, and no
discrete focal consolidation on CXR, no need for empiric tx for
PNA. Renal US with e/o renal cyst c/f abscess but given lack of
fever, improving leukocytosis and clinical improvement with Abx,
unlikely to be loculated abscess.
- D/c Bactrim SS QD x 10 days (___)
___ on CKD (B/L Cr 1.8)
Worsening chronologically with IV diuresis in ICU. Differential
includes prerenal azotemia vs Type I CRS vs ATN. No e/o
post-obstruction (renal US without hydro, bladder scan < 200cc).
No e/o granular casts on ___. CKD likely ___ DM
(A1c 7.0%). Improving with PO hydration on home Lasix 40mg PO
QD.
- C/w home 40mg PO Lasix
- Encourage PO intake
- Chem should be checked at facility on ___ to ensure
improvement of creatinine. If Cr > 2.3, then hold Lasix and
hydrate orally for 48 hours. If Cr equal to 2.3, then decrease
Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg
PO QD and resume home Metop Succ XL 200mg PO BID given HR ___.
# Long QT
# Dementia
# Delirium
Combination of toxic metabolic encephalopathy ___ UTI and
in-hospital delirium. Mentation improved dramatically with
treatment of UTI. Suspect continued improvement with transfer to
a familiar setting (namely his nursing facility)
CHRONIC ISSUES
=======================
# Anemia
Iron studies, B12, folate all wnl in ___. Potentially ___
chronic cardiac or renal disease
# Hypothyroidism
Continued home levothyroxine
# T2DM
Continued home glargine with low dose ISS
# Hypertension
Continued home amlodipine, isosorbide mononitrate
# BPH
Continued home finasteride, tamsulosin
To Do:
[] Complete Bactrim Bactrim SS QD x 10 days (___)
[] Chem should be checked at facility on ___ to ensure
improvement of creatinine. If Cr > 2.3, then hold Lasix and
hydrate orally for 48 hours. If Cr equal to 2.3, then decrease
Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg
PO QD and resume home Metop Succ XL 200mg PO BID given HR ___.
[] Once infection is complete and Cr and returned to baseline,
consider outpatient cardiology evaluation for coronary angiogram
to assess for CAD
I spent 40 mins in discharge planning, coordination of care, and
patient/family education.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO QHS
2. Tamsulosin 0.4 mg PO QHS
3. Polyethylene Glycol 17 g PO EVERY OTHER DAY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Finasteride 5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Lactulose 30 mL PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. GuaiFENesin ___ mL PO BID
12. Metoprolol Succinate XL 200 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. melatonin 3 mg oral QHS
15. Glargine 9 Units Bedtime
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 9 Days
4. Glargine 9 Units Bedtime
5. amLODIPine 10 mg PO DAILY
6. Docusate Sodium 100 mg PO QHS
7. Finasteride 5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. GuaiFENesin ___ mL PO BID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Lactulose 30 mL PO DAILY
12. Levothyroxine Sodium 50 mcg PO DAILY
13. melatonin 3 mg oral QHS
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO EVERY OTHER DAY
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. Tamsulosin 0.4 mg PO QHS
18. Vitamin D 400 UNIT PO DAILY
19. HELD- Metoprolol Succinate XL 200 mg PO BID This medication
was held. Do not restart Metoprolol Succinate XL until Pending
repeat creatinine and potassium on ___, if stable or improving,
can resume
20.Outpatient Lab Work
Please check a chemistry on ___. If Creatinine >2.3, please
hold Lasix for 48 hours and recheck creatinine. If Cr equal to
2.3, please decrease dose of Lasix to 20mg PO QD. If Cr <2.3,
continue Lasix 40mg PO QD and resume home Metop (give SBP > 100,
HR > 70).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated UTI
Heart failure exacerbation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for a urinary tract infection causing a heart
failure exacerbation requiring an ICU admission to assist with
your bleeding. Fortunately, with getting you to urinate more and
placing you on correct antibiotics, we have been able to get you
back to breathing room air.
We will need to check your kidney function on ___ to make sure
you are on the best dose of Lasix.
Weigh yourself every morning, call your doctor if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
19982989-DS-18 | 19,982,989 | 27,049,214 | DS | 18 | 2151-02-09 00:00:00 | 2151-02-11 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o M w/ HFpEF (HFpEF, EF 50% ___, possible COPD,
CKD,
dementia, T2DM, BPH, and recent admission for CHF exacerbation
from ___ (discharge weight 70.2 kg (154.76 lb)) presenting
from nursing facility with shortness of breath since this
morning. He also endorses some chest pain. Further history is
unavailable due to patient acuity. He arrives on BiPAP.
In the ED, the patient was unable to be weaned off BiPAP and
found to be in an acute heart failure exacerbation.
- Initial vitals were: T97, BP 118-145/52-83, HR70s, RR low20s,
Sat100% on BiPAP
- Exam notable for: Bilateral peripheral edema. Scattered rales.
Diminished at the right lower lung field.
- Labs notable for: Hb 8.5, BUN 47, Cr 2.1 (baseline 2.1-2.3 per
last admission), alk phos 173, trop 0.06, lactate 1.6, ___
14416 (21,000 in previous admission)
- Studies notable for: EKG Sinus rhythm with ventricular
bigeminy
- Patient was given: 40mg Lasix, then redosed with 80mg Lasix;
Vanc+Zosyn, nitroglycerin SL
On arrival to the CCU, patient continues on BiPAP and is overall
confused. Family bedside and reports that the patient continues
to experience shortness of breath although much less now that he
has respiratory support.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- DMII
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries: Unknown
- HFpEF, EF 55% ___ (?46% on ___
- NSR
3. OTHER PAST MEDICAL HISTORY
-BPH
-Head lesion after falling off a horse many years ago
-Shoulder surgery status post motor vehicle accident
-h/o prostate surgery
-Olfactory groove Meningioma
-L hip replacement
-Hypothyroidism
Social History:
___
Family History:
Per report, has family history of lung cancer and heart disease,
but unclear what disease specifically or in whom.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
PHYSICAL EXAMINATION:
VS: afebrile BP: HR:70s Sat 100% on BiPAP
GENERAL: Well developed, well nourished. On BiPAP. Oriented to
person and place but not situation, somewhat confused.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP at earlobe at 65 degrees.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
labored with accessory muscle use. Scattered rales. Diminished
at
the right lower lung field.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: moves all extremities spontaneously without FND
DISCHARGE PHYSICAL EXAM:
=======================
GENERAL: Oriented x0. Delirious and agitated.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: CTAB. No chest wall deformities or tenderness.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. Trace
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: A&O x1.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:18AM BLOOD WBC-8.2 RBC-3.02* Hgb-8.5* Hct-29.4*
MCV-97 MCH-28.1 MCHC-28.9* RDW-17.3* RDWSD-62.2* Plt ___
___ 10:18AM BLOOD Neuts-82.6* Lymphs-8.3* Monos-7.8
Eos-0.9* Baso-0.2 Im ___ AbsNeut-6.74* AbsLymp-0.68*
AbsMono-0.64 AbsEos-0.07 AbsBaso-0.02
___ 10:18AM BLOOD ___ PTT-34.2 ___
___ 10:18AM BLOOD Glucose-137* UreaN-47* Creat-2.1* Na-139
K-4.6 Cl-101 HCO3-26 AnGap-12
___ 10:18AM BLOOD ALT-18 AST-19 CK(CPK)-35* AlkPhos-173*
TotBili-0.5
___ 10:18AM BLOOD CK-MB-4 ___
___ 10:18AM BLOOD Albumin-3.7
___ 10:25AM BLOOD ___ pO2-23* pCO2-57* pH-7.30*
calTCO2-29 Base XS--1
___ 10:45AM BLOOD Type-ART PEEP-10 pO2-401* pCO2-47*
pH-7.33* calTCO2-26 Base XS--1 Intubat-NOT INTUBA
___ 10:45AM BLOOD O2 Sat-98
___ 01:42PM URINE Color-Straw Appear-Clear Sp ___
___ 01:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 01:42PM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE
Epi-1
___ 01:42PM URINE Mucous-RARE*
PERTINENT LABS:
==============
___ 10:18AM BLOOD cTropnT-0.06*
___ 05:00PM BLOOD CK-MB-5 cTropnT-0.06*
___ 10:18AM BLOOD Lipase-16
___ 10:25AM BLOOD Lactate-1.6
___ 03:29PM BLOOD Lactate-1.4
DISCHARGE LABS:
==============
___ 07:53AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.1* Hct-31.4*
MCV-98 MCH-28.4 MCHC-29.0* RDW-16.3* RDWSD-58.0* Plt ___
___ 05:34AM BLOOD ___ PTT-33.3 ___
___ 07:53AM BLOOD Glucose-189* UreaN-43* Creat-2.4* Na-143
K-5.0 Cl-104 HCO3-24 AnGap-15
___ 05:34AM BLOOD ALT-14 AST-33
___ 05:46AM BLOOD ALT-15 AST-23 LD(LDH)-176 AlkPhos-155*
TotBili-0.7
___ 07:53AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.5
RELEVANT MICRO:
==============
___ 1:42 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. < 10,000 CFU/mL.
___ 10:18 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 10:39 am BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
RELEVANT IMAGING:
=================
___ Cardiac Pefusion Pharm
FINDINGS: Left ventricular cavity size is normal
There is considerable soft tissue attenuation especially on the
rest images,
limiting interpretation. Rest and stress perfusion images
reveal a probable
moderate fixed perfusion defect in the inferolateral wall.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 55%
IMPRESSION: Probable moderate fixed perfusion defect in the
inferolateral wall.
Soft tissue attenuation limits interpretation.
___ Stress (see above)
INTERPRETATION: This ___ yo man with h/o HFpEF, CKD, possible
COPD,
and NIDDM was referred to the lab from the inpatient floor for
evaluation of mild regional systolic dysfunction c/w CAD. The
patient
was administered 0.4 mg Regadenoson (Lexiscan) IV Bolus over 20
seconds.
There were no reports of chest, back, neck, or arm discomforts
during
the study. In the setting of baseline STT abnormalities, the ST
segments
were uninterpretable for ischemia. Rhythm was sinus with rare
isolated
APBs and one VPB. There was an appropriate and heart rate
response to
the infusion. Post-MIBI, the Regadenoson was reversed with 60 mg
Caffeine IV.
IMPRESSION: No anginal type symptoms with uninterpretable EKG
for
ischemia. Nuclear report sent separately.
___ CT Head:
FINDINGS:
There is no evidence of infarction or hemorrhage. There is
redemonstration of
a hypodense extra-axial mass in the floor of the anterior
cranial fossa with
mild associated vasogenic edema measuring 3.7 x 3.2 cm,
previously measuring
3.7 x 3.2 cm on prior study dated ___. There are
bilateral
periventricular and subcortical white matter hypodensities,
nonspecific but
compatible with sequelae of chronic small vessel ischemic
disease. There is
prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. There is mild mucosal
thickening of the
left ethmoid air cells. Otherwise, the visualized portion of
the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Stable olfactory groove meningioma, unchanged in size from
prior study
dated ___.
___ Renal Ultrasound:
IMPRESSION:
1. No evidence of stones or hydronephrosis.
2. 1.4 cm cystic structure with thin avascular septations in the
upper pole of
the left kidney has decreased in size compared to prior,
previously 1.9 cm.
This likely represents a minimally complex cyst which requires
no further
follow-up, and is unlikely an abscess.
___ CXR:
IMPRESSION:
Cardiomegaly is severe, unchanged. Patient continues to be in
interstitial
pulmonary edema. Bilateral pleural effusion, large on the right
and moderate
on the left is unchanged. No pneumothorax.
___ TTE
CONCLUSION:
The left atrial volume index is normal. 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 a small area of regional left ventricular
systolic dysfunction with hypokinesis of the
inferoseptum, inferior, and inferolateral walls (see schematic)
and preserved/normal contractility of the
remaining segments. There is beat-to-beat variability in the
left ventricular contractility due to the irregular
rhythm. Quantitative biplane left ventricular ejection fraction
is 46 % (normal 54-73%). Normal
right ventricular cavity size with normal free wall motion. The
aortic valve is not well seen. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is mild
[1+] mitral regurgitation. The pulmonic valve leaflets are not
well seen. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
There is mild pulmonary artery systolic
hypertension. There is a trivial pericardial effusion. A right
pleural effusion is present
IMPRESSION: Suboptimal image quality. Normal left ventricular
wall thickness and cavity size with
mild regional systolic dysfunction c/w CAD. Normal right
ventricular cavity size and systolic
function. Mild mitral regurgitation. Mild tricuspid
regurgitation.
___ CXR
IMPRESSION:
Moderate pulmonary edema worsened slightly since ___.
Moderate right pleural effusion is changed in distribution, but
probably not in overall volume. Moderate cardiomegaly
unchanged. No pneumothorax.
___ EKG
Sinus rhythm
Ventricular bigeminy
Compared with the previous tracing of ___, ventricular
ectopic activity now present.
___ CXR
IMPRESSION:
Moderate right and probable small left pleural effusion.
Significant
atelectasis in the right middle and lower lobes. Congestion
with probable
mild edema.
Brief Hospital Course:
___ with a history of HFpEF (HFpEF, EF ___, possible
COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF
exacerbation from ___ presenting with shortness of breath
from his nursing facility concerning for acute on chronic HFpEF
exacerbation requiring CCU admission for BiPAP. Discharged
euvolemic.
TRANSITIONAL ISSUES
====================
Discharge wt: unknown
Discharge Cr: ___: 2.4 (not at baseline)
Discharge diuretic: torsemide 30mg PO daily
[] discharged on torsemide 30 daily, may need titration to
prevent future hospitalizations--please weight at ___ home
daily and adjust diuretic accordingly
[] can consider spiranolactone once patient's kidney function
improves
[] Consider ___ if renal function allows
[] Ziopatch can be considered as an outpatient to assess if
arrythmias are contributing to his presentation
[] Would enforce daily weights at nursing home as well as 2g Na
diet and 2L fluid restriction
[] Patient has been having urinary retention during admission,
needs f/u regarding this
[] Patient discharged on Cr of 2.4 (somewhat above baseline),
please recheck creatine ___ to ensure torsemide dose is
appropriate
[] needs f/u creatine in 1 week to assess for resolution of ___.
[] Needs diet advanced as tolerated
[] On olanzapine, need to monitor for medication adverse
effects.
[] Advance diet as tolerated
[] Will need further evaluation for etiology of increased recent
admissions for HF excerbation
# CODE STATUS: Full (presumed)
# CONTACT: ___ ___ (daughter)
BRIEF HOSPITAL COURSE:
======================
___ with a history of HFpEF (HFpEF, EF ___, possible
COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF
exacerbation from ___ presenting with shortness of breath
from his nursing facility concerning for acute on chronic HFpEF
exacerbation requiring CCU admission for BiPAP. He was diuresed
with Lasix IV, along with Lasix gtt. Transferred to the floor
where IV diuresis was continued but then transitioned to POs.
Held PO diuresis for a few days in setting of ___. Then
discharged on torsemide 30 daily PO. His course was complicated
by severe agitation in the setting of delirium and dementia,
improved with Foley removal.
# CORONARIES: unknown
# PUMP: HFpEF, EF 50% ___
# RHYTHM: normal sinus rhythm
ACUTE ISSUES:
=============
# Acute on chronic HFpEF Exacerbation:
Previous admission mid ___ for HFrEF exacerbation, now with
similar presentation with SOB, chest pain, BNP elevation, small
bump in trop, and stable ECG. He required CCU admission for
BiPAP. He was diuresed with Lasix IV, along with Lasix drip then
transferred to the floor where IV diuresis was continued but
then transitioned to POs. Held PO diuresis for a few days in
setting of ___. Then resumed. Discharged on torsemide 30 daily.
His course was complicated by severe agitation in the setting of
delirium and dementia. Also discharged on metoprolol 25 daily,
isosorbide mononitrate 30, atrovostatin 80, ASA 81, and
torsemide 30 daily. Discharge dry weight unknown and discharge
creatinine of 2.4 (not baseline creatinine due to ___.
Goals of care discussion held with daughter who continues to
prefer pursuing aggressive care.
# Hypoxemic respiratory failure
# Potential PNA:
Likely patient's dyspnea represents HF exacerbation. Less likely
PNA in light of lack of fever, elevation of WBC, however
pulmonary exam on admission revealed decreased diminished lung
sounds at the right lower lung field, concerning for PNA. CXR in
ED showed moderate right and probable small left pleural
effusion along with significant atelectasis in the right middle
and lower lobes and congestion with probable mild edema. He was
given vancomycin/Zosyn in the ED, but these were discontinued on
admission given low likelihood for infection. Improved
oxygenation with diuresis. Approrpiate sats on RA at discharge.
# Chronic Kidney Disease:
Baseline Cr in the low 2's on last discharge, at baseline.
Likely underlying CKD vs cardiorenal. Given acute volume
overload state, seemed appropriate to continue diuretic and
monitor renal function. Renal U/S ___ without evidence of
obstructive process/hydro.
# Hyperactive delirium
# Dementia:
Patient with underlying dementia complicated by delirium in the
ICU. Tried to regulate sleep wake cycle with ramelteon qhs and
Zyprexa standing, required IV antipsychotic doses
intermittently. No signs of metabolic disturbance, infection,
worsened hypoxia or hypercarbia as contributing factors. Likely
worse ___ hospital stay. Delerium improved over hospitalization.
#Nutritional Status
Had mental status changes that required patient to be NPO for a
few days but then transitioned back to a diet. Please advance as
tolerated.
CHRONIC/STABLE/RESOLVED ISSUES:
===============================
# Hypothyroidism
Patient continued on home levothyroxine 50mcg daily
# BPH
Patient continued home finasteride 5mg daily and home tamsulosin
0.4mg daily
# T2DM
Monitored
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO QHS
6. Finasteride 5 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D 400 UNIT PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. OLANZapine 5 mg PO QHS delerium
2. Torsemide 30 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO QHS
7. Finasteride 5 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Acute on Chronic HFpEF Exacerbation
Hypoxemic hypercapnic respiratory failure
SECONDARY DIAGNOSES
====================
Acute Delirium
Dementia
Poor nutrition
Chronic Kidney Disease
Benign Prostatic Hyperplasia
Hypothyroidism
Type 2 Diabetes Mellitus
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 ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having shortness of breath
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were placed on a breathing mask to help you breathe
- You were treated with a water pill to help clear the fluid
in your lungs that made it hard for you to breathe
- You were given medications to treat your high blood pressure
- You were seen by our specialists in geriatrics who
recommended medications to help with your behavior disturbances
at night
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up or down by more than 3 lbs in a day or 5 pounds
in a week.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19983009-DS-20 | 19,983,009 | 26,466,419 | DS | 20 | 2142-09-09 00:00:00 | 2142-09-09 15:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypokalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male w/ history of pancreatic cancer (please see below
for history and current regimen), diabetes presenting with
hypokalemia. Patient reports intermittent hypokalemia in the
past, usually during chemotherapy. Last chemo was about a month
ago. K was 1.9 in clinic yesterday, and received 40 IV and 60 PO
KCl. Patient has no vomiting, minimal intermittent diarrhea and
has been eating regularly. No chest pain, shortness of breath or
syncope. Patient was recently in ___ for daughter's wedding.
In the ED, initial vitals were: 98.2 66 116/71 18 100% RA
- Exam notable for: Lungs CTAB, Heart RRR, Abdomen soft,
minimally tender.
- Labs notable for: K of 2.0 initially, which repeated was 2.1
and then 2.4 after repletion. Mild LFT elevation and anemia (Hgb
10)
- Imaging was notable for:
- Patient was given: 60meq Kcl x 2, 40meq IV Kcl x1, Mg Sulf
2g, LR,
Transfer vitals: 97.5 56 115/79 16 100% RA
Upon arrival to the floor, patient reports he feels well. He
has not had any recent weakness or numbess, No muscle pain. No
CP, SOB, Abd pain. Notes some diarrhea, ___ times per day
recently, not significantly watery. This is normal for him. No
fevers/chills.
Past Medical History:
ONCOLOGIC HISTORY: ___ was initially diagnosed with
acute pancreatitis in ___. Imaging raised concern for
intraductal papillary mucinous neoplasm (IPMN), and he was
followed with serial MRI. MRI ___ identified
interval change in the configuration of his known pseudocyst.
The study was repeated on ___ at which time an
enhancing soft tissue abnormality was seen. Upper endoscopy then
identified a large amount of mucus at the pylorus. Biopsy by FNA
did not show carcinoma. On ___ he was taken to the
operating room by Dr. ___ and underwent Whipple's
pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid
carcinoma (mucinous noncystic carcinoma) arising from an
intraductal IPMN. There was no lymphovascular/perineural
invasion; 5 of 18 lymph nodes were involved. He was diagnosed
with pT3N1Mx stage IIB mucinous noncystic carcinoma of the
pancreas. He received six cycles of adjuvant gemcitabine under
the care of Dr. ___, which completed in ___, followed by adjuvant radiation with concurrent
capecitabine, which completed ___. He was then
followed with surveillance imaging. CT in ___ identified a
right upper lobe lung nodule for which he underwent CT-guided
FNA. Cytology was suspicious for malignancy. He underwent repeat
biopsy in ___ with similar results and was eventually
taken to the operating room for VATS wedge resection ___. Pathology confirmed the finding of metastasis from his
pancreatic colloid carcinoma. He initiated systemic chemotherapy
with FOLFIRINOX ___. He completed 14 cycles as of
___ and then entered a treatment break. In ___ he
developed peritoneal carcinomatosis with intra-abdominal ascites
and a pulmonary embolism. He resumed cycle ___ FOLFIRINOX and
completed an additional two cycles as of ___. Due to
progression of peritoneal carcinomatosis he then transitioned to
nab-paclitaxel/gemcitabine. He completed four cycles of this as
of ___ at which time there was further disease
progression. Initiated treatment with 5fu/Liposomal irrinotican
and LCV on ___. CURRENT TREATMENT PLAN: Liposomal
irinotecan/ ___ CI D1 and D15 OTHER PAST MEDICAL HISTORY:
1. Pancreatic colloid carcinoma, as detailed in the history of
present illness.
2. Diabetes mellitus.
3. GERD.
4. Tuberculosis, for which he had isoniazid and rifampin.
5. Hyperlipidemia.
6. Chronic pancreatitis.
7. Anemia.
8. Umbilical hernia repair in ___.
9. Appendectomy in ___.
Social History:
___
Family History:
His mother with diabetes, passed in her early ___ of jaundice.
Father with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VITAL SIGNS: 97.9 126/78 52 18 100% RA
GENERAL: Patient appears comfortable, in NAD
HEENT: MMM, no scleral icterus, CN II-XII intact
NECK: supple
CARDIAC: RRR, no m/g/r, normal s1 and s2
LUNGS: CTAB, no w/c/r
ABDOMEN: L side is firm with multiple masses. No significant
tenderness. R side is soft. Normal bowel sounds, nondistended,
EXTREMITIES: WWP, no ___ edema
NEUROLOGIC: CNII-XII intact, upper and lower extremity strength
SKIN: Port in place on R chest appears c/d/i
DISCHARGE PHYSICAL EXAM
======================
VITAL SIGNS: 98.0 PO 122 / 81 L Standing 97 18 100 RA
GENERAL: Patient appears comfortable, in NAD
HEENT: MMM, no scleral icterus, CN II-XII intact
NECK: supple
CARDIAC: RRR, no m/r/g, normal s1 and s2
LUNGS: CTAB
ABDOMEN: LUQ and LLQ are firm, rigid with palpable ill-defined
masses. No significant tenderness. R side is soft. Normal bowel
sounds, nondistended,
EXTREMITIES: WWP, no ___ edema
NEUROLOGIC: CNII-XII intact, upper and lower extremity strength
SKIN: Port in place on R chest appears c/d/i
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 11:10AM BLOOD WBC-8.1 RBC-4.73 Hgb-10.4* Hct-33.4*
MCV-71* MCH-22.0* MCHC-31.1* RDW-19.6* RDWSD-49.1* Plt ___
___ 11:10AM BLOOD UreaN-8 Creat-0.7 Na-142 K-1.9* Cl-95*
HCO3-35* AnGap-14
___ 11:10AM BLOOD ALT-54* AST-169* AlkPhos-100 TotBili-0.4
___ 11:10AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.8 Mg-1.8
Iron-32*
___ 11:10AM BLOOD calTIBC-185* Ferritn-1427* TRF-142*
___ 11:10AM BLOOD CEA-4.8*
DISCHARGE LAB RESULTS
====================
___ 05:28AM BLOOD WBC-5.8 RBC-3.95* Hgb-8.8* Hct-28.3*
MCV-72* MCH-22.3* MCHC-31.1* RDW-19.9* RDWSD-50.0* Plt ___
___ 05:28AM BLOOD Glucose-78 UreaN-7 Creat-0.6 Na-138 K-3.6
Cl-103 HCO3-27 AnGap-12
___ 05:28AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8
MICROBIOLOGY
============
___ Stool culture: negative
___ C diff: negative
IMAGING
=======
___ RUQ Ultrasound:
1. Pneumobilia without intrahepatic or extrahepatic biliary
dilatation.
2. The patient is status post cholecystectomy.
3. Mild right-sided hydronephrosis, stable when compared to the
CT from an outside facility on ___.
4. A heterogeneously hyperechoic ill-defined Mass is identified
within the left upper quadrant adjacent to the spleen and does
not demonstrate flow on color Doppler imaging. This is of
unclear etiology and could represent a heterogeneous mass,
hematoma or fluid collection. Further evaluation with
contrast-enhanced imaging such as a multiphasic CT is
recommended.
___ CT Chest, Abdomen, and Pelvis:
1. No intrahepatic or extrahepatic biliary duct dilation. There
is pneumobilia.
2. Interval increase in the size and mass effect related to
bulky soft tissue peritoneal and mesenteric masses from
metastatic disease representing progression of metastatic
carcinomatosis.
3. There are multiple new subcapsular splenic lesions and
increase in size of the previously seen splenic lesions, due to
progression of to metastatic disease.
4. Moderate right hydronephrosis and proximal to mid hydroureter
with a delayed nephrogram. Hydronephrosis is not significantly
changed from prior and is due to extrinsic mass effect on the
ureter in the pelvis.
Brief Hospital Course:
___ h/o stage IIB pancreatic colloid carcinoma with progressive
disease in lung and peritoneum, who presents with hypokalemia
secondary to diarrhea:
# Hypokalemia:
Patient with severe hypokalemia to 1.9 initially in setting of
some recent diarrhea, and chemo 6 weeks ago. Likely a
combination of diarrhea and chemotherapy effect, patient's K has
been low in the past. Given slow response to repletion, likely
significant whole body depletion. He was aggressively repleted
with IV and PO potassium. He was discharged on PO Potassium 60
mEq daily, with close heme/onc follow-up.
# Diarrhea:
Patient with nonbloody diarrhea, formed stools, ___ times/day,
likely contributing to symptoms. No associated infectious
symptoms and C. diff negative. However does have recent travel
history to ___. Stool cultures and O&P studies negative. He
was give loperamide 2mg QID, which helped with his symptoms.
# Elevated transaminases: Patient with transaminitis in a
hepatocellular pattern with AST > ALT. Differential would
include chemotherapy effect, disease progression, GI infection.
Based on imaging findings disease progression is most likely.
# Metastatic pancreatic colloid carcinoma: h/o stage IIB
pancreatic colloid carcinoma with progressive disease in lung
and peritoneum. Progressive on FOLFIRINOX, now on ___.
Missed C3D1 due to current episode of hypokalemia. CT torso now
with progressive disease. He was discharged with close heme/onc
follow-up on ___.
# DMII. Patient had several episodes of morning hypoglycemia.
His Lantus was decreased to Lantus 8U at bedtime because of
morning hypoglycemia. He was told to check his blood sugars
every morning and call his PCP if blood sugars remained low.
# HTN. Continued home lisinopril.
# Pancreatic cancer/pancreatitis. Continued enzyme replacement.
Continued lovenox prophylaxis.
TRANSITIONAL ISSUES
====================
- Discharge K: 3.6
- Discharge potassium regimen: 60 mEq Potassium daily
- CT torso with contrast done while inpatient showing
progression of peritoneal and splenic disease
- The patient's PO magnesium was held while he was an inpatient,
and he was repleted with IV magnesium. PO magnesium was
restarted at discharge knowing that it may worsen his diarrhea.
Please continue to monitor.
- Patient to follow up on ___ with his outpatient oncology
team. He should have his potassium rechecked at that time.
# CODE: Full code (confirmed)
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Lisinopril 2.5 mg PO DAILY
3. Magnesium Oxide 500 mg PO DAILY
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID
W/MEALS
6. Pegfilgrastim Onpro (On Body Injector) 6 mg SC Frequency is
Unknown
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Glargine 23 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Enoxaparin Sodium 80 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Medications:
1. LOPERamide 2 mg PO QID
RX *loperamide [Anti-Diarrhea] 2 mg 2 mg by mouth four times per
day Disp #*120 Tablet Refills:*0
2. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Potassium Chloride 60 mEq PO DAILY
Hold for K >
RX *potassium chloride 10 mEq 6 capsule(s) by mouth daily Disp
#*180 Capsule Refills:*0
4. Enoxaparin Sodium 80 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID
W/MEALS
6. Lisinopril 2.5 mg PO DAILY
7. Magnesium Oxide 500 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- Pegfilgrastim Onpro (On Body Injector) 6 mg SC
Frequency is Unknown This medication was held. Do not restart
Pegfilgrastim Onpro (On Body Injector) until you speak with
oncologist
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Diarrhea
Hypokalemia
Pancreatic cancer
SECONDARY DIAGNOSIS:
DMII
GERD
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 ___.
Why did you come to the hospital?
=================================
You were admitted to ___ because your potassium was very low.
You were also having diarrhea.
What did we do for you?
=======================
We gave you potassium both by IV and by mouth and your
potassium slowly came back up. We did some stool studies to see
if you had an infection causing diarrhea, and they have so far
not showed an infection.
What do you need to do?
=======================
- Only take 8 Units of Lantus at bedtime since your blood sugars
in the morning have been low. Check your blood sugar every
morning, and decrease your bedtime Lantus dose if your blood
sugars remain low. Call your primary care doctor if your sugars
are low.
- We have increased the amount of potassium that you should be
taking at home as pills. You will follow up with your oncologist
in clinic and discuss chemotherapy at that time.
- Please get your potassium checked at your Heme/Onc appointment
on ___.
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
19983009-DS-22 | 19,983,009 | 27,741,621 | DS | 22 | 2143-06-20 00:00:00 | 2143-06-20 19:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with PMH of metastatic pancreatic colloid
carcinoma admitted from the ED with persistent fatigue,
weakness, and poor po intake and new diarrhea of two days
duration.
Patient hospitilazed ___ - ___ with weakness, fatigue
and diarrhea. He was found to have ___ and concern for bowel
obstruction and intestinal necrosis, and improved with
supportive therapy. He was discharged to rehab ___ and
received single agent nal-iri on ___.
Per oncology, pt with persistent weakness and poor po appetite
since before his last admission which continued at ___. His
weight at ___ was down to 74 lbs from 93lbs on admission and he
was initiated on mirtazapine and ranitidine. He was brought to
the ED for failure to thrive and persistent diarrhea x2 days.
In the ED, initial VS were pain 0, T 98.8, HR 97, BP 92/67, RR
18, O2 100%RA.
Initial labs: Na 142, K 5.2, HCT 25, Cr 0.7, Ca 7.7, Mg 1.6, P
3.8, WBC 5.2, HCT 24.5, PLT 340. Lactate 1.2. Patient was given
1L NS prior to transfer.
ED exam notable for:
Constitutional - No Fever/chills, +FTT, decreased appetitie,
weight loss
Head / Eyes - No Diplopia
ENT / Neck - No Epistaxis
Chest/Respiratory - No Cough, No Dyspnea
Cardiovascular - No Chest pain
GI / Abdominal - No Black stool, No Bloody stool
GU/Flank - No Dysuria
Musc/Extr/Back - No Back pain, No Joint pain
Skin - No Rash, No Diaphoresis
Neuro - No Headache
Imaging:
No new imaging
CT abd ___:
"IMPRESSION:
1. Multiple dilated small and large bowel loops are identified.
There is persistent stenosis of the sigmoid colon from the
external compression caused by large pelvic masses, which is the
likely the main site of bowel
obstruction.
2. Pneumatosis intestinalis of the small bowel loops in the
right abdomen is concerning for bowel ischemia and new from
prior study.
3. Severe right hydronephrosis is new since ___, but
similar compared to ___.
4. Multiple large peritoneal masses appear grossly similar to
___. Previously noted hepatic lesions are not
demonstrated on this noncontrast exam."
Patient received:
-CTX 1g x1
-1 L D51/2NS
-lisnopril 2.5mg
-norepi started at 0.12
Consults:
Oncology in ED
Vitals on transfer:
80s/60s, HR ___, RR 12 100% RA
Upon arrival to ___, pt reports feeling tired but "better." He
denies fever/chills, CP, cough, dyspnea, abdominal pain, N/V, or
dysuria. He reports limited appetite or fluid consumption for
several days.
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___ was
initially diagnosed with acute pancreatitis in ___. Imaging
raised concern for intraductal papillary mucinous neoplasm
(IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his
known pseudocyst. The study was repeated on ___ at
which time an enhancing soft tissue abnormality was seen. Upper
endoscopy then identified a large amount of mucus at the
pylorus. Biopsy by ___ did not show carcinoma. On ___
he was taken to the operating room by Dr. ___ and
underwent ___'s pancreaticoduodenectomy. Pathology showed a
4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising
from an intraductal IPMN. There was no
lymphovascular/perineural invasion; 5 of 18 lymph nodes were
involved. He was diagnosed with pT3N1Mx stage IIB mucinous
noncystic carcinoma of the pancreas. He received six cycles of
adjuvant gemcitabine under the care of Dr. ___,
which completed in ___, followed by adjuvant radiation
with concurrent capecitabine, which completed ___. He
was then followed with surveillance imaging.
CT in ___ identified a right upper lobe lung nodule for
which he underwent CT-guided FNA. Cytology was suspicious for
malignancy. He underwent repeat biopsy in ___ with
similar results and was eventually taken to the operating room
for VATS wedge resection ___. Pathology confirmed
the finding of metastasis from his pancreatic colloid carcinoma.
He initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then entered
a treatment break. In ___ he developed peritoneal
carcinomatosis with intra-abdominal ascites and a pulmonary
embolism. He resumed cycle ___ FOLFIRINOX and completed an
additional two cycles as of ___. Due to progression of
peritoneal carcinomatosis he then transitioned to
nab-paclitaxel/gemcitabine. He completed four cycles of this as
of ___ at which time there was further disease
progression. Mr. ___ initiated treatment with 5fu/nal-iri on
___. Snapshot analysis showed variants in ___ and p53"
He was hopitilazed ___ - ___ with weakness, fatigue and
diarrhea, found to have ___ and concern for bowel obstruction
and intestinal necrosis. Improved with supportive therapy.
Discharged to rehab ___. Received single agent nal-iri on
___ as he cannot receive ___ infusion at SNF.
Past Medical History:
1. Pancreatic colloid carcinoma, as detailed in the history of
present illness.
2. Diabetes mellitus.
3. GERD.
4. Tuberculosis, for which he had isoniazid and rifampin.
5. Hyperlipidemia.
6. Chronic pancreatitis.
7. Anemia.
8. Umbilical hernia repair in ___.
9. Appendectomy in ___.
Social History:
___
Family History:
His mother with diabetes, passed in her early ___ of jaundice.
Father with diabetes
Physical Exam:
ADMISSION PHYISCAL EXAM:
==============================
VS: 87/95, HR 93, RR 10, 100% on RA
GENERAL: cachetic appearing, NAD
EYES: Anicteric sclerea, PERLLA, EOMI, no chemosis
ENT: clear OP, no JVD, no LAD
CARDIOVASCULAR: RRR, no m/r/g, 2+ radial and DP pulses
RESPIRATORY: CTAB, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: rock hard L quadrants, soft RUQ, scaphoid,
large central palpable mass, nontender without rebound or
guarding
MUSKULOSKELATAL: Warm, well perfused extremities, 2+ pitting
edema to mid tibia
NEURO: Alert, oriented, CN II-XII intact, no focal deficits
SKIN: stage 2 pressure injury coccyx, no additional rash or
lesions
DISCAHRGE PHYISCAL EXAM:
==============================
VS: ___ 2343 Temp: 98.3 PO BP: 119/82 HR: 65 RR: 18 O2 sat:
97% O2 delivery: RA
GENERAL: Cachectic appearing man, appears older than stated age,
laying in bed in NAD
EYES: Sclera anicteric
HEENT: OP clear, MMM, no OP lesions
LUNGS: CTAB - no wheezes, rhonchi, or rales
CV: RRR, no m/r/g
ABD: +BS, S, NT, +large central palpable mass that is stable in
size
EXT: Poor muscle bulk
SKIN: warm, no rashes appreciated
NEURO: AOx3, no facial asymmetry
Pertinent Results:
ADMISSION LABS:
=============================
___:12AM BLOOD WBC-5.2 RBC-2.91* Hgb-8.2* Hct-24.5*
MCV-84 MCH-28.2 MCHC-33.5 RDW-16.1* RDWSD-48.7* Plt ___
___ 12:12AM BLOOD Neuts-77.0* Lymphs-18.3* Monos-2.9*
Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.00 AbsLymp-0.95*
AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01
___ 12:12AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-142
K-5.2* Cl-107 HCO3-25 AnGap-10
___ 12:12AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.6
___ 08:53PM BLOOD ___ pO2-47* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
___ 12:16AM BLOOD Lactate-1.2 K-4.6
DISCHARGE LABS:
==============================
___ 03:18AM BLOOD WBC-3.4* RBC-3.03* Hgb-8.5* Hct-26.1*
MCV-86 MCH-28.1 MCHC-32.6 RDW-16.2* RDWSD-50.4* Plt ___
___ 04:50AM BLOOD Neuts-50.6 ___ Monos-10.8 Eos-1.7
Baso-0.4 Im ___ AbsNeut-1.22* AbsLymp-0.86* AbsMono-0.26
AbsEos-0.04 AbsBaso-0.01
___ 04:19AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+*
Target-1+*
___ 03:18AM BLOOD Glucose-102* UreaN-<3* Creat-0.3* Na-138
K-3.8 Cl-102 HCO3-30 AnGap-6*
___ 06:27AM BLOOD ALT-9 AST-13 LD(LDH)-189 AlkPhos-161*
TotBili-0.2
___ 03:18AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.7
MICROBIOLOGY:
==============================
___ BLOOD CULTURE X2 - NEGATIVE
___ URINE CULTURE - ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ STOOL - C. DIFF - NEGATIVE
___ FECAL CULTURE - NEGATIVE FOR GNR, CAMPYLOBACTER,
SALMONELLA, SHIGELLA
IMAGING:
==============================
___ KUB IMPRESSION:
Dilated air-filled loops of large and small bowel may reflect
ileus or
early/partial obstruction. Fecal material is visualized within
the rectum and is noted to project over the descending colon as
well.
Brief Hospital Course:
FICU COURSE ___
=============================
ASSESSMENT AND PLAN
====================
Mr. ___ is a ___ male with a past medical history of
metastatic pancreatic colloid carcinoma admitted from the ED
with hypotension in the setting of poor PO intake and new
diarrhea of two days duration concerning for septic shock and
severe hypovolemia.
ACTIVE ISSUES
=============
#Septic shock
The patient presented with hypotension and leukocytosis with
diarrhea x2 days. On arrival, he was noted to have a positive
UA. Hence, his sepsis was thought to be from either a GI or
urinary source. It was thought that severe hypovolemia was also
contributing to his hypertension. His abdominal exam was
similar to previous examinations based on a review of records
and hence, his presentation was less likely to be from a
perforation although there was concern given that he was found
to have bowel necrosis during her recent hospitalization. He
was started on norepinephrine in the ED with the goal of
maintaining MAPs >60. Repeat abdominal imaging was not pursued
as they were multiple, very recent imaging studies in our
system. He was volume resuscitated with crystalloid and was
continued on ceftriaxone and metronidazole for antibiotic
coverage based on the concern of GI or urinary source. He was
eventually weaned off norepinephrine on ___ and remained
stable. At this time, he was thought to be stable enough to
transfer to the medical floor for further care.
#Diarrhea
His diarrhea was attributed to irinotecan during his last
admission and the offending agent had been discontinued as of
___. At that time, C. diff and stool cultures were all
negative. His current diarrhea was not temporally associated
with chemotherapy so there was concern for an infectious
etiology. C. difficile and stool culture were sent. He was
continued on metronidazole. He was given fluids and his
electrolytes were repleted as needed. His C. difficile came
back negative and he was started on loperamide for symptomatic
relief.
#UTI
Upon presentation, the patient's UA was found to be positive for
possible UTI. Urine cultures were sent for further evaluation.
However, the patient remained asymptomatic. Of note, during his
last admission, he failed a voiding trial and a foley was
re-inserted after which he developed a leukocytosis with
positive UA. UCx grew >100,000 E. coli and he was initiated on
Ceftriaxone 2gm q24h (___). The foley was removed and
his urinary retention resolved. At discharge, his leukocytosis
had resolved and he was discharged on Bactrim DS BID for
completion of a 7-day course (___). He was started on
ceftriaxone based on previous data.
# Metastatic pancreatic cancer
# Chronic partial bowel obstruction
The patient had known bulky peritoneal and mesenteric metastatic
disease. A palliative care consult was placed to further assist
the family. The patient's outpatient oncology team was notified
of his current admission. He was continued on ondansetron and
Compazine as needed.
# Anorexia
# Severe protein calorie malnutrition
This was in the setting of progressive metastatic pancreatic
cancer. A nutrition consult was placed and the patient was given
Ensure 3 times daily. PO intake was also encouraged.
CHRONIC ISSUES
==============
# Diabetes
The patient was noted to be hypoglycemic on arrival. His home
doses of insulin were held in the setting. He was placed on an
insulin sliding scale.
# GERD
His home omeprazole 20mg QHS was restarted.
# History of PE
He was continued on Lovenox 60mg daily (1.5mg/kg/day) per prior
oncology recommendations.
=========================================
OMED COURSE: ___ - ___
=========================================
Mr. ___ is a ___ male with history of
metastatic pancreatic cancer admitted from the ED with
hypotension in the setting of poor PO intake and diarrhea of two
days duration concerning for septic shock from a urinary source
and severe hypovolemia initially admitted to the ICU requiring
multiple liters of IVF and pressors. He was subsequently called
out to the oncology floor where he was observed prior to
discharge with course complicated by relative hypotension.
#s/p Septic Shock:
#E. Coli UTI
Hypotension and leukocytosis requiring temporary levophed
support which resolved with aggressive fluid resuscitation.
Likely from severe dehydration secondary to poor PO intake,
diarrhea as well as possible contribution from UTI. He completed
a 7 day course of ceftriaxone (last day ___.
#Relative ___ on ___ to 70/40,
asymptomatic in the setting of not receiving IV fluids. He was
responsive to IVF and had stable blood pressures. He will
require IV fluids at home to manage his blood pressure and he
was also written for low dose midodrine 10 mg TID.
#Diarrhea: Likely secondary to chemotherapy. Stool studies
negative. Continued loperamide and provided supportive therapy
with IVF and electrolyte repletion.
# Severe Protein-Calorie Malnutrition: Secondary to progressive
metastatic pancreatic cancer. Supplemental Ensure continued at
discharge.
# Metastatic Pancreatic Cancer:
# Chronic Partial Bowel Obstruction: Known bulky peritoneal and
mesenteric metastatic disease. He will follow-up with outpatient
Oncology on ___. Zofran and Compazine were as needed
# GERD: Held due to diarrhea, can restart home omeprazole 20mg
as an outpatient.
# Pulmonary Embolism: Continued home lovenox.
Transitional Issues:
[ ] He should receive 500 ml IVF BID
[ ] Continue vitamin D 50,000 units qweek for 8 weeks ___,
received 1 dose ___. Last dose ___
[ ] Sacral ulcer, stage II: please ensure that the patient is
turned every couple of hours and that the area is closely
monitored and cared for
[ ] Consider restarting omeprazole.
[ ] New Medications: Midodrine 10 mg PO TID, Neutra-Phos 2 PKT
PO/NG TID, Potassium Chloride 40 mEq PO BID, Simethicone 40-80
mg PO/NG QID:PRN bloating
[ ] Held Medications: None
CODE: Full Code (confirmed)
EMERGENCY CONTACT HCP: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Lisinopril 2.5 mg PO DAILY
3. Mirtazapine 15 mg PO QHS
4. Enoxaparin Sodium 60 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. Omeprazole 20 mg PO DAILY
6. sod phos di, mono-K phos mono ___ mg oral daily
7. Vitamin D 5000 UNIT PO DAILY
8. lipase-protease-amylase 20,000-68,000 -109,000 unit oral BID
9. Glargine 23 Units Bedtime
10. insulin lispro 100 unit/mL subcutaneous SSI
11. Potassium Chloride 60 mEq PO BID
12. Prochlorperazine 10 mg IV Q8H:PRN nausea
Discharge Medications:
1. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
2. Neutra-Phos 2 PKT PO TID
RX *potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg
2 powder(s) by mouth three times per day Disp #*180 Packet
Refills:*0
3. Potassium Chloride 40 mEq PO BID
RX *potassium chloride 20 mEq 2 tablet(s) by mouth twice per day
Disp #*120 Tablet Refills:*0
4. Enoxaparin Sodium 60 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. Famotidine 20 mg PO BID
6. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 2 mg by mouth four times a day Disp #*30
Capsule Refills:*0
7. Magnesium Oxide 400 mg PO DAILY
8. Mirtazapine 15 mg PO QHS
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg IV Q8H:PRN nausea
11. sod phos di, mono-K phos mono ___ mg oral daily
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
13. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000
unit oral TID W/MEALS
14.Hospital Bed
Name: ___
Date of Birth: ___
Diagnosis: Metastatic Pancreatic Cancer, pain due to emaciation
Length of Need: 99
15.Standard Manual Wheelchair
Including seat abd back cushion, elevating leg rests, anti-tip
and break extensions. Length = 13 months. Diagnosis: metastatic
pancreatic carcinoma
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS:
Sepsis from a urinary source
Urinary tract infection
SECONDARY DIAGNOSIS:
Mucinous noncystic colloid carcinoma of the pancreas
Irinotecan induced diarrhea
Urinary retention
Poor nutritional status, weakness
Sacral ulcer, stage II
History of pulmonary embolism
Type II Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you felt weak, were
having diarrhea, your blood pressure was low and you had a
urinary tract infection.
You were initially admitted to the ICU due to the low blood
pressure, but you were able to brought to the oncology floor
once your blood pressure improved.
We believe your diarrhea is from your irinotecan chemotherapy
and we treated this with Imodium (loperamide).
You also developed a bladder infection while you were in the
hospital. You were treated with an IV antibiotic for 5 days.
We discussed the best place for you to be discharged and after
talking with your family, it seems that home with increased
support will be the best. You will have a visiting nurse and IV
fluids at home.
It was truly a pleasure taking part in your care. We wish you
all the best with your future health.
Sincerely,
The team at ___
Followup Instructions:
___
|
19983512-DS-14 | 19,983,512 | 23,377,766 | DS | 14 | 2141-08-24 00:00:00 | 2141-08-24 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left ___ digit wound
Major Surgical or Invasive Procedure:
___: L ___ digit I&D
History of Present Illness:
___ PMH Sweet's Syndome & hypothyroid presented to ___
clinic today with left ___ toe with pain, edema, erythema and
serous draining lesion. Per report, pt intially presented to
___ urgent care clinic yesterday. She states the symptoms first
started on ___ and pt tried to treat herself with abx at
home including Keflex ___ BID x2 days), PCN (x1 day) and
Augmentin (x1 day). She relates worsening redness, edema and
pain today in clinic. She states that she was recently on a
cruise in ___ (___). She denies any trauma, but
reports that she first noticed a lesion with a white tip ___.
She states the redness has gotten worse in addition to the pain.
She denies N/F/V/C, SOB, CP.
Per report, a L foot stab incision and the lesion was de-roofed
today in clinic expressing pus and was cultured. Pt. was not
able to tolerate a full I&D and was referred to the ED for
further evaluation. She was given one dose of Ceftriaxone 2g IV
in office, started on Augmentin 875-125 mg BID.
Past Medical History:
sweet syndrome, eosinophilic esophagus, arthroscopic knee
surgery, R knee reconstruction
Social History:
___
Family History:
Father- MI, DM, CKD; Mother- healthy; Grandmother- colon ___
Physical Exam:
Admission PE:
V:98 89 18 98% RA
NAD, AOx3
RRR, no respiratory distress, soft non tender distress
___: ___: palpable, crt <3 sec, protective sensation intact. L
foot ___ digit deviated laterally with dorsal PIPJ lesion,
taught skin with surounding erythema extening to disal midfoot,
hyperpigmentation, drainage, tender to palpation, active and
passive ROM intact.
Pertinent Results:
Admission labs:
___ 04:23PM LACTATE-1.0
___ 04:37PM ___ PTT-25.6 ___
___ 04:37PM PLT SMR-NORMAL PLT COUNT-425
___ 04:37PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
___ 04:37PM NEUTS-79* BANDS-0 LYMPHS-15* MONOS-4 EOS-2
BASOS-0 ___ MYELOS-0
___ 04:37PM WBC-12.1* RBC-4.77 HGB-13.3 HCT-41.2 MCV-87
MCH-27.9 MCHC-32.2 RDW-14.3
___ 04:37PM estGFR-Using this
___ 04:37PM GLUCOSE-87 UREA N-9 CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
Discharge labs:
___ 07:45AM BLOOD WBC-11.8*# RBC-4.45 Hgb-12.3 Hct-38.4
MCV-86 MCH-27.7 MCHC-32.0 RDW-14.4 Plt ___
___ 07:45AM BLOOD Glucose-93 UreaN-9 Creat-0.9 Na-139 K-3.8
Cl-100 HCO3-29 AnGap-14
___ 07:45AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
Brief Hospital Course:
The patient presented to Emergency Room on ___. After
thorough evaluation, it was deemed necessary to admit the
patient to the podiatric surgery service and taken to the OR for
a left ___ digit I&D. There were no adverse events in the
operating room; please see the operative note for details.
Afterwards, pt was taken to the PACU in stable condition, then
transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled with IV pain medication
that was then transitioned into an entirly oral pain medication
regimen on a PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. Urine output remained
adequate throughout the hospitalization. The patient received
subcutaneous heparin throughout admission.
After four days on IV antibiotics, there was only minor
improvement of the infection and derm was consulted in light of
pt's history of Sweet's syndrome. Dermatology determined that
the most likely etiology of the lesion is a Sweet's lesion and
recommended she be discharged with clotrimazole cream BID
applications. She was discharged on ___ ___ for
assistance with dressing changes and will f/u with both
dermatology and podiatry in ___ days.
Medications on Admission:
omeprazole, Luvox
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
2. Levothyroxine Sodium 50 mcg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*30 Tablet
Refills:*0
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
RX *clobetasol 0.05 % Apply to affected area twice a day
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neutrophilic Dermatosis, left second digit
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
These are the discharge instructions for post-operative
discharge instructions.
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, severe increase in pain to operative site or pain
unrelieved by your pain medication, nausea, vomiting, chills,
foul smelling or colorful drainage from your incisions/wounds,
redness or swelling around your incisions, or any other symptoms
which are concerning to you.
Diet: regular diet
Medication Instructions:
Resume your home medications.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. Please, take your antibiotics as prescribed, it is critical
for you to take them as prescribed and for the full course of
the regimen.
Wound Care:
Please, apply clobetasol twice daily with xeroform on top and
then dry,sterile dressing to cover.
You may shower but please keep dressings clean, dry, and intact.
Do not submerge your foot/leg in water.
Please call the doctor or page the ___ pager, if you have
increased pain, swelling, redness, or drainage to the operative
sites.
If you have any questions, please call the ___ clinic at
___.
Followup Instructions:
___
|
19983512-DS-15 | 19,983,512 | 29,724,208 | DS | 15 | 2141-12-28 00:00:00 | 2141-12-28 15:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Bactrim
Attending: ___.
Chief Complaint:
Purulent, draining RLE wound with ___
Major Surgical or Invasive Procedure:
___: Local Kenalog injection (10mg) into RLE ___'s lesion
___: Local Kenalog injection (10mg) into RLE ___'s lesion
History of Present Illness:
Ms. ___ is a ___ with PMH significant for Sweet's syndrome
(on periodic prednisone) who presented to the ___ ED with
worsening pain and an expanding lesion on her lateral RLE. The
lesion was located above the lateral malleolus and was a 4x5cm
bulla with central eschar and surrounding warmth and erythema,
which had been getting worse since ___. She had been seeing
Derm 2x a week for this, and was on PO Cipro without
improvement. The wound drained purulent, foul-smelling
discharge. She had pain up her entire RLE. She had not noticed
any other swelling. She had never had a lesion like this before.
All other lesions were stable per patient. In the past, her
lesions were not debrided as border disruption can cause spread
of the lesion.
She first noticed this lesion and was admitted to ___
___ on ___. She was discharged on ___ on a
prednisone taper (40mg daily with 10mg taper q2d). When she
reached 20mg daily, she was seen at ___ on ___ with
expansion and worsening of her lesion, her taper was elevated to
80mg daily. She noted continued worsening and on ___ was
started on 64mg methylprednisone and Cipro. Despite this, she
noted the lesion to grow significantly, turn black, and become
purulent over the 2 days prior to admission. She stated that
solumedrol is the only steroid that calms her Sweet's flares.
Endorsed occasional night sweats and nausea. Denied fevers,
chills, CP/SOB/palpitations, abdominal pain, hematemesis,
V/C/D/melena/BRBPR, dysuria, numbness, tingling. Her last BM was
4 days prior to admission.
In the ED initial vitals were: pain 10 99.5 87 122/82 16
100% RA
She received IV Morphine 5mg x2, IV ketorolac 30mg, IV fentanyl
25mcg, IV methylpred 125mg, Zosyn 4.5g, IV Doxy 100mg
Labs were notable for a WBC 17.5 with left shift, lactate 2.2
Upon transfer to the floor, vitals were: pain 7 97.9 79
102/56 17 99% RA
Past Medical History:
Sweet syndrome
Eosinophilic esophagitis
Hypothyroidism
R knee arthroscopic surgery
R knee open ACL reconstruction
L ___ toe Sweet's lesion excision
C-section
Social History:
___
Family History:
Father and grandmother with thyroid disease. Grandmother with
colon ca. Extensive family history of heart disease.
Physical Exam:
Admission Physical Exam:
Vitals: 98.2 76 138/72 18 98%RA pain 8 Wt: 120.9kg
GENERAL: Patient comfortable in bed, appears stated age
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, one lesion noted on the roof of her mouth with a purulent
overlay
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, nl S1,S2, no m/r/g
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, NT/ND, no HSM, BS+, no guarding or rebound
tenderness.
EXTREMITIES: WWP. 2+ ___ pulses. RLE 2+ pitting edema on
dorsum of foot to 3 inches above ankle. No cyanosis or clubbing,
moving all 4 extremities with purpose
NEURO: A&Ox3. CN II-XII intact. Motor and sensation intact
grossly in all 4 extremities.
SKIN: RLE 4x5cm erythematous lesion with purulent discharge and
necrotic eschar. Gauze dressing C/D/I. Circular healing lesions
with overlying scab noted on L palm, LLE x 2, and RLE x 1,
ranging from 1.5cm diameter to 3cm.
Discharge Physical Exam:
Vitals: 98.3 98.1 70 110/53 18 98% RA
GENERAL: Patient comfortable in bed at rest, appears stated age
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, one well-healing lesion noted on the roof of her mouth with
a granulation tissue overlay
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, nl S1,S2, no m/r/g
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, ND, mildly TTP in all quadrants, no HSM, BS+, no
guarding or rebound tenderness.
EXTREMITIES: WWP. 2+ ___ pulses. RLE trace edema on dorsum of
foot to 3 inches above ankle. No cyanosis or clubbing, moving
all 4 extremities with purpose. SILT S/S/SP/DP/T. ___ ___.
NEURO: A&Ox3. CN II-XII intact. Motor and sensation intact
grossly in all 4 extremities.
SKIN: RLE 4x5cm erythematous lesion with purulent discharge and
necrotic eschar. Improving erythema and edema compared to prior
with less purulent discharge. Gauze dressing C/D/I. Circular
healing lesions with overlying scab noted on L palm, LLE x 2,
and RLE x 1, ranging from 1.5cm diameter to 3cm.
Pertinent Results:
Admission Labs:
___ 07:05AM WBC-17.5* RBC-4.31 HGB-11.9* HCT-37.8 MCV-88
MCH-27.6 MCHC-31.4 RDW-15.3
___ 07:05AM NEUTS-80.3* LYMPHS-15.8* MONOS-3.5 EOS-0.3
BASOS-0.1
___ 07:05AM ALT(SGPT)-19 AST(SGOT)-11 ALK PHOS-51 TOT
BILI-0.3
___ 07:05AM GLUCOSE-81 UREA N-18 CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
___ 07:15AM LACTATE-2.2*
During hospitalization:
___ 07:11AM BLOOD WBC-14.0* RBC-3.90* Hgb-10.9* Hct-33.8*
MCV-87 MCH-27.8 MCHC-32.1 RDW-14.9 Plt ___
___ 07:49AM BLOOD WBC-12.6* RBC-4.34 Hgb-12.0 Hct-37.9
MCV-87 MCH-27.6 MCHC-31.6 RDW-15.2 Plt ___
___ 07:49AM BLOOD Triglyc-176* HDL-67 CHOL/HD-2.9
LDLcalc-93
Imaging:
___ R Tib/Fib AP/Lat: Soft tissue defect lateral to the
distal fibular with no underlying osseous abnormality.
Micro:
Blood cultures -- no growth
Brief Hospital Course:
Ms. ___ is a ___ with PMH significant for Sweet's syndrome
(on prednisone) who presented to the ___ ED with worsening
pain and an expanding lesion on her lateral RLE, improved with
IV steroids.
# Leg lesion: Sweets vs Pyoderma Gangrenosum. Initially she was
started on antibiotics in the ED but after careful evaluation by
medicine and dermatology there was not felt to be a true
infection, corroborated by the deep tissue sample negative
culture despite superficial swab growing pseudomonas, so
antibiotics were not continued. Dermatology injected kenalog x2
and recommended high dose IV steroids (125mg Methylpred daily)
and discharge on 60mg prednisone twice daily with associated
prophylactic medications (dapsone, vitamin D, calcium, PPI) at
least until she seems dermatology in follow up ___, and
likely for several weeks. She did have clear visible improvement
in the leg lesion during her stay. Pain was severe and
controlled with IV and PO narcotics.
#Acute pain: from leg lesion. She was treated with opiates
successfully (BID PO prior to discharge). She was instructed on
use, especially with respect to benzodiazepine, which she had
recently been taking at night priot to hospitalization to help
her sleep (sleeplessness has been due to pain), to avoid over
sedation.
# Medication error: due to a POE ordering error, patient
received 3x the intended dose of methylprednisolone on one night
of her stay. She reported feeling somewhat "on edge" that
morning, which was treated with ativan and trazodone for sleep,
and fingersticks were monitored for 24 hours and were normal. An
incident report was filed, and the patient was informed on the
day of discovery.
CHRONIC ISSUES:
# Hypothyroidism - continued home levothyroxine
# Eosinophilic esophagitis - continued home PPI
Tranisitional issues:
- Taper off pain meds and bowel regimen as symptoms allow
- Continue dapsone and vitamin D/Calcium as long as on high dose
steroids, taper per dermatology (TBD)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
3. TraZODone 50 mg PO HS:PRN insomnia
4. Lorazepam 0.5 mg PO HS:PRN insomnia
5. Omeprazole 20 mg PO BID
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Omeprazole 20 mg PO BID
3. TraZODone 50 mg PO HS:PRN insomnia
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q8H pain
6. Dapsone 100 mg PO DAILY
RX *dapsone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO BID:PRN constipation
take if no BM x1 day
RX *polyethylene glycol 3350 17 gram/dose 17g powder(s) by mouth
once or twice daily Disp #*238 Gram Gram Refills:*0
8. PredniSONE 60 mg PO BID
You will continue at this dose until further instructed by
dermatology.
RX *prednisone 20 mg 3 tablet(s) by mouth twice a day Disp #*84
Tablet Refills:*0
9. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
10. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) one tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
11. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
RX *clobetasol 0.05 % apply to base of ankle wound twice a day
Refills:*0
12. Lorazepam 0.5 mg PO Q8H:PRN anxiety/insomnia
RX *lorazepam 0.5 mg one tab by mouth every 8 hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Sweet's syndrome-associated lesion vs. Pyoderma gangrenosum
Secondary:
Sweet's syndrome
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires crutches.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___.
As you know, you were admitted to the inpatient Medicine service
with a worsening lesion above your right ankle that had
increased pain, redness, swelling despite oral steroid
treatment. The Dermatologists saw you and thought this lesion
could represent a flare of a Sweet's lesion or pyoderma
gangrenosum. Per their recommendations, we started you on IV
solumedrol to encourage healing. Though antibiotics were
initially started in the Emergency Room, there was no concern
for infection, and they were quickly stopped during your
hospitalization.
Your pain was controlled on medications, and your lesion
improved significantly. A transition to oral steroids was made,
and you were discharged home in stable condition with an
improving lesion and close follow-up scheduled with Dermatology.
Please review your medication list carefully as some other
medications were also added to decrease your risk of side
effects of high-dose steroids.
We wish you the best of luck. Take care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19983512-DS-17 | 19,983,512 | 28,279,474 | DS | 17 | 2142-03-07 00:00:00 | 2142-03-09 22:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Bactrim
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with Sweet's syndrome, history of eosinophilic
esophagitis, hypothyroidism, calculous cholecystitis s/p lap
cholecystectomy 6 wks ago (___), on methylprednisolone,
dapsone, and cyclosporine for Sweet syndrome presenting with
acute on chronic abdominal pain. She was in her USOH on the
night prior to presentation when she developed acute abdominal
pain around 8pm. She was able to fall asleep but awoke again
around 3am with severe abdominal pain. Pain is located in the
epigastric region, and radiates bilaterally to the shoulders and
upper back. Pain was constant and "unbearable" from 3am until
around 8am when she arrived at the ___ ED. Abdominal pain has
no clear exacerbating factors, and was not relieved with TUMS or
omeprazole, or with changing positions, walking around, or lying
down. No relation to food. Has been nauseated but no vomiting.
Denies fevers, chills, diaphresis, diarrhea, constipation, chest
pain, shortness of breath, palpitations, dysuria, although she
notes urinary frequency with nocturia for several weeks. She
states that her abdominal pain began around the time of her
admission for cholecystitis in early ___, but has
persisted following surgery. It occurs on a near-daily basis,
and is usually present when she pushes in the epigastric area.
She has had several exacerbations with severe abdominal pain,
and it is at these times that the pain radiates to the back,
although she states that this current episode is the worst so
far.
She also notes right sided shoulder pain felt in the anterior
upper outer chest and radiating through the top of the
acromioclavicular region into the scapula. This pain is
sometimes exacerbated by movements and can be reproduced with
palpation of the area.
Of note, she reportedly had a negative abdominal CT scan 3 weeks
ago, ordered by her PCP.
In the ED, initial vitals were: T 97.5 HR86 BP 159/103 RR 16
SPO2 100%.
Labs were notable WBC count 10.1, Hgb 11.6 (baseline ___, ALT
133, AST 191, Alk phos 107, Tbili 0.9, Dbili 0.6. Lipase 37.
Chem 7 within normal limits except bicarb of 30. UA with small
leukocyte esterase, few bacteria, 5 epithelial cells.
Preliminary read of abdominal ultrasound was unremarkable.
She was treated with Maalox, Donnatal, viscous lidocaine, zofran
4mg IV x 2, morphine 5mg IV x 3, and 1000mL normal saline.
Vitals prior to transfer were T97.9 HR80 BP110/75 RR 18 SPO2 96%
RA
Review of systems:
(+) Per HPI. Notes night sweats for several months, increasing
lower extremity edemal, and weakness in her thighs since ___. Also notes moon facies and buffalo hump
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies vomiting, diarrhea, constipation. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
PAST MEDICAL HISTORY:
Sweet syndrome; dx'd age ___
Eosinophilic esophagitis
Hypothyroidism
Cholelithiasis/cholecystitis
PAST SURGICAL HISTORY:
Laparoscopic cholecystectomy ___
R knee arthroscopic surgery
R knee open ACL reconstruction
L ___ toe Sweet's lesion excision
C-section
Social History:
___
Family History:
Father and grandmother with thyroid disease. Grandmother with
colon cancer. Extensive family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================================
Vitals: T 98 BP 106/57, HR 80, RR 16, SPO2 97RA
General: Alert, oriented, no acute distress, able to move and
sit up in bed without difficulty
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present. Mild to
moderate tenderness in the epigastrium without guarding. Very
mild tenderness to deep palpation in the RLQ. No RUQ tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses. 1+ nonpitting edema in
bilateral lower extremities. R lateral ankle with approximately
5x5 cm2 ulcer with red-yellow fibrinous base and surrounding
violaceous/grey erythema without rolled borders. Unable to
appreciate undermined edges. Very tender
MSK: No joint swelling, erythema, or increased warmth. Able to
reproduce mild pain with palpation of soft tissue beneath AC
joint anteriorly, and over several focal tender points on
scapula and thoracic paraspinal muscles. Active and passive
shoulder ROM intact, with mild pain with Neer impingement test
on right. some reproduction of pain in right shoulder with
empty can test. Able to perform ___, posterior lift-off,
and resisted internal rotation without weakness/pain.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait normal.
DISCHARGE PHYSICAL EXAM:
================================
Vitals: T 97.8 BP 115/72, HR 77, RR 20, SPO2 98RA
General: Alert, oriented, no acute distress, able to move and
sit up in bed without difficulty
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present. Mild
tenderness in the epigastrium, RUQ, and RLQ, no guarding
Ext: Warm, well perfused, 2+ pulses. R lateral ankle with
approximately 5x5 cm2 ulcer with red-yellow fibrinous base and
surrounding violaceous/grey erythema without rolled borders.
Unable to appreciate undermined edges. Very tender
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait normal.
Pertinent Results:
ADMISSION LABS:
=======================================
___ 09:15AM BLOOD WBC-10.1# RBC-3.67* Hgb-11.6* Hct-35.0*
MCV-95 MCH-31.6 MCHC-33.1 RDW-13.7 Plt ___
___ 09:15AM BLOOD Neuts-75.7* Lymphs-16.4* Monos-6.5
Eos-0.8 Baso-0.6
___ 09:15AM BLOOD Glucose-105* UreaN-10 Creat-0.6 Na-141
K-4.0 Cl-102 HCO3-30 AnGap-13
___ 09:15AM BLOOD ALT-133* AST-191* AlkPhos-107*
TotBili-0.9 DirBili-0.6* IndBili-0.3
___ 09:15AM BLOOD Lipase-37
___ 09:15AM BLOOD Albumin-3.9
PERTINENT LABS:
=======================================
___ 05:15AM BLOOD WBC-9.5 RBC-3.49* Hgb-11.2* Hct-33.7*
MCV-97 MCH-32.1* MCHC-33.2 RDW-13.7 Plt ___
___ 05:15AM BLOOD Glucose-112* UreaN-7 Creat-0.7 Na-139
K-4.6 Cl-102 HCO3-30 AnGap-12
___ 05:15AM BLOOD ALT-374* AST-251* AlkPhos-152*
TotBili-0.6
___ 05:15AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8
DISCHARGE LABS:
=======================================
___ 05:30AM BLOOD WBC-9.7 RBC-3.53* Hgb-11.2* Hct-33.6*
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.6 Plt ___
___ 05:30AM BLOOD Glucose-100 UreaN-9 Creat-0.7 Na-138
K-3.8 Cl-101 HCO3-30 AnGap-11
___ 05:30AM BLOOD ALT-221* AST-74* AlkPhos-125* TotBili-0.4
___ 05:30AM BLOOD GGT-139*
___ 01:00PM BLOOD %HbA1c-4.4* eAG-80*
STUDIES:
=======================================
LIVER OR GALLBLADDER US ___
The liver is normal in echotexture, without focal lesions or
intrahepatic biliary ductal dilatation. Main portal vein is
patent with hepatopetal flow. The CBD measures 6 mm. The patient
is status post cholecystectomy. Imaged portion of the pancreas
appears within normal limits, without masses or pancreatic
ductal dilation, with portions of the pancreatic tail obscured
by overlying bowel gas. The spleen measures 12.2 cm, and is
normal in echogenicity. The right kidney measures 10.7 cm. The
left kidney measures 11.6 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones or hydronephrosis in the kidneys.
Visualized portions of aorta and IVC are within normal limits.
There is no ascites.
IMPRESSION: Unremarkable abdominal ultrasonographic examination
in this patient with prior cholecystectomy.
MRCP (MR ABD ___ ___
Included views of the lung bases are clear. There is no
pericardial pleural effusion. The heart size is normal.
The liver parenchyma demonstrates mild heterogeneous on T1
weighted out of phase images in comparison to in phase
sequences, denoting steatosis (series 12, image 13). Again seen
arising from the caudate lobe is a well-circumscribed 14 mm
lesion demonstrating high internal signal intensity on T2
weighted sequences, with peripheral nodular enhancement and
centripedal enhancement on delayed sequences, most compatible
with a hemangioma (series 4, image 18). A 4 mm segment III
hepatic cyst is present (series 4, image 20). No concerning
hepatic mass is detected. There is no intra or extrahepatic bile
duct dilation. No peribiliary enhancement is detected. The
patient is post cholecystectomy.
The pancreas demonstrates normal signal intensity and bulk. A 3
mm cystic lesion within the pancreatic head is again seen,
likely a tiny side branch IPMN (series 4, image 34). No
concerning pancreatic lesion is detected. Pancreatic duct is
normal in caliber.
The spleen, adrenal glands, stomach, and intra-abdominal loops
of small and large bowel are within normal limits. Arising from
the posterior interpolar aspect of the left kidney is a
well-circumscribed 6 mm hemorrhagic or proteinaceous cyst,
denoted by a high internal signal intensity on T2 weighted
sequences, intermediate signal intensity on T1 weighted
precontrast images, without appreciable internal contrast
enhancement (series 4, image 60, series 18, image 61). No
concerning renal mass is detected. There is no collecting system
obstruction.
There is no mesenteric or retroperitoneal lymphadenopathy, and
no free fluid.
The abdominal aorta, celiac trunk, SMA, and renal arteries are
patent and normal in caliber. A replaced left hepatic artery
arises from the left gastric (series 16, image 31).
There are no osseous lesions concerning for malignancy or
infection.
IMPRESSION:
1. No intra or extrahepatic bile duct dilation. No ductal
stones. Post cholecystectomy.
2. Mild heterogeneous hepatic steatosis.
3. 3 mm cystic lesion within the pancreatic head is unchanged,
likely a tiny side branch IPMN. ___ year followup recommended.
4. 14 mm caudate lobe hemangioma and 3 mm segment III hepatic
cyst. No concerning hepatic mass.
MICROBIOLOGY:
=======================================
___ 2:46 pm SEROLOGY/BLOOD
VARICELLA-ZOSTER IgG SEROLOGY (Final ___:
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
___ 2:46 pm Blood (CMV AB)
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ 2:46 pm Immunology (CMV)
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
Brief Hospital Course:
___ year old woman with history of Sweet's Syndrome on
cyclosporine, methylprednisolone, and dapsone, cholecystitis s/p
cholecystectomy in ___, and hypothyroidism presented with
acute on chronic epigastric pain radiating to the back, with no
clear etiology but improved symptoms at discharge.
ACTIVE ISSUES:
============================
# Abdominal Pain
The etiology of patient's abdominal pain was unclear. She had no
alarm features such as vomiting, diarrhea, fevers, or severe
pain, and labs revealed mild transaminitis and mildly elevated
bilirubin, with normal WBC count, normal lipase, and normal
urinalysis. Abdominal ultrasound was unrevealing, and per report
recent CT scan was negative. On hospital day 2, ALT and AST
increased to 374 and 251 respectively, indicative of
hepatocellular injury. Hepatology was consulted, and recommended
an MRCP, which only showed mild hepatic steatosis with no intra
or extrahepatic bile duct dilatation. A further work up for
auto-immune and infectious etiologies of hepatitis were pursued
with many studies pending at the time of discharge. She had mild
nausea, but no vomiting and was able to tolerate a regular diet
without improvement or worsening of her pain. Pain was
controlled initially with intravenous morphine but she was
rapidly transitioned to oral tramadol and oxycodone as needed
for breakthrough pain. Her symptoms improved to be tolerable,
and she was discharged with close outpatient follow up for
further evaluation.
CHRONIC DIAGNOSES:
============================
# ___'s Syndrome
Patient had a stable right lateral ankle wound, 5x5cm,
consistent with pyoderma gangrenosum and likely manifestation of
Sweet's Syndrome. There were no signs of superinfection. Wound
was dressed daily with Adaptic nonadherent dressing. She was
continued on dapsone 50mg daily and cyclosporine 100mg daily,
which she reported taking at home. It was later clarified prior
to discharge that she should have been taking cyclosporine 300
mg daily. She was admitted on a methylprednisolone taper, and
was scheduled to transition from methylprednisolone 4mg PO daily
to prednisone 5mg daily, but was continued on methylprednisolone
4mg daily until discharge, at which time she started the
prednisone taper.
# Hypothyroidism
She was continued on home dose levothyroxine 150 mcg PO daily.
# History of Eosinophilic Esophagitis
She had no recent symptoms, and continued takin omeprazole 20mg
PO BID.
TRANSITIONAL ISSUES:
============================
- Patient currently taking only 100 mg cyclosporine daily (was
prescribed 300 mg daily per her pharmacy and last Dermatology
note dated ___ will need clarification of regimen with
Dermatology regarding Sweet's Syndrome flare treatment.
- Patient on last week of steroid taper for Sweet's flare,
starting prednisone 5 mg PO daily tomorrow (___) for 7 days.
- On MRCP, there was an unchanged in size, 3 mm cystic lesion
within the pancreatic head, likely a tiny side branch IPMN. ___
year followup recommended.
- Patient has a number of labs pending at discharge, including
IgG levels, ___, AMA, anti-smooth muscle, ceruloplasmin, EBV
viral load, Varicella IgM, HSV IgM and IgG, EBV VCA IgG and IgM,
EBV EBNA IgG, and HCV viral load.
- Pt will need LFTs trended at next outpt hepatology f/u appt
Medications on Admission:
1. Dapsone 50 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. TraZODone 25 mg PO HS:PRN insomnia
6. Methylprednisolone 4 mg PO DAILY
7. CycloSPORINE (Sandimmune) 100 mg PO Q24H
Discharge Medications:
1. Dapsone 50 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. PredniSONE 5 mg PO DAILY Duration: 7 Days
RX *prednisone 5 mg 1 tablet(s) by mouth Daily Disp #*7 Tablet
Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Capsule Refills:*0
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
9. DiCYCLOmine 10 mg PO BID
RX *dicyclomine 10 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*1
10. CycloSPORINE (Sandimmune) 100 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hepatitis (unknown etiology)
Secondary: Sweet's 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 meeting you and taking care of you during your
hospitalization at ___. You
were admitted to the hospital after an episode of severe
abdominal pain. Testing revealed injury to the liver, of unknown
cause, and we performed an extensive work up of potential
causes. Many of the lab tests are still pending. We performed an
MRI of your liver, which showed no clear etiology for your
abdominal pain. It did show, however, a small cyst in your
pancreas for which you'll need repeat imaging in ___ years and
benign cysts in your liver, which do not require follow up.
Fortunately, your abdominal pain improved, and we recommend
follow up with your outpatient providers.
It was a pleasure to take care of you during your stay. Please
do no hesitate to contact us with any questions and concerns.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19984491-DS-5 | 19,984,491 | 29,623,707 | DS | 5 | 2163-03-06 00:00:00 | 2163-03-06 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female who presents to ___ on ___ with a
mild TBI s/p fall at home around 9 AM, hit head on nightstand,
found to have SDH at OSH acute right sided 5mm SDH On Coumadin,
INR was 2.8. Given vitamin K at OSH. INR on arrival here
improved to 2.6. Per the patient family she has a history of
PE/DVT and AVR thrombus.
===================
Medicine accept note:
Ms. ___ is an ___ yoF with PMH sig for dementia, DVT, PE,
AVR thrombus, on warfarin, HTN, HLD, and proximal aortic
dissection s/p AVR who presented from assisted living facility
to ___ on ___ with a mild TBI s/p fall. Of note,
pt has no known recent history of cardiac ischemia, syncopal
episodes, orthostasis, epileptic activity, or falls. Of note,
patients baseline mental status is AOx1, her functional status
is independent with ADLs, no walker or cane needed, in fact she
is a brisk walker.
On the morning of ___, the pt was found conscious, with a
head contusion, on the ground by the side of her bed by aids at
her assisted living facility where she lives with her husband
and her disabled son. She was lying, in pajamas, on her right
hip. The fall was unwitnessed, but the aid attributed the pt's
contusion to having hit her head on the nightstand. No bowel or
bladder incontinence or evidence of tongue biting. Pt does not
remember the fall, nor the preceding events, the fall was not
witnessed. Per daughter report, pt has not mentioned any recent
episodes of dizziness, chest pain, or shortness of breath, and
noted no fever, chills, night sweats, nausea, or vomiting. Prior
to fall, pt ambulated with ease, not using walker or cane, and
ascended and descended stairs without assistance. Pt has had no
known recent sick contacts, though moved to an assisted living
facility two months ago, and no recent travel. She has poor
fluid intake throughout the day, though eats three full meals
per day at her facility. Per daughter, pt has significant
baseline dementia, though is always oriented to self and
location.
Pt presented to OSH where she was found to have acute right
sided 5mm SDH on Coumadin (INR 2.8), and she received vitamin K.
CT C-spine and head performed. Upon presentation to ___ ED, pt
had INR of 2.6. Chest (PA&LAT), ankle, and hip x-rays performed
all unremarkable. Pt was monitored by the neurosurgical service
and is planned for follow-up CT scan in two months. Warfarin was
restarted on ___ because of INR of 2.0, and she was started on
Keppra 500 mg BID x7 days (end date ___ for seizure
prophylaxis. UA was taken and was positive for large nitrite and
leuk, treatment for asymptomatic UTI initiated with TMP/SMX (day
1: ___. Pt was transferred to the medicine service for fall
work-up.
On ___, pt was AOx1, alert, conversational, and responded to
commands appropriately. Pt denied dizziness, headache, blurry
vision, chest pain, SOB, fever, chills, dysuria, or urinary
urgency. Pt reports no ankle or hip pain or stiffness. Per
daughter, pt is back to baseline.
Past Medical History:
Dementia, HLD, DVT, PE, thrombus, HTN, OA, s/p AVR on Coumadin
AVR, bilateral Hip replacements
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical exam:
GCS:15
Gen: WD/WN, comfortable, NAD.
HEENT: bruise and scrape over r eye, swollen
Neck: supple
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect, pleasantly confused (baseline)
Orientation: Oriented to person only.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 mm to 1.5 mm
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Handedness: Right
Discharge physical exam:
PE
Vitals: Tmax=99.4 102-123/60-70 50-70 92-98%RA
General: AOx2. Resting calmly.
HEENT: Normocephalic, head, hair, scalp WNL. Ecchymosis with
scrape over right eye. PERRLA. EOMI. MMM. No lesions on bucal
mucosa, tongue, or lips.
Neck: No LAD. No JVD.
Lungs: Lungs clear do percussion posteriorly and clear to
auscultation anteriorly and posteriorly.
CV: RRR with nl S1 and S2. No rubs, murmurs, gallops.
Abdomen: Abdomen non-tender to light and deep palpation in all 4
quadrants.
Back: no CVA tenderness. No spinous process or paraspinal muscle
pain.
Ext: Warm and well-perfused. Tenderness to deep palpation on
lateral aspect of dorsum of foot anterior to lateral malleolus.
Neuro: CNs II-II in tact. Strength ___ throughout, ___ with R
dorsiflexion. Light touch, vibration, and proprioception in tact
throughout.
Pertinent Results:
===================
Admission labs:
===================
___ 01:28PM BLOOD WBC-5.6 RBC-4.37 Hgb-12.0 Hct-38.3 MCV-88
MCH-27.5 MCHC-31.3* RDW-14.2 RDWSD-45.9 Plt ___
___ 01:28PM BLOOD Neuts-71.9* ___ Monos-5.7
Eos-0.9* Baso-0.7 Im ___ AbsNeut-4.01 AbsLymp-1.13*
AbsMono-0.32 AbsEos-0.05 AbsBaso-0.04
___ 01:28PM BLOOD ___ PTT-38.7* ___
===========
Micro
===========
___ 1:28 pm BLOOD CULTURE Blood Culture, Routine (Pending):
___ 2:55 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
============
Radiology:
============
___
NCHCT (OSH) 5mm SDH
CT Cervical Spine: negative
Chest XR
FINDINGS:
PA and lateral views of the chest provided.
Sternotomy wires are noted. Linear opacities in the bilateral
lower lobes
likely represent bibasilar atelectasis versus scarring. There
are
atherosclerotic calcifications involving the aortic arch and
descending
thoracic aorta. No radiopaque cardiac valve is seen. S-shaped
curvature of
the thoracolumbar spine is noted.
IMPRESSION:
1. No radio opaque cardiac valve is seen.
2. Bibasilar atelectasis.
___ Ankle XRAY
FINDINGS:
No fracture, dislocation, or degenerative change is detected.
The mortise is
congruent on this non stress view. The tibial talar joint space
is preserved
and no talar dome osteochondral lesion is identified. No
suspicious lytic or
sclerotic lesion is identified. No soft tissue calcification or
radiopaque
foreign body is identified.
MPRESSION:
No acute fracture or dislocation of the right ankle
___ Hip XRAY
The patient is status post bilateral total hip arthroplasties
with evidence of
revision on the right. There is no acute fracture or
dislocation identified.
Evaluation the sacrum is however obscured by overlying bowel.
There are no
gross degenerative changes. There is no suspicious lytic or
sclerotic lesion.
Vascular calcification is present as are calcifications over the
right gluteal
region likely reflective of injection granulomas.
IMPRESSION:
Status post bilateral total hip arthroplasties. No evidence of
an acute
fracture of the pelvis or right hip.
===================
Discharge labs:
===================
___ 04:50AM BLOOD WBC-5.0 RBC-3.78* Hgb-10.4* Hct-32.7*
MCV-87 MCH-27.5 MCHC-31.8* RDW-14.2 RDWSD-44.7 Plt ___
___ 04:50AM BLOOD Neuts-60.3 ___ Monos-11.3 Eos-1.2
Baso-0.6 Im ___ AbsNeut-3.00 AbsLymp-1.30 AbsMono-0.56
AbsEos-0.06 AbsBaso-0.03
___ 04:50AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-91 UreaN-32* Creat-1.5* Na-135
K-3.4 Cl-97 HCO3-23 AnGap-18
___ 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8
Brief Hospital Course:
Ms. ___ is an ___ year old woman with past medical history
of dementia (AOx1), deep vein thrombosis, pulmonary embolism,
and aortic dissection with aortic valve replacement on warfarin
who presented to ___ with a mild traumatic brain injury
following a fall at her assisted living facility. The fall was
not witnessed and she does not remember the fall or the
preceding events. On head CT, patient was found to have an
acute, right-sided 5mm subdural hematoma while on Coumadin, with
an INR of 2.8. She received vitamin K, which reduced her INR to
2.6. She received chest, hip, and ankle x-rays, with no
concerning findings obviated. Urinalysis was performed finding
positive leukocyte esterase and nitrites, and urine culture was
positive for gram negative rods. A three-day course of TMP-SMZ
was initiated (end-date ___. Patient was monitored by
neurosurgical service, and transferred to medicine for work-up
of possible syncope. Telemetry and orthostatics were
non-concerning. Fall was likely mechanical.
#SDH: Unwitnessed fall ___ with no focal neurological
deficit. NCHT ___ done in OSH showing 5mm SDH, corroborated by
___ radiology and neurosurgery. SDH was small/stable so no
intervention required. Neurological exam was completely benign
and remained that way during hospital stay with ___ strength
bilaterally in all extremities, 2+ DTR and symmetric facial
tone. Per daughter at bedside, pt remained cognitively at
baseline. Of note, pt was given vitamin K at OSH and her INR
reduced from 2.8 to 2.6 after administration. Warfarin was held
___ and then resumed at an average home dose of 5mg Warfarin
on ___. Pt did well with q4H neuro checks and remained
stable. Per neurology recommendations, patient was restarted on
warfarin and started Keppra 500mg x 7 days (end date ___.
Pt requires follow up with neurosurgery with Dr. ___ in
clinic in 10 weeks with a repeat NCHCT at that time.
#UTI: She had an abnormal urinalysis on admission and was
prescribed a three day course of Bactrim, end date ___. Urine
cultures grew pan-sensitive E.coli. No complaints of dysuria.
#Fall: Given no recent history of syncope, orthostasis, chest
pain, SOB or any other concerning symptoms, her episode may have
been ___ to mechanical fall. Please refer to the accept note for
more details for the event of the fall. Other etiologies of fall
that are likely in this situation include AMS more than baseline
___ to infectious cause(UTI). Another cause may be orthostasis
___ to poor fluid intake per daughters report, though patient
does not c/o symptoms and orthostatic vitals were negative.
Cardiac etiology of valvular defect is unlikely as this did not
occur during exertion. Arrythmia cannot but ruled out, but again
is less likely given no history of prior syncope and pt did not
declare herself on telemetry. Medication list reviewed and no
recent changes and no drug interactions likely to precipitate
this event. No loss of bowel or bladder control reduce
likelihood of seizure. We believe fall was most likely
mechanical. Consider work up with holter monitor and echo if
patient has another episode.
#Hip and ankle pain: Pt reported right hip and knee pain s/p
fall due to impact of fall from standing. No fracture visualized
on ankle or hip x-ray. Pt is able to bear weight on ankle and
has no pain at base of the fifth metatarsal. No further imaging
needed. Pain well controlled with Acetaminophen 650 mg PO:PRN.
___
Pt presented with Cr of 1.1 and Cr level peaked on ___ to 1.5.
Per patients daughter, nurses and patient herself, she does not
like to drink water and has to be reminded to drink frequently.
Cr may also be falsely elevated secondary to Bactrim for UTI
treatment. Trial of 500IV NS given over 2 hours on ___. Of
note, HCTZ was discontinued secondary to creatinine elevation.
SBP remained <160 per neurosurgery requests. Follow up with Cr
levels on ___ and consider restarting HCTZ. Discharge
orthostatic vitals negative on discharge after 500IV NS.
#Code status: currently full code, per HC proxy. Daughter plans
to discuss this further with other family members.
CHRONIC ISSUES
==============
#Dementia: Pt is at baseline per daughter. AOx1 (name, location
[hospital], year ___. Can state days of week and months
backward and spell WORLD backward. Pt was encouraged normal
sleep-wake schedule to minimize likelihood of delirium
#Hypercoagulability: s/p DVT x3, PE, AVR thrombosis, protein S
deficiency . Continued warfarin at a changed dose of 5 mg PO
q24. See above for more details. INR monitored by Dr. ___
___ (PCP - ___. Followed by cardiology at ___ (Dr.
___
#HTN: Continued home amlodipine 2.5 mg PO q24, atenolol 50 mg
PO q24, held HCTZ 25mg ___ iso elevated Cr.
#HLD: Continued home atorvastatin 20mg PO q24
#Depression :Continued home citalopram 10mg
TRANSITIONAL ISSUES:
1. Continue Levetiracetam 500mg PO BID for 7 days (end date:
___
2. Monitor INR closely given that warfarin was stopped ___
then restarted ___ with changes to home dose. Home dose 4mg
MTWThF, 8mg ___, changed to 5mg PO once daily. Next INR check
on ___. Follow-up head CT in 2 months (Approx: ___
4. Consider echo for possible cardiac etiology of fall
5. Recheck Cr level ___. Rise 1.1-->1.5 secondary to either
prerenal etiology or falsely elevated iso Bactrim for UTI
treatment. HCTZ held starting ___. Can resume once Cr back to
baseline at 1.0-1.1.
-Code Status: Full code, further discussion needed
-Communication: ___ - daughter (___)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 2.5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Atenolol 50 mg PO BID
4. Vitamin D 1000 UNIT PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Warfarin 4 mg PO 5X/WEEK (___)
7. Warfarin 2 mg PO 2X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN itching
3. LevETIRAcetam 500 mg PO BID Duration: 3 Days
End date ___. Senna 17.2 mg PO QHS:PRN constipation
5. Warfarin 5 mg PO DAILY
Please follow up with INR and change accordingly.
6. amLODIPine 2.5 mg PO DAILY
7. Atenolol 50 mg PO BID
8. Atorvastatin 20 mg PO QPM
9. FoLIC Acid 1 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
xRight subdural hemorrhage without surgical intervention
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 Ms. ___,
You were admitted after you fell and hit your head while
getting out of bed at the assisted living facility. You were
taken to an outside hospital where they performed a head CT and
found a small amount of bleeding around your brain. You were
given vitamin K to reduce your likelihood of further bleeding.
Upon transfer to ___, you received chest (PA&LAT), ankle, and
hip x-rays, all of which showed no concerning findings such as
fracture. You were monitored by the neurosurgical service, and
were transferred to medicine to help determine the cause of your
fall. While at the hospital, it was also found that you had a
urinary tract infection and treatment with an antibiotic was
started. You did very well, and got less confused and stronger
as your hospital stay progressed.
Discharge Instructions:
-We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
-You may 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.
Medications
-Your Coumadin was restarted while you were in the hospital.
Please follow-up with your PCP (Dr. ___: ___
to closely monitor your INR.
-You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated in your discharge instructions. It is
important that you take this medication consistently and on
time. THIS MEDICATION IS FOR 7 DAYS ONLY, PLEASE STOP ON
___ AFTER THE EVENING DOSE.
-You may use Acetaminophen (Tylenol) for minor discomfort.
What You ___ Experience:
-You may have difficulty paying attention, concentrating, and
remembering new information.
-Emotional and/or behavioral difficulties are common.
-Feeling more tiredness, restlessness, irritability, and mood
swings are also common.
-Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet.
Headaches:
-Headache is one of the most common symptom 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.
-___ 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:
-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
We are wishing you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19984573-DS-18 | 19,984,573 | 29,579,818 | DS | 18 | 2113-02-16 00:00:00 | 2113-02-18 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ single vehicle high speed ___ car vs pole with extensive
damage to vehicle, ejected from car, +ETOH (145). Patient
remembers entire event and reportedly had GCS 15 at scene. In
the ED imaging showed grade II splenic lac and effusion of left
knee without fracture.
Past Medical History:
PMH:
none
PSH:
hernia as child
MEDS AT HOME:
none
Allergies:
NKDA
Social History:
___
Family History:
non contributory
Physical Exam:
Admitting exam
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact, Pupils equal, round and reactive to light left
conjunctiva injection
C. collar in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended tenderness in the left upper
quadrant no rebound or guarding
Extr/Back: No T. or L-spine tenderness +2 DP bilaterally
tenderness over the patella with mild effusion of the left
no pain with range of motion bilateral hips and ankles no
pain with range of motion bilateral upper extremities
Skin: Warm and dry scattered abrasions on the left side of
his body
Neuro: Speech fluent and x3 strength 5 out of 5 in the
upper and lower extremities
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact, Pupils equal, round and reactive to light left
conjunctiva injection
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, non-tender
quadrant no rebound or guarding
Extr/Back: Left knee effusion
Neuro: Speech fluent and x3 strength 5 out of 5 in the
upper and lower extremities
Pertinent Results:
___ 12:47AM BLOOD WBC-10.3 RBC-4.70 Hgb-15.4 Hct-43.1
MCV-92 MCH-32.7* MCHC-35.6* RDW-11.8 Plt ___
___ 04:10AM BLOOD WBC-12.9* RBC-4.21* Hgb-13.7* Hct-39.1*
MCV-93 MCH-32.5* MCHC-35.0 RDW-12.4 Plt ___
___ 07:42AM BLOOD Hct-38.1*
___ 01:39PM BLOOD Hct-35.8*
___ 08:00PM BLOOD WBC-7.9 RBC-4.09* Hgb-13.6* Hct-38.3*
MCV-94 MCH-33.3* MCHC-35.7* RDW-12.0 Plt ___
___ 06:25AM BLOOD WBC-7.3 RBC-3.94* Hgb-12.9* Hct-36.6*
MCV-93 MCH-32.7* MCHC-35.2* RDW-12.3 Plt ___
___ 04:10PM BLOOD WBC-7.1 RBC-4.22* Hgb-13.9* Hct-39.0*
MCV-93 MCH-33.0* MCHC-35.7* RDW-11.9 Plt ___
___ 05:40AM BLOOD Hct-40.5
___ 12:47AM BLOOD UreaN-12 Creat-1.3*
___ 06:25AM BLOOD Glucose-85 UreaN-8 Creat-0.8 Na-138 K-3.5
Cl-101 HCO3-27 AnGap-14
___ 04:10AM BLOOD ALT-34 AST-49* AlkPhos-47 TotBili-0.9
___ 12:47AM BLOOD Lipase-95*
___ 12:47AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:47AM BLOOD Glucose-95 Lactate-2.1* Na-144 K-3.6
Cl-103 calHCO3-28
CT C-spine
Final Report
INDICATION: High-speed motor vehicle crash; unrestrained
driver.
COMPARISONS: None.
TECHNIQUE: Helical axial MDCT images were obtained through the
cervical spine
without the administration of IV contrast. Sagittal and coronal
reformatted
images were obtained and reviewed.
FINDINGS: There is no fracture, subluxation, or thickening of
the
prevertebral soft tissues. Disc space heights are preserved.
There are small
central disc protrusions at C3-4 and C4-5, without evidence of
significant
spinal canal narrowing, though resolution of intraspinal detail
on CT is
limited. A small calcification is present in the nuchal
ligament at C5.
Numerous non-enlarged cervical lymph nodes are within normal
limits in a
patient of this age. There is mild pleural/parenchymal scarring
at the imaged
lung apices.
IMPRESSION: No fracture or malalignment.
CT torso
IMPRESSION:
1. Grade 2 splenic laceration measuring 2 cm. Surrounding
heterogeneity of
the splenic parenchyma likely represents some additional
parenchymal hematoma.
There is no evidence of a subcapsular hematoma or perisplenic
fluid.
2. Rounded opacity at the left base adjacent to the spleen is
likely due to a
tiny pulmonary contusion or a small focal region of atelectasis.
3. 5-mm right lower lobe pulmonary nodule. In the absence of
specific risk
factors, a followup CT is recommended at 12 months. If factors
such as
smoking exist, recommend a followup CT in 6 to 12 months.
CT head No evidence of an acute intracranial injury. No
fracture.
Left knee xray - Small to moderate joint effusion.
Brief Hospital Course:
Given his splenic injury, Mr. ___ was admitted to the trauma
ICU for monitoring and serial hematocrits. Imaging studies from
the ED revealed CT c-spine negative, head CT negative. His pain
was well-controlled and hematocrit remained stable. He was
deemed stable for transfer to the surgical floor for additional
monitoring. While on the floor, the paitent was complaining of
left knee pain and having difficulty ambulation. Knee
radiographs were negative for fracture. Pt was evaluated by
physical therapy who gave him crutches with which he was able to
ambulate without difficulty. He was given a referral for
outpatient physical therapy. His hematocrits remained stable
and his pain controlled. Pt was discharged with follow up.
Medications on Admission:
none
Discharge Medications:
1. Outpatient Physical Therapy
Evaluate and treat: Left Knee pain
2. Acetaminophen 1000 mg PO Q8H
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain ___
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Spleen injury, Left knee injury
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 after a car wreck. You
suffered an injury to your spleen. You were observed for in the
ICU and onteh floor. Your blood counts were stable. You must
not participate in any contact sports for atleast 6 weeks.
You sustained an injury to your liver/spleen. You should go to
the nearest Emergency department if you suddenly feel dizzy or
lightheaded, as if you are going to pass out. These are signs
that you may be having internal bleeding from your liver/spleen
injury.
Your liver/spleen injury will heal in time. It is important that
you do not participate in any contact sports or any other
activity for the next 6 weeks that may cause injury to your
abdominal region.
Avoid aspirin producs, NSAID's such as Advil, Motrin, Ibuprofen,
Naprosyn, or Coumadin for at least ___ weeks unless otherwise
directed as these can cause bleeding internally.
Don't drive or operate heavy machinery while on oxycodone as it
can make you sleepy.
Followup Instructions:
___
|
19984710-DS-16 | 19,984,710 | 29,213,398 | DS | 16 | 2179-03-17 00:00:00 | 2179-03-17 08:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / amoxicillin / Augmentin / Keflex / erythromycin
base / tramadol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
endoscopy
mild erythema in the lower esophagus consistent with mild
esophagitis ___ A)
Stomach:
Lumen: Evidence of a previous Roux-en-Y Gastric Bypass was
seen.
Mucosa: Erythema and edema of the mucosa was noted in the
stomach consistent with gastritis. Cold forceps biopsies were
performed for histology at the stomach.
Excavated Lesions A single non-bleeding 12 mm ulcer was found
in the near gastro-jejunal anastamosis.
Other A suture was seen.
Duodenum:
Other duodenum was not seen due to post surgical anatomy. The
efferent and blind jejunal limbs were without abnormality.
Impression: Mild erythema in the lower esophagus consistent with
mild esophagitis ___ A) esophagitis
Previous Roux-en-Y Gastric Bypass of the stomach
Erythema and edema of the mucosa in the stomach (biopsy)
Ulcer in the near gastro-jejunal anastamosis
A suture was seen.
Duodenum was not seen due to post surgical anatomy. The efferent
and blind jejunal limbs were without abnormality.
Otherwise normal EGD to post-anastamotic jejunal limbs
Recommendations: - high dose BID PO PPI
- no NSAID use
- further care per inpatient team
History of Present Illness:
___ with h/o gastric bypass surgery, active injection cocaine
use, methadone maintenance treatment presentingwith ___ days of
upper abdominal pain. Pain started without incident or trauma,
progressed to become severe and has impaired appetite and oral
intake. Pain is currently ___ and located above umbilicus and
is non-radiating. She has not eaten meals for the past 5 days
due to low appetite and pain. She did say eating improves pain.
She had two episodes of hematemesis that were a teaspoon or
less.
She is passing flatus. She has not moved her bowels in this
period.
She was diagnosed with strep pharyngitis and prescribed
clindamycin recently.
She recently approx. 3 d ago binged on cocaine and shared a
needle.
She has had a mild cough without SOB, but productive of green
phlegm for the past few days.
She has also developed mid and lower back pain in this time
without associated weakness.
She has had fevers to 102 in the past week.
ROS: She denies incontinence, dysuria, or hematuria. She last
took methadone yesterday. 10pt ROS as per HPI
In the ED she received analgesics, underwent CT abdomen that did
not show bowel obstruction and had ___ surgery
consultation.
PMH:
s/[ gastric bypass at ___ withj dr. ___ ___ years ago
s/p ccy
h/o lap surgery for sbo
s/p bil oopheroectomy for chronic cysts
h/o endometriosis
h/o fibromyalgia
h/o interstitial cystitis
IBS
s/p umbilical hernia repair
sh;
smokes ___ ppd, recently in drug/psych treatment at ___ in
mid ___ for 10 days. active cocaine use, recently shared
needle. homeless, no alcohol use.
fh
not pertinent for management of current chief complaint
allergies: throat closes to amox, augmentin, penicillin,
erythromycin, hives to Keflex
meds
last written on ___ for ___ pharmacy in ___
baclofen
chlorpromazine
docusate
folic acid
gabapentin
gylcolax powder
multivitamin
prazosin
sertraline
sucralafate
thiamine
prescribed by ___ on ___: clindamycin
Physical Exam:
97.9 108/70 74
fatigued but non toxic
ctab
rrr nmrg
slight tenderness pain to percussion of mid upper back between
scapula and midline lower back just above hips
epigastric discomfort and pain to palpation, no rebound or
guarding, no palpable organomegaly
no suprapubic discomfort
normal steady gait
full ___ motor strength in all extremities
calm and attentive, aox3, fluent speech
symmetric facial features
discharge
avss
aox3
calm and cooperative
standing up and breathing easily
conversant
soft abdomen
Pertinent Results:
___ 07:15AM BLOOD WBC-9.6 RBC-4.09 Hgb-11.3 Hct-35.1 MCV-86
MCH-27.6 MCHC-32.2 RDW-13.0 RDWSD-40.9 Plt ___
___ 07:15AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-142
K-4.8 Cl-102 HCO3-29 AnGap-11
___ 08:40PM BLOOD ALT-18 AST-19 AlkPhos-115* TotBili-<0.2
___ 08:40PM BLOOD Albumin-4.0 Iron-23*
___ 08:40PM BLOOD calTIBC-399 VitB12-327 Ferritn-19 TRF-307
___ 07:15AM BLOOD 25VitD-38
___ 09:05AM BLOOD CRP-6.6*
___ 09:05AM BLOOD HIV Ab-NEG
___ 09:05AM BLOOD HCV Ab-POS*
HCV Viral Load Not Detected log10 IU/mL
MRI spine
1. No evidence of infection orspinal cord compression in the
thoracic or
lumbar spine.
2. Minimal degenerative changes of the lumbar spine as described
above.
CXR
IMPRESSION:
Lungs are low volume with an ill-defined parenchymal opacity in
the lingula
concerning for pneumonia and posterior segment of the left upper
lobe. Heart
size is normal. Cardiomediastinal silhouette is unremarkable.
There is no
pleural effusion. No pneumothorax is seen
Abdominal CT
IMPRESSION:
1. No acute process within the abdomen or pelvis. Specifically,
no small
bowel obstruction.
2. Moderate stool burden from ascending to descending colon.
3. Unchanged splenomegaly.
Brief Hospital Course:
use, methadone maintenance treatment presenting with ___ days of
upper abdominal pain found to have marginal ulcer on endoscopy
performed on ___. Contributing factors to ulcer include past
gastric bypass surgery and ongoing NSAID use (taken for dental
pain).
PPI BID
Sucralafate.
She was found to have low iron level and relatively low ferritin
as well. Will treat with PO iron and vitamin C with awareness
that absorption may be influenced by PPI and that it may
exacerbate constipation. If she does not respond or tolerate,
IV
iron infusion would be a good option for her.
Supplementing nutrition with MVI, thiamine, folate, B12.
HCV VL detected, but unquantifiable. HIV VL negative
Because she had back pain and active IVDU, we obtained imaging
and MRI spine did not show evidence of osteomyelitis. CRP 6,
ESR 29
Treating a diagnosed pneumonia (minimally symptomatic with cough
but no hypoxia) with doxycycline 100mg BID for 7d, ___.
Methadone maintenance: 150mg daily per patient receives at
___ ___,
last dose given during admission on ___
transitional
she will f/u with gi for repeat endoscopy
f/u h. pylori serology
f/u gi path biopsy
f/u with her usual gastric bypass surgeon
get referral to ___ treatment of hepatitis C
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clindamycin 300 mg PO Q8H
2. Thiamine 100 mg PO DAILY
3. Sucralfate 1 gm PO QID
4. Sertraline 50 mg PO QHS
5. Prazosin 2 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN
8. Docusate Sodium 100 mg PO BID
9. ChlorproMAZINE 50 mg PO Q4H:PRN agitation
10. Baclofen 10 mg PO TID
11. Methadone 150 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Cyanocobalamin 250 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 250 mcg 1 lozenge(s) by mouth
daily Disp #*100 Lozenge Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*12 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 #*30 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation
8. Baclofen 10 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. Methadone 150 mg PO DAILY
11. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN
12. Multivitamins 1 TAB PO DAILY
13. Prazosin 2 mg PO QHS
14. Sertraline 50 mg PO QHS
15. Sucralfate 1 gm PO QID
16. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
marginal ulcer
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were hospitalized for evaluation of abdomoinal pain and had
endoscopy that showed you had an ulcer in the stomach near the
connection to the intestines.
we recommend you take a proton pump inhibitor, pantoprazole for
the next 8 weeks.
you will require repeat endoscopy to schedule another look at
this ulcer to see how it is healing.
we are treating you with doxycycline an antibiotic to treat
pneumonia. be aware it can cause photosensivity, and irritate
the esophagus, so drink plenty of water with it and sit upright
after taking it.
we diagnosed low iron levels and recommend iron therapy. take
iron ___ apart from the pantoprazole and take it with a
vitamin c tablet or some orange juice
Followup Instructions:
___
|
19984781-DS-19 | 19,984,781 | 23,944,999 | DS | 19 | 2165-06-06 00:00:00 | 2165-06-06 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of hypertension,
hypothyroidism,
and insomnia , osteoarthritis, sjogrens syndromw who presents
with weakness, abdominal discomfort and fever.
Patient was in her usual state of health until ___
morning.
She went out the grab coffee, started walking up her steps and
felt significantly light headed, dizzy and very weak. She held
on
to her railing for support and very slowly made it up her 16
steps. Symptoms continued and worsened with activity. That
night,
generalize malaise continued, she checked her temperature at
101.5, she did not take anything and slept. ___, she went
to
visit her PCP, and needed support just to stand up. On ___
she also noticed worsening lower abdominal discomfort. Her PCP
was very concerned for urosepsis so sent her to the ED.
Of note, patient recently became very sexually active again for
the first time in ___ years. She shares that since its been so
long, at first it was not very comfortable and that she felt a
UTI coming along. No dysuria, just lower abdominal
discomfort/awareness.
No spotting, malodorous discharge (though her sense of smell is
not very good), increased discharge, back pain. Positive for
constipation which has been chronic.
Past Medical History:
hypothyroidism,
xerosis/eczema of the skin
history of mosquito bite reactions
eosinophilia
fibromyalgia
right hip greater trochanteric bursitis
s/p right total hip replacement
SJOGREN'S SYNDROME
right knee osteoarthritis
disc disease s/p discectomy
postmenopausal/atrophic vaginitis
L5/S1 disc disease/herniation s/p discectomy ___ (no
hardware); p/w severe back pain following a fall; MRI ___
showed a large right sided disc herniation with free fragment
formation of L5- S1 with some compromise of the thecal sac and
the right sided neural foramen
h/o erythema nodosum ___ years ago; developed while in
___. Seen by dermatologist but did not undergo etiologic
evaluation
HTN
6. h/o pneumonia x2; microbiologic etiology unknown
IBS
Raynaud's phenomenon
Infertility
hip osteoarthritis
elbow fracture s/p fall ___
Social History:
___
Family History:
Positive for diabetes, brother, osteoporosis
father, and arthritis mother
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: 98.8 PO 132 / 74 L Lying 71 18 97 Ra
GENERAL: NAD, smiling, conversing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, 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, some TTP in lower quadrants/suprapubic
superficially, more tender to deep palpation b/l, 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
DISCHARGE PHYSICAL EXAM:
VS: 98.8 110 / 62 75 18 98 Ra
GENERAL: NAD, smiling, conversing
HEENT: mildly icteric sclera, pale conjunctiva, icterus under
tongue
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, very mild discomfort with deep palpation
of the lower abdomen
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, diffuse macular rash on the back
with papular rash on thighs
Pertinent Results:
ADMISSION LABS:
================
___ 09:08PM URINE ___
___ 09:08PM URINE ___
___ 09:08PM URINE ___
___ 09:08PM URINE ___
___ 09:08PM URINE ___ SP ___
___ 09:08PM URINE ___
___
___
___ 09:08PM URINE RBC-<1 ___
___
___ 06:42PM ___
___ 06:20PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 06:20PM ___ this
___ 06:20PM ___
___ 06:20PM ___
___
___ 06:20PM ___
___ IM ___
___
___ 06:20PM PLT ___
DISCHARGE LABS:
================
___ 04:50AM BLOOD ___
___ Plt ___
___ 04:50AM BLOOD ___
___
___ 04:50AM BLOOD ___ LD(___)-373*
___
___ 04:50AM BLOOD ___
INTERVAL LABS:
==============
___ 04:10AM BLOOD Ret ___ Abs ___
___ 04:10AM BLOOD ___ LD(LDH)-390* ___
___
___ 04:50AM BLOOD ___ LD(___)-447*
___
___ 06:36AM BLOOD ___ LD(LDH)-455*
___
___ 04:42AM BLOOD ___ LD(___)-418*
___
___ 04:10AM BLOOD ___ cTropnT-<0.01
___ 06:20PM BLOOD ___
___ 04:10AM BLOOD ___ Hapto-<10*
___
___ 04:10AM BLOOD ___
___ 04:10AM BLOOD Free ___
___ 04:10AM BLOOD ___ HAV ___
___ 06:36AM BLOOD ___
___ 04:50AM BLOOD ___ F ___
___
___ 01:15PM BLOOD HIV ___
___ 04:10AM BLOOD HCV ___
___ 03:50PM BLOOD HCV ___ DETECT
URINE:
======
___ 01:15AM URINE ___
___
___ 05:27AM URINE ___
___ 09:08PM URINE ___
MICROBIOLOGY
=============
___ 4:42 am Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ 4:50 am SEROLOGY/BLOOD TAKE FROM CHEM # ___
___.
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
___ 4:10 am SEROLOGY/BLOOD ADDED DBIL ___.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: ___.
___ 2:29 am SWAB Source: Vaginal.
**FINAL REPORT ___
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
Indeterminate. Altered vaginal flora that does not meet
criteria for
diagnosis of bacterial vaginosis. If signs and/or symptoms
persist,
repeat testing may be warranted.
Interpretive criteria have only been established for
___
women and ___ women on hormone replacement
therapy. As
low estrogen levels alter vaginal flora, results should be
interpreted with caution in ___ women. Refer
to the on
line laboratory manual.
Note, neither lactobacilli nor
Gardnerella/Bacteroides/Mobiluncus
morphotypes observed. The absence of these morphotypes
likely
represents normal flora in ___ women.
YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR
YEAST.
IMAGING:
========
___ CT ABD & PELVIS WITH CO
IMPRESSION:
1. No acute ___ or pelvic findings to correlate with
patient's
symptoms.
2. Extensive stool burden is visualized throughout the colon and
rectum.
3. Narrowing of the proximal celiac axis which can be normal
variant or
potentially seen in median arcuate ligament syndrome, to be
correlated
clinically.
___ PELVIS U.S., TRANSVAGIN
IMPRESSION:
No free pelvic fluid. The ovaries are not visualized.
___ LIVER OR GALLBLADDER US
IMPRESSION:
Normal abdominal ultrasound with no focal findings to correlate
with recent
findings of transaminitis.
Brief Hospital Course:
Ms. ___ is an ___ female with a past medical history
of osteoarthritis, diverticulosis, fibromyalgia, Raynaud's
phenomenon who presented with fever, generalized weakness and
abdominal pain. In the ED, abdominal pain was evaluated with a
CT abdomen that revealed a high stool burden but was otherwise
negative. Abdominal pain was initially treated with
Doxycycline/Unasyn for suspicion of pelvic inflammatory disease
that was ruled out with negative STI panel and TVUS, and
improved bowel regimen. Labs on arrival were significant for
anemia (9.7) and transaminitis. Her anemia was eventually found
to be cold autoimmune hemolytic anemia with unclear trigger,
with largely negative workup. Transaminitis also had unclear
etiology and at discharge her LFTs were stable. Patient also had
a diffuse macular rash on her back that improved with steroid
cream and sarna lotion. At discharge cryoglobulins, ___,
antismooth antibodies, SPEP, Mycoplasma antibodies and flow
cytometry were pending.
#Cold Autoimmune Hemolytic Anemia: Patient presented with a
history of generalized fatigue with elevated LFTs. Direct
Coomb's test was positive with negative IgG and 3+ C3 and
positive cold agglutinins, indicative of cold autoimmune
hemolytic anemia. Trigger for hemolysis is unclear, however,
patient has a history of positive ___ and ___, with
occasional h/o dry eyes and dry mouth. Patient also had
decreased IgG and slight elevated IgM. RF positive. Hepatitis
serology, HIV serology, CMV, monospot, RPR, STI panel negative.
At discharge cryoglobulins, ___, antismooth antibodies, SPEP,
Mycoplasma antibodies and flow cytometry were pending. She was
treated with folic acid and B12, is responding appropriately
(retic:7.9%) and did not approach transfusion threshold this
hospitalization.
#Transaminitis: Patient had elevated LFTs this hospitalization
with unclear etiology, that stabilized and started to decrease
at discharge. Infectious workup negative as above with blood
cultures pending and negative UA and urine culture. Unlikely
DILI given very short course of antibiotics. RUQ US without any
obvious pathology. CMV negative. Possible autoimmune hepatitis
with CMV viral load and antismooth antibodies pending at
discharge.
#Rash: Patient had diffuse itchy macular rash on her back with a
papular rash on her thighs that proved with Triamcinolone
Acetonide 0.1% Cream and Sarna Lotion.
#Hypothyroidism: Patients thyroid function tests were within
normal limits. Patient continued levothyroxine
#HTN: Patient was continued HCTZ.
#Depression: Patient was continued duloxetine
TRANSITIONAL ISSUES:
=====================
# Cold agglutinin hemolytic anemia. Will have follow up with
primary care and hematology; pending results as above for
investigation of etiology.
#CODE: Full (presumed)
#Name of health care proxy: ___
Relationship: Friend
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 60 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Systane (propylene glycol) (peg ___ glycol) ___
% ophthalmic (eye) DAILY
Discharge Medications:
1. Cyanocobalamin 50 mcg PO DAILY
RX *cyanocobalamin (vitamin ___ [Vitamin ___ 50 mcg 1
tablet(s) by mouth DAILY Disp #*60 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #*60 Tablet
Refills:*0
3. Sarna Lotion 1 Appl TP BID
RX ___ [Sarna ___ 0.5 %-0.5 % TP 1 Appl
twice a ___ Refills:*0
4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
RX *triamcinolone acetonide 0.1 % TP 1 Appl three times a ___
Refills:*0
5. DULoxetine 60 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Systane (propylene glycol) (peg ___ glycol)
___ % ophthalmic (eye) DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
1. Cold autoimmune hemolytic anemia
2. transaminitis
SECONDARY DIAGNOSIS
===================
1. Hypothyroidism
2. HTN
3. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you experienced fever, fatigue and
abdominal pain. Please see more details listed below about what
happened while you were in the hospital and your instructions
for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- You were evaluated for your abdominal pain and were ruled out
for infection, and it was treated with a bowel regimen.
- You fatigue and weakness was assessed and was determined to be
secondary to an autoimmune condition (cold autoimmune hemolytic
anemia. You were treated with medication (folic acid and vitamin
B12). You were also evaluated for possible causes triggering
this condition, however your workup was negative.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Please, follow up with your primary care provider
- ___, follow up with hematology
Your ___ care team
Followup Instructions:
___
|
19984875-DS-21 | 19,984,875 | 26,828,045 | DS | 21 | 2118-01-13 00:00:00 | 2118-01-13 16:41:00 |
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 temporal ___ lesion
Major Surgical or Invasive Procedure:
___ - Left craniotomy for resection of left temporal ___
lesion
History of Present Illness:
___ is a ___ year old female with a history of lung
cancer who presented to the Emergency Department on ___
with a new onset seizure. CT of the head concerning for a left
temporal ___ lesion. The Neurosurgery Service was consulted
for question of acute neurosurgical intervention. Patient was
admitted to ___ further
evaluation and management.
Past Medical History:
- arthritis
- iron deficiency anemia
- lung cancer status post lobectomy
- panic disorder
- status post hip replacement in ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
-------------
Vital Signs: T 97.7F, HR 115, BP 133/70, RR 18, O2Sat 99% room
air
General: Elderly female laying on stretcher.
Head, Eyes, Ears, Nose, Throat: Right periorbital ecchymosis and
edema. Pupils equal, round, and reactive to light. Extraocular
movements full.
Lungs: No respiratory distress.
Extremities: Warm and well perfused.
Neurologic:
Mental status: Awake and alert, follows simple commands.
Orientation: Oriented to person only.
Language: Nonfluent speech. Perseverative. Impaired naming.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No drift.
Sensation: Intact to light touch.
On Discharge:
-------------
General:
Vital Signs: T 98.1F, HR 74, BP 125/61, RR 16, O2Sat 96% room
air
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place - With options [x]Time - With
options
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: Pupils equal, round, and reactive to light
Extraocular Movements: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip
Right5 5 5 5 5
Left 5 5 5 5 5
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right5 5 5 5 5 5
Left 4+* 4+* 4+* 5 5 5
*Pain limited.
[x]Sensation intact to light touch
Surgical Incision:
[x]Clean, dry, intact
[x]Staples
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Brief Hospital Course:
___ year old female with a left temporal ___ lesion.
#Left Temporal ___ Lesion
MRI of the ___ was obtained and confirmed the presence of a
left temporal ___ lesion. Patient was started on Keppra to
treat her seizures. She was also started on dexamethasone for
cerebral edema. CT of the chest, abdomen, and pelvis did not
reveal any areas of lung cancer recurrence or other metastases.
Neuro Oncology and Radiation Oncology were consulted. Patient
was taken to the operating room on ___ for a left
craniotomy for resection of the left temporal ___ lesion. The
procedure was uncomplicated and well tolerated. Tissue was sent
for pathology. Patient was extubated in the operating room and
recovered in the PACU. Patient was transferred to the step down
unit postoperatively for close neurologic monitoring.
Postoperative CT of the head showed expected postoperative
changes and was negative for any acute intracranial hemorrhage.
Postoperative MRI of the ___ also showed expected
postoperative changes. Patient was eventually transferred to the
floor. Patient was evaluated by Physical Therapy and
Occupational Therapy, both of whom recommended rehabilitation.
On ___, patient was neurologically stable. Patient was
afebrile with stable vital signs, tolerating activity,
tolerating a regular diet, voiding and stooling without
difficulty, and her pain was well controlled with oral pain
medications. She was discharged to ___
___ in ___ on ___ in stable
condition. She will follow-up in the ___ with
Dr. ___ ___ days after surgery for staple removal. She
will also follow-up in the ___ Tumor Clinic with Dr. ___ on
___ to determine further treatment.
#History of Lung Cancer
Medical Oncology was consulted given the patient's history of
lung cancer. Patient will follow-up with Medical Oncology after
discharge as an outpatient.
#T4 Compression Fracture
There was an age indeterminate T4 anterior compression deformity
noted on CT of the chest. Patient does not have any tenderness
to palpation. No activity restrictions or bracing indicated.
#Left Lower Extremity Pain
There was no acute fracture on x-ray of the left lower
extremity, however there was a small knee joint effusion.
Ultrasound of the left lower extremity was negative for deep
vein thrombosis.
Medications on Admission:
- furosemide 20mg by mouth once daily
- lorazepam 0.5mg by mouth three times daily
- oxycodone 15mg by mouth Q6H as needed for pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain
Do not exceed 3000mg in 24 hours.
2. Dexamethasone 2 mg PO/NG DAILY Duration: 1 Dose
Please take on ___ at 08:00.
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
3. Dexamethasone 2 mg PO/NG Q12H Duration: 2 Doses
Please take on ___ at 20:00 and ___ at 08:00.
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
4. Docusate Sodium 100 mg PO/NG BID:PRN Constipation
While taking oxycodone. ___ discontinue once off oxycodone. Hold
for loose stools.
5. Famotidine 20 mg PO/NG BID Duration: 5 Doses
While taking dexamethasone. ___ discontinue once off
dexamethasone.
6. Heparin 5000 UNIT SC BID
___ discontinue once patient is mobilizing adequately and
consistently.
7. LevETIRAcetam 1000 mg PO BID
8. OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN Pain
Duration: 7 Days
Home medication is 15mg Q6H PRN pain.
9. Senna 17.2 mg PO/NG QHS:PRN Constipation
While taking oxycodone. ___ discontinue once off oxycodone. Hold
for loose stools.
10. Furosemide 20 mg PO/NG DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left temporal ___ lesion
Discharge Condition:
Mental Status: Confused, sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, requires assistance or aid, cane or
walker.
Discharge Instructions:
Surgery:
- You underwent surgery to remove a ___ lesion from your
___.
- Please keep your incision dry until your staples are removed.
- You may shower at this time, but keep your incision dry.
- It is best to keep your incision open to air, but it is okay
to cover it when outside.
- Call your neurosurgeon if there are any signs of infection
like fever, redness, 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 six months.
Medications:
- Please do NOT take any blood thinning medication (aspirin,
Coumadin, ibuprofen, Plavix, etc.) until cleared by your
neurosurgeon.
- You have been discharged on levetiracetam (Keppra). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may experience headaches and incisional pain.
- You may also experience some postoperative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day after surgery. You may
apply ice or a cool or warm washcloth to help with the swelling.
The swelling will be its worst in the morning after laying flat
from sleeping, but will decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. If you are taking narcotics (prescription
pain medications), try an over the counter stool softener.
When To Call Your Neurosurgeon At ___:
- Severe pain, redness, swelling, or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit.
- Nausea or vomiting.
- Extreme sleepiness or 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 legs.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden numbness or weakness in the face, arms, or legs.
- 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:
___
|
19984875-DS-22 | 19,984,875 | 24,610,259 | DS | 22 | 2118-02-13 00:00:00 | 2118-02-13 19:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / latex
Attending: ___.
Chief Complaint:
Per admitting Neurosurgery Team:
Left posterior parietal mets
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting Neurosurgery Team:
___ year old female with history of lung cancer and left
posterior parietal mets to brain (s/p resection ___
presented to ___ with right-arm focal seizure, and word-finding
difficulty. She received 10mg IV dexamethasone and underwent a
NCHCT with increased edema. She was transferred to ___. Of
note, the patient recently started Cyberknife on ___. She
was admitted to the ___ for close neurologic monitoring.
Past Medical History:
Per admitting Neurosurgery Team:
- arthritis
- iron deficiency anemia
- lung cancer status post lobectomy
- panic disorder
- status post hip replacement in ___
Social History:
___
Family History:
Per admitting Neurosurgery Team:
Noncontributory
Physical Exam:
Per admitting Neurosurgery Team:
PHYSICAL EXAMINATION ON ADMISSION:
===================================
Gen: alert, cachectic.
Pupils: ___
EOMs: unable to formally assess, tracks examiner
Extrem: Warm and well-perfused. RUE with notable focal sz
activity
Neuro:
Mental status: Awake and alert, partially cooperative with exam
Orientation: expressive aphasia, with fluent non-relevant
speech.
Unable to orient.
Language: expressive aphasia, with fluent non-relevant. Some
receptive language intact with intermittent ability to follow
simple commands
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1mm
bilaterally.
III, IV, VI: Extraocular movements unable to formally assess,
tracks examiner.
V, VII: Facial strength unable to formally assess, but no
notable
facial droop.
VIII: Hearing intact to voice.
XII: would not stick out tongue to command
Motor: Right upper extremity with focal seizure activity. Right
lower extremity withdraws to noxious. Left upper and left lower
extremities assessed with confrontational motor exam, patient
able to participate with simple commands and is 4+/5.
Sensation: left-side intact to light touch
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
VS: 97.9 128/76 70 18 98%RA
GENERAL: Well-appearing lady, in no distress sitting in chair in
solarium comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Comprehensive aphasia but with linear thought process,
mentating coherently. CN II-XII intact. Strength full
throughout.
Sensation to light touch intact.
SKIN: No significant rashes.
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
Neurosurgery course:
##Brain lesion, metastatic lung carcinoma with cerebral edema
The patient was admitted to the ___ on ___ with right upper
extremity seizure activity. She underwent a CT of the head which
showed edema. On ___, she underwent a MRI of the brain which
revealed edema but no new lesions. On ___, the patient remained
neurologically stable and it was determined she would be
transferred to the ___ service on ___ to start
Cyberknife treatment.
Medical oncology course:
Ms. ___ is a ___ year-old lady with metastatic NSCLC (s/p
lobectomy, brain mets) c/b seizures s/p resection of R post
temporal lobe mass (___) who presented with seizure and
aphasia finding progression of residual disease seen on brain
MRI, started on high dose steroids, uptitrated antiepileptics
and received 5 fractions of SRS with significant improvement. .
#Seizure disorder
#Comprehensive aphasia
#Encephalopathy
#CNS metastatic disease
#Cerebral edema
Encephalopathy is likely post-ictal and resolved during the
course of the admission. Aphasia and seizure episode possible
triggered by edema in setting of progression of residual
disease. With marked improvement in encephephalopathy and
aphasia
since ___ likely secondary to high-dose steroids, uptitrated
levetiracetam. OT Received 5 fractions of SRS while in-house. OT
recommended home with 24h care +ADL/IADL assistance which family
was able to provide. Initially on dexamethasone 4mg q6h, tapered
to 4mg q12h. Was started on dapson for PJP ppx and famotidine
for PUD ppx.
#Anxiety
#Panic disorder
Treated with BusPIRone 5 mg PO TID and LORazepam 1 mg PO/NG
DAILY:PRN xrt to good effect.
#Cancer associated chronic pain: Received intermittent tramadol
25 mg PO Q6H:PRN pain with minimal requirement by the end of the
admission.
#Metastatic NSCLC: With cerebral metastatic recurrence after
lobectomy.
Next steps in systemic treatment per Dr. ___
___ ISSUES
===================
1. Started on dexamethasone 4mg q6h, tapered to 4mg q12h prior
to discharge. Taper per Dr. ___.
2. Started on dapsone 100mg daily for PJP prophylaxis
40 minutes spent formulating and coordinating this patient's
discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain
2. Dexamethasone 2 mg PO/NG DAILY
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
3. Docusate Sodium 100 mg PO/NG BID:PRN Constipation
4. Furosemide 20 mg PO/NG DAILY
5. Famotidine 20 mg PO/NG BID
6. LevETIRAcetam 1000 mg PO BID
7. Senna 17.2 mg PO/NG QHS:PRN Constipation
8. Heparin 5000 UNIT SC BID
9. OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN Pain
10. Dexamethasone 2 mg PO/NG Q12H
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain
RX *acetaminophen 325 mg ___ capsule(s) by mouth four times a
day Disp #*60 Capsule Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. BusPIRone 5 mg PO TID
RX *buspirone 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
4. Dapsone 100 mg PO DAILY PJP ppx
RX *dapsone 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
6. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
7. Dexamethasone 4 mg PO Q12H
RX *dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
8. LevETIRAcetam 1000 mg PO TID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
10. Furosemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure disorder
Secondary neoplasm of the brain, progression
Vasogenic cerebral edema
Wernicke's aphasia
Non-small cell lung cancer
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 Ms. ___,
You were admitted for seizures due to growth in your brain
tumor. You were started on steroids, anti-seizure medications
and were given Cyberknife radiosurgery. You improved
significantly. You are ready to continue recovering at home. It
was a pleasure to take care of you.
Your ___ Team
Followup Instructions:
___
|
19985000-DS-17 | 19,985,000 | 25,310,042 | DS | 17 | 2169-07-13 00:00:00 | 2169-07-15 22:28:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / morphine / Dilaudid
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old woman with history of Crohns
disease s/p laparoscopic ileocecectomy in ___ and recent
diagnosis of C.diff colitis on ___ who presents with
worsening diarrhea and inability to keep herself fully hydrated.
.
Patient reports ___ bowel movement/day at baseline. She had
previously been on ___ for her crohn's which had been stopped
due to her pregnancy and breast feeding. She has been on ___
dose of prednisone since her deliver in ___. Currently taking
3mg prednisolone daily. Reports around ___ weeks ago she
started having worsening diarrhea ___ along with abdominal
crampying and fevers. She was found to have c-diff on ___
and started on PO vanc with improvment in abdominal pain and
fevers. Continues to have non-bloody diarrhea. Reports feeling
fatigued and not being able to keep herself hydrated at home.
Able to take pos without nausea or vomiting. Last colonoscopy
in ___ which showed ___ an erosion in the distal neoterminal
ileum and anastomosis. Biopsies showed focal cyptitis at the end
of the colon.
Past Medical History:
Crohn's disease of the terminal ileum and colon, mostly in the
cecum and ascending colon. She is status post an ileocecectomy
via laparoscopy ___ and had a Meckel's diverticulum
removed at that same time
Social History:
___
Family History:
Father has ulcerative colitis. Mother healthy. Older brother
healthy. Paternal grandmother has GI problems.
Physical Exam:
Admission Physical:
VS - Temp 97.4F, BP 92/62, HR 85, R 18, O2-sat 98% RA
GENERAL - well-appearing thin female, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
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/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
.
Discharge Physical Exam:
VS - 97.8 90/50 81 100%RA
GENERAL - appears fatigued but no acute distress
HEENT - sclerae anicteric, dry mucous membranes, OP clear, no
ulcers
NECK - supple, no cervical or supraclavicular lymphadenopathy
LUNGS - Unlabored breathing, clear to ausculattion bilaterally
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft, non-distedned, no tenderness to palpation.
NO rebound or guarding.
EXTREMITIES - warm and well perfused
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
Pertinent Labs:
___ 04:34PM BLOOD WBC-13.4* RBC-4.85 Hgb-14.0 Hct-41.0
MCV-85 MCH-28.9 MCHC-34.2 RDW-13.0 Plt ___
___ 05:24AM BLOOD WBC-9.7 RBC-3.81* Hgb-11.1* Hct-32.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-13.3 Plt ___
___ 04:34PM BLOOD Neuts-89.2* Lymphs-7.1* Monos-2.9 Eos-0.4
Baso-0.3
___ 05:24AM BLOOD ESR-40*
___ 04:34PM BLOOD Glucose-80 UreaN-15 Creat-0.6 Na-136
K-3.9 Cl-100 HCO3-22 AnGap-18
___ 05:27AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9
___ 05:24AM BLOOD CRP-10.6*
___ 04:34PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:34PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:34PM URINE RBC-4* WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
___ 04:34PM URINE CastGr-2* CastHy-3*
___ 04:34PM URINE UCG-NEGATIVE
.
___ 2:33 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
ADDON REQUEST FOR CDT PER FAX BY ___ ON
___ @8AM.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
.
MRE:
IMPRESSION:
1. Diffusely abnormal ileum with wall thickening and transmural
enhancement. The features are not typical for active Crohn's
disease and are more suggestive of infectious enteritis.
2. Normal appearing colon.
Brief Hospital Course:
___ year old woman with history of Crohns disease s/p
laparoscopic ileocecectomy in ___, who was started on po
vancomycin on ___ for positive c-diff test who now presents
with worsening diarrhea and inability to keep herself fully
hydrated.
.
# Diarrhea - One week prior to admission she started having
fevers, abdominal cramps and worsening diarrhea up to 15
times/day. She had positive c-diff on ___ at ___ and
was started on po vancomycin. She presented to ___ with
persistent watery diarrhea and volume depletion despite taking
her po vancomycin. Repeat C-diff test and other stool studies
during current hospital stay negative was negative. Patient had
MR ___ with recommendation from GI consult team which
did not reveal any evidence of active Crohns' flare but did
suggest infectious enteritis. On the day of discharge she had 4
loose bowel movements and was tolerating her full diet. She was
discharged on same dose of prednisolone to be tapered by her
gastroenterologist. She will continue and complete treatment
for c-diff on ___ with higher dose of po vancomycin. She was
also restarted on her imodium.
.
#Crohns disease: Last colonoscopy done on ___ which showed
signs of chronic active colitis. MR enterography did not show
any signs of active Crohn's flare. She will continue on her
current dose of prednisolone and follow up with her
gastroenterologist for further care.
.
# Contact: ___ ___
# CODE: Full code
.
Transitions of care;
- Patient will follow up with her gastroenterologist for further
management of her Crohn's disease and for tapering down of her
steroid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 75 mg PO QHS
2. Prenatal Vitamins 1 TAB PO DAILY Start: In am
3. prednisoLONE *NF* 3mg/1mL Oral daily
4. Loperamide 2 mg PO ___ TIMES A DAY Diarrhea
Please take once a day to four times a day as needed for
diarrhea
5. Cholestyramine 4 gm PO BID
6. Vancocin *NF* (vancomycin) 125 mg Oral QID
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
2. Sertraline 75 mg PO QHS
3. Loperamide 2 mg PO ___ TIMES A DAY Diarrhea
Please take once a day to four times a day as needed for
diarrhea
4. Cholestyramine 4 gm PO BID
5. prednisoLONE *NF* 3mg/1mL Oral daily
6. Vancocin *NF* (vancomycin) 250 mg Oral QID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diarrhea
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 care of you during
your hospitalization at ___. You were admitted because of
worsening diarrhea and not being able to keep yourself hydrated.
You were given intravenous fluids. You had MRI of your abdomen
which did not show any signs of active crohn's disease. Your
diarrhea was noted to imporve on the day of discharge. Please
make a follow up appointment with your PCP and
gastroenterologist for further care.
You will be leaving on 250mg four times daily of po vancomycin
to be taken until ___.
Followup Instructions:
___
|
19985259-DS-4 | 19,985,259 | 23,988,340 | DS | 4 | 2129-12-23 00:00:00 | 2129-12-23 15:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
dyspnea, LUQ abdominal pain, anxiety
Major Surgical or Invasive Procedure:
cardiac catheterization ___
ICD placement ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of HTN, HLD,
CAD, dilated CMY (EF 40-45% ___ presenting with dyspnea,
abdominal pain and anxiety.
Patient reported shortness of breath and ongoing LUQ,
intermittent abdominal pain described as a "rolling sensation"
that began 1 hour prior to presentation. He denies chest pain,
shortness of breath, cough, nausea, vomiting, diarrhea, lower
extremity swelling.
Vitals on arrival:
97.0 74 136/84 18 98% RA
Labs: notable for normal CBC with elevated MCV 100, bicarb 21, K
3.9, Mg 2.1, Cr 1.0, glucose 224, lactate 4.0, troponin T 0.02,
normal coags. LFTs notable for normal alk phos and tbili,
elevated AST 184 ALT 81.
Imaging: CXR showed Interstitial opacities noted bilaterally
suggestive of possible interstitial edema.
Subsequent to arrival patient developed wide complex tachycardia
with ECG showing monomorphic VT. He received adenosine 6mg, 12mg
IV with no change. He was subsequently loaded with amiodarone
150mg x1 and started on gtt. Subsequently received metoprolol
5mg IV x1`, lidocaine 100mg IV x1, without conversion and
subsequently hypotensive requiring cardioverted at 200J x1 with
subsequent to normal sinus rhythm. At that time he was noted to
have ECG with sinus rhythm, rate 75, normal axis, >1mm ST
elevations in leads V1-V2, ST depressions in II, III, avF as
well as V4-V6 concerning for anterior STEMI and CODE STEMI was
called.
Patient went to the cath lab where he was found to have LAD with
small first diag with 70% stenosis not amenable to intervention.
No other significant lesion noted. Patient had R radial access
but was not able to engage catheter, subsequently R femoral
access, sheath was pulled in the cath lab at the conclusion of
the procedure. He received lidocaine gtt at 2mg/min, aspirin
325mg PO.
On arrival to the CCU, patient reports feeling well, overwhelmed
with ED course and frustrated that his pants were cut off. He
denies chest pain, lightheadedness, shortness of breath.
Abdominal discomfort has resolved. He refuses statin as he
states it causes his muscles to ache.
REVIEW OF SYSTEMS:
(+) per HPI
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. Denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, joint pains, cough, hemoptysis,
black stools or red stools. Denies recent fevers, chills or
rigors. Denies exertional buttock or calf pain. All If the other
review of systems were negative.
Past Medical History:
HTN
HLD
CAD
Dilated Cardiomyopathy diagnosed ___ at ___, (EF 40-45% ___
Social History:
___
Family History:
Father CAD/PVD
Mother diabetes, Died on hospice, dementia
Sister ___ Cancer
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION:
VS: 98.7 74 139/71 26 94% on 4L
Weight: 85kg (83.4kg at ___ ___
GEN: older gentleman lying flat in bed, anxious appearing but
speaking in full sentences in NAD
HEENT: PERRL, EOMI, no scleral icterus, MMM
NECK: supple, JVP elevated at 10cmH20
CV: RRR, S1, S2 without appreciable m/r/g
LUNGS: crackles at bilateral bases, no wheezes or rhonchi
ABD: soft, non distended, non tender to palpation
EXT: warm, well perfused, 1+ DP and ___ pulses bilaterally
SKIN: warm, well perfused, no rashes, R groin with dressing in
place, c/d/I no palpable thrill or audible bruit
NEURO: axoxIII, CNII-XII grossly intact, gait not assessed
DISCHARGE:
VS: Tm98.0 123-153/55-69 ___ 18 97-100RA
Weight: 80.1kg
GENERAL: Well-appearing, alert, no NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK: Supple with flat JVP
CARDIAC: RRR, normal S1S2; no murmurs
LUNGS: Resp were unlabored. No crackles, wheezes or rhonchi.
Good air movement
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c. Trace ___ edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION:
================================
___ 08:17PM BLOOD WBC-5.6 RBC-4.06* Hgb-14.0 Hct-40.7
MCV-100* MCH-34.5* MCHC-34.4 RDW-13.5 RDWSD-49.4* Plt ___
___ 08:17PM BLOOD Neuts-52.5 ___ Monos-11.3 Eos-1.6
Baso-0.5 Im ___ AbsNeut-2.93 AbsLymp-1.88 AbsMono-0.63
AbsEos-0.09 AbsBaso-0.03
___ 08:17PM BLOOD ___ PTT-25.9 ___
___ 08:17PM BLOOD Glucose-224* UreaN-18 Creat-1.0 Na-133
K-7.4* Cl-100 HCO3-21* AnGap-19
___ 08:17PM BLOOD ALT-81* AST-184* AlkPhos-50 TotBili-0.4
___ 08:17PM BLOOD Lipase-56
___ 08:17PM BLOOD cTropnT-0.02*
___ 08:17PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.1 Mg-2.1
___ 08:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:30PM BLOOD Glucose-224* Lactate-4.0* Na-140 K-3.9
Cl-106 calHCO3-21
IMAGING/STUDIES:
================================
+ CARDIAC CATH (___):
Right dominant
LMCA short without significant disease
LAD 30% proximal
___ diagonal is small with 70% stenosis
circumflex without significant disease
___ marginal very small with severe mid disease
___ marginal is large caliber without significant disease
AV groove continues as a small vessel
RCA is with 30% mid
Right PDA is without significant disease
Impressions: Branch vessel coronary artery disease
Guideline directed medical therapy for CAD
Admit to CCU for management of ventricular tachycardia
+ TTE ___
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is moderately depressed (LVEF=30- 35%) secondary to moderate
global hypokinesis with akinesis of the lateral wall. No masses
or thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate (___) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality requiring the use of
contrast for better endocardial border definition. Moderately
dilated left ventricular cavity with moderate global systolic
dysfunction and regional involvement as described above.
Mild-moderate aortic regurgitation. Mild mitral regurgitation.
+ Cardiac MRI ___
Please note that this report only pertains to extracardiac
findings.
There are no extracardiac findings.
The entirety of this Cardiac MRI is reported separately in the
Electronic
Medical Record (OMR) - Cardiovascular Reports.
PRELIMINARY RESULTS: suggestive of ischemic cardiomyopathy. LVEF
34%. LV end diastolic volume index: 139ml/m2 (severely
increased). RVEF 68% (normal). There is transmural late
gadolinium enhancement in the basal-distal anterior and
anteroseptal walls, distal anterolateral wall, and apex and
subendocardial (___) based LGE in the mid anterolateral wall
most consistent with myocardial infarction
___ CXR
In comparison with study of ___, there has been placement of
a left
subclavian pacer with leads extending to the right atrium and
apex of the
right ventricle. No postprocedure pneumothorax. The cardiac
silhouette is again enlarged without definite vascular
congestion or evidence of acute focal pneumonia.
DISCHARGE:
================================
___ 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8
MCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt ___
___ 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137
K-4.8 Cl-104 HCO3-23 AnGap-15
___ 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of HTN, HLD,
CAD, dilated CMY (EF 40-45% ___ presented with dyspnea and
left upper quadrant pain found to have sustained polymorphic
ventricular tachycardia with subsequent ST elevations in setting
of prolonged episode of sustained VT and adenosine
administration. Admitted to CCU due to monomorphic VT.
# CORONARIES: See cath report, ___ diag with 70% stenosis
# PUMP: this admission - EF ___
# RHYTHM: normal sinus, previously wide complex tachycardia
# VENTRICULAR TACHYCARDIA: Patient was found to be in wide
complex tachycardia consistent with monomorphic VT. Patient was
evaluated by EP who felt VT likely originating in the LV apical
region secondary to scar and may be amenable to VT ablation.
Stabilized on lidocaine gtt and remained stable off drip with
continued episodes of non-sustained ventricular tachycardia.
Increased home metoprolol XL to 50mg BID. Repeated discussions
were had regarding VT ablation and/or antiarrhythmic
medications. Mr. ___ was adamant about not doing either. He
was also very resistant to ICD implant, but eventually agreed.
He underwent ICD placement ___ without complications.
# ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: LVEF 40-45%
secondary to dilated cardiomyopathy per ___ records. Patient
had previous workup at ___ that was reportedly negative for
sarcoid, hemochromatosis, amyloid, HIV, syphilis,
hypothyroidism. Now with new O2 requirement, CXR with increased
vascular congestion and crackles on exam consistent with acute
decompensated sCHF. Secondary to prolonged VT. Repeat TTE EF of
___, nml RV, no AS, mild to moderate AR, akinesis of the
lateral wall of the LV. Global hypokinesis. Diuresed well with
80mg IV Lasix. Appeared euvolemic on physical exam, and
ambulating on own without SOB.
# CAD: Patient presented with VT, received adenosine x 2, after
defibrillation and conversion to sinus rhythm had ST elevations
in V1-V2, ST depressions in II, III, aVF concerning for anterior
STEMI. Cardiac cath showed branch vessel CAD with 70% occlusion
of ___ diag not amenable to intervention and no other
significant CAD or evidence of acute plaque rupture. Medical
management included aspirin, atorvastatin 20mg (pt refused
higher dose due to myalgias), metoprolol, losartan. Cardiac MRI
consistent with ischemic cardiomyopathy.
CHRONIC ISSUES:
#HTN: continued home losartan after achieving hemodynamic
stability
#HLD: Statin as above
TRANSITIONAL ISSUES:
-pt to complete 3 days of abx, 500mg TID Keflex (day 3 =
___ for post-ICD placement prophylaxis
# Discharge weight: 80kg
# Code: Full
# Contact: son ___ ___, ex wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO BID
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Cephalexin 500 mg PO Q8H Duration: 1 Day
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*4 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia due to ischemic cardiomyopathy, treated
with ICD placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Cardiac ICU for an abnormal heart beat. You required
electric shock of your heart to regain a regular rhythm. To
prevent this in the future, an ICD device was placed to help
keep your heart in a regular rhythm.
During your admission, you also had a imaging of your heart that
showed scarring of your heart muscle likely due to a heart
attack in the past. However, imaging of your heart did not show
occlusions of the blood vessels around your heart.
You are now doing well and are ready for discharge. Please
continue to take your medications subscribed you to and
follow-up with your cardiologist.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
19985293-DS-15 | 19,985,293 | 21,731,208 | DS | 15 | 2184-08-25 00:00:00 | 2184-08-25 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol / lisinopril
Attending: ___
Chief Complaint:
Fever and chills
Major Surgical or Invasive Procedure:
PICC placement and removal
History of Present Illness:
___ female with history of lap gastrojejunostomy in
___ for duodenal stricture, causing gastric outlet
obstruction, nonresectable pancreatic cancer now on chemo,
resultant biliary obstruction status post multiple draining
stent placements by ___ (see below, but last on ___ had
cholangiogram with balloon dilation and extenson of existing
stent, and exchange of existing PTBD catheter), now presents
with diaphoretic episodes, chills, and found to have bacteremia.
History was obtained from the daughter/HCP. She reports that
patient began having low-grade fevers five days prior to
admission. She then developed intermittent chills for a few
days, but no abdominal pain. She had her first day of
chemotherapy (gemcitabine, C1D1 ___ the day prior to
presentation. Routine blood cultures were drawn at her
chemotherapy session, and they returned positive on ___. The
family was notified to bring the patient to the ED.
In the ED, initial vitals: T 97.8, HR 86, BP 124/58, 16, O2 94%
RA
- Exam notable for: normal mental status
- Labs were notable for: WBC 8.4 -> 10.8, Hgb 7.5 -> 6.8, Plt
299, INR 1.1, Cr 1.1 -> 0.9, Mg 1.7, Albumin 2.7, Lactate 2.1 ->
1.4, UA normal,
- Imaging: CXR showed patchy bibasilar opacities. CT
demonstrated new air fluid collection near the lesser sac of the
stomach concerning for contained duodenal perforation with
abscess. She was evaluated by surgery who did not feel she was a
surgical candidate.
- Patient was given: 3.5L NS, Vancomycin, Cefepime, Oxycodone
for pain
She was initially going to be admitted to ___, but
developed hypotension while getting a CT scan. She was fluid
resuscitated and a right IJ line was placed. She was started on
levophed (0.12) for low MAPs. She was given 1u pRBC transfusion
for hgb 6.8, during which she had a blood transfusion reaction
with rigors. Coombs was negative. She then spiked a fever to
104.8. Goals of care were discussed with the family, but no
conclusion was reached.
On arrival to the MICU, she was alert and oriented x3. She
denied any abdominal pain or overall discomfort. She required
increasing doses of lovophed at 0.3 mcg/kg/min to maintain MAP >
65. A 500 cc LR bolus was given. A goals of care conversation
was had with the family, who determined that she would like to
be DNR/DNI.
Past Medical History:
Locally advanced pancreatic adenocarcinoma diagnosed ___
Malignant CBD obstruction s/p PTBD
HTN
HLD
Moderate AS
Remote carotid endarterectomy
Gastric outlet obstruction s/p gastrojejunostomy ___
Social History:
___
Family History:
No known cancer is first degree relatives.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS: 98.8, HR 103, BP 113/60, RR 19, 95% RA
GENERAL: Alert and oriented, lying in bed, denies pain
HEENT: AT/NC, EOMI, PERRL
NECK: nontender supple neck, no LAD, no JVD, right IJ pain
CARDIAC: RRR, S1/S2, ___ systolic crescendo decrescendo murmur
in the USB
LUNG: CTA, no wheezes
ABDOMEN: nondistended, +BS, nontender
EXTREMITIES: WWP, no ___ edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE PHYSICAL EXAM
==========================
Vitlas: 97.8 106/71 86 18 97% RA
General: alert, sitting in bed, no acute distress
Neuro: oriented, moving all extremities
Abd: soft, nontender throughout
Pertinent Results:
ADMISSION LABS
=============================
___ 08:39AM BLOOD WBC-7.3 RBC-2.89* Hgb-8.7* Hct-26.4*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 RDWSD-47.6* Plt ___
___ 11:30AM BLOOD Neuts-88* Bands-0 Lymphs-9* Monos-1*
Eos-1 Baso-1 ___ Myelos-0 AbsNeut-7.39*
AbsLymp-0.76* AbsMono-0.08* AbsEos-0.08 AbsBaso-0.08
___ 11:30AM BLOOD ___ PTT-31.7 ___
___ 08:39AM BLOOD UreaN-24* Creat-1.0 Na-131* K-3.5 Cl-94*
HCO3-28 AnGap-13
___ 08:39AM BLOOD ALT-15 AST-25 AlkPhos-178* TotBili-0.6
___ 11:30AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.3 Mg-1.7
___ 11:46AM BLOOD Lactate-2.1*
DISCHARGE LAB
==============================
___ 06:10AM BLOOD WBC-8.0 RBC-3.60*# Hgb-10.6*# Hct-31.2*#
MCV-87 MCH-29.4 MCHC-34.0 RDW-14.9 RDWSD-48.1* Plt ___
___ 05:56AM BLOOD Glucose-65* UreaN-10 Creat-1.0 Na-133
K-3.5 Cl-100 HCO3-21* AnGap-16
MICROBIOLOGY
=============================
___ 12:01 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 4:25 am BLOOD CULTURE Source: Line-RIJ TLC.
Blood Culture, Routine (Preliminary):
LACTOBACILLUS SPECIES.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S).
Reported to and read back by ___. (___) AT ___ ON
___.
IMAGING
=============================
CT abdomen/pelvis ___ IMPRESSION:
1. Interval development of an approximately 3.3 x 4.1 cm air and
fluid
collection anterior to the common hepatic artery within the
lesser sac of the stomach, which likely represents a contained
perforation/abscess originating from the stomach/duodenum, where
the pancreatic mass is invading.
2. Chronically obstructed and distended gallbladder containing
multiple small gallstones and sludge. New pericholecystic fluid
is nonspecific and may be reactive to the adjacent inflammatory
process.
3. Interval removal of right-sided PTBD, with mild right
intrahepatic biliary ductal dilatation. Trace perihepatic
fluid.
4. Interval increase in size of nonspecific hyperattenuating and
soft tissue density rounded areas in the left rectus abdominus
muscle possibly hematomas. metastatic implants would be unusual
in this location, but cannot be completely excluded and
attention to this region on follow-up imaging is recommended.
5. Small amount of pelvic free fluid.
CXR ___ IMPRESSION:
Patchy bibasilar opacities likely reflect atelectasis.
Brief Hospital Course:
Ms. ___ is an ___ female with history of lap
gastrojejunostomy (___) for duodenal stricture causing
gastric outlet obstruction, non-resectable pancreatic cancer now
on chemo, biliary obstruction status post multiple draining
stent placements by ___, who p/w septic shock and GNR bacteremia
in the setting of a contained duodenal perforation.
# Goals of care: Given patient's grave clinical status, a family
meeting was held during which it was decided that the patient
and her family would prefer to prioritize quality of life and
discharge from hospital. Thus, patient was discharged home on
hospice and confirmed DNR/DNI.
# Septic shock:
# GNR Bacteremia: Patient in septic shock secondary to GNR/GPR
bacteremia in the setting of duodenal perforation and abscess,
likely caused by pancreatic mass invasion. Initially on
norepinephrine for hypotension, which was weaned. Per ID,
treated with zosyn for coverage of intra-abdominal organisms.
Blood cultures grew E. coli. Surgery was consulted but did not
feel there were any surgical options at this time given that the
perforation is contained. The patient's pain was well controlled
on minimal IV dilaudid. Patient was kept NPO ___, but
started on clears on ___ per surgery recommendations. Her diet
was advanced to regular and it was well tolerated. Per ID, she
was transitioned to PO levofloxacin and flagyl for an indefinite
course. Will defer to hospice to help patient transition off
antibiotics.
# Anemia: Normocytic anemia with baseline hgb ___. Likely from
ACD and malignancy. Hb droped to 6.5 and she was transfused 2
units to aid with weakness symptoms and improved to 10 at
discharge. Family requested additional work-up for transfusions
in the future, but this was discouraged given goals of care as
above.
# Pancreatic cancer: Diagnosed in ___. It is locally
advanced and unresectable (encases vasculature). C1D1 of
gemcitabine on ___. She has had numerous prior biliary
stents, with the last PTBD exchange on ___. Per
communications with outpatient oncologist, there is no plan for
additional chemotherapy given infection and complications as
noted above.
> 30 minutes were spent on discharge care, planning, and
coordination.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
5. Vitamin D 1000 UNIT PO DAILY
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 17.2 mg PO BID
10. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral
DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Q48H Disp #*14
Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4h:prn Disp #*10 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 17.2 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pancreatic cancer
duodenal perforation with abscess formation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted for abdominal pain
and a CT scan found that this was likely caused by a small
perforation (a hole) in a part of your intestine. This hole
caused an abscess (a collection of bacteria - an infection)
because bacteria from the gut leaked into the surrounding area.
You were treated with antibiotics. Fortunately, from your last
CT scan, it appears as though the perforation (hole) seemed to
close and nothing is leaking from your small intestines anymore.
It is safe for you to eat. The abscess size is stable.
Unfortunately, there is no further treatment for your cancer at
this time given the many complications you have had. The
surgeons evaluated you and your scans and did not think any
operation would be beneficial. We are treating you with
antibiotics, but this is more of a "Band-Aid" to hopefully
prevent significant progression of the abscess, but it will not
work forever. You should discuss with your hospice team when
would be a good time to stop these antibiotics.
You and your family discussed the treatment options with many of
your providers in the hospital and you decided that it would be
best to focus on the quality of your life rather than on
treating these individual problems. We hope that you are
comfortable at home and enjoy the remainder of your days with
loved ones. The hospice team will help with this transition and
help you manage your symptoms at home.
Please take care,
Your ___ Team
Followup Instructions:
___
|
19985545-DS-15 | 19,985,545 | 26,220,192 | DS | 15 | 2138-11-18 00:00:00 | 2138-11-18 15:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
depression, poor self-care
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o married M ___ police officer with h/o depression and
anxiety, recent misuse of prescribed medications (opiates and
benzodiazepine), also multiple myeloma diagnosed in ___ s/p BMT
undergoing phase 1 clinical trial at ___, self-presenting w/
wife with reports of severe depression. Psychiatry consulted to
assist with management and safety evaluation.
CHIEF COMPLAINT: "Things seem to be getting worse in my life..."
HISTORY OF PRESENT ILLNESS:
Patient reports worsening depression over last few months, with
more intese worsening over last two weeks, in setting of
on-going cancer treatment for multiple myeloma, and multiple
psychosocial stressors. Specifically, reports significant stress
over two of his children (son and daughter) who are undergoing
active substance treatment, with son who is former ___
dealing w/ Percocet dependence after multiple surgeries, and
daughter w/ notable h/o sexual trauma from patient's father,
depression, and ___ abuse in attempt to self-treat her
depression. Patient reports he has grown increasingly "sick and
tired" of how he is feeling, and that he has become "so
depressed" that he spends almost his entire day in bed.
Patient denies any suicidal ideation, intent, or plan, but
states repeatedly that he wants his life to be "different,"
"happier," and "in a different place." Admits to taking excess
medications every day for some time (weeks-months) in attempt to
self-medicate the "stress" and "depression." Reports taking on
average ___ oxycodone 30 mg tabs/day, and 2 oxycontin tabs bid
(should be taking 1 tab bid). Also reports taking on average 8
tabs clonzaepam 0.5 mg/day (should be taking no more than ___.
Patient admits he often does not know what he is taking, and
states that is another reason he is here today. Reports wanting
help for his depression and misuse of medications, expressing
interest in hospitalization.
Of note, patient reports he has not seen his psychiatrist in
about a year, and never followed up w/ referrals to outpatient
therapy. Reports completing intake w/ one therapist in
community, but did not follow through because it was not a good
fit. Refers to offers of support from friends and family that
don't seem
"sincere," and becomes tearful when discussing his on-going
depressive symptoms. Admits to being extremely private at
baseline. Expresses notable grief, concern, feelings of guilt
over his children's struggles, and admits to worry over not
wanting to be a burden to his wife.
Wife (who is oncology nurse at ___ confirms history reported
above. Confirms patient has not been getting out of bed to
attend to basic self care, and will not shower/bathe, or change
his clothes, and he is crying now every day. Reports patient
rarely eats, such that he has lost a fair amount of weight over
last few months (30 lbs). Denies acute safety concerns in terms
of suicidality, but reports patient is severely depressed and
managing his own medications, with no clear sense of what he is
taking, such that he is often sedated in bed. Reports on-going
marital stressors since before patient was diagnosed, with her
serving as patient's only support. Reports patient is generally
very private, and the fact that he was agreeable to come to ED
today and is asking for hospitalization are "big cries for
help."
Past Medical History:
PAST PSYCHIATRIC HISTORY:
Diagnosis: h/o depression, anxiety
Hospitalizations: none
SA/SIB: none
Harm to others: none
Prior med trials: h/o sertraline in past, patient reports he did
not find it to be helpful, no other trials of anti-depressants
Treaters: previously saw psychiatrist Dr. ___ at ___ for
many years, per OMR saw for ___ mins/twice monthly. Not seen
in
last year. Saw. Dr. ___ for psychiatric intake in
___ w/ no further follow up. Denies h/o therapy.
PAST MEDICAL HISTORY: per OMR
MULTIPLE MYELOMA
pomalidomide, Velcade and Decadron therapy
*S/P AUTOLOGOUS STEM CELL TRANSPLANT
ACUTE RENAL FAILURE
AUTO HPC, APHERESIS INFUSION
GOUT
STEM CELL COLLECTION
STUDY ___
THERAPUTIC PLASMAPHERESIS
Social History:
SUBSTANCE ABUSE HISTORY:
EtOH: denies use since multiple myeloma diagnosis in ___,
previous heavy use, denies h/o withdrawal, DTs, detox treatment
Illicits: denies, including IVDU, per OMR previous MJ use
Tobacco: none
FORENSIC HISTORY: ___
SOCIAL HISTORY: ___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Father- depression, opiate abuse/dependence (Percocets), per OMR
possible h/o ECT when psychiatrically hospitalized
Sisters, brother- EtOH
Son- opiate abuse/dependence (Percocets)
Daughter- ___ abuse
Multiple family members w/ h/o depression and anxiety. Denies
h/o
suicide.
Physical Exam:
ADMISSION PHYSICAL ___
Neuropsychiatric Examination:
ROS: bilateral arm pain, diffuse body pain ___ MM, weakness,
nonproductive cough, neck and occipital headache denies visual
changes Numbness, , Seizures, Intolerance to heat/cold, , SOB,
Chest pain, Abdominal pain, N/V, Diarrhea/Constipation,
Melena/Hematechezia, Dysuria/Polyuria, Swelling
PHYSICAL EXAMINATION:
VS: BP: 122/72 HR: 68 temp: 97.8 resp:18 O2 sat: 100%
on RA
MENTAL STATUS EXAM:
--appearance: ___ year old man wearing hospital gown, appears as
stated age, lean with brusing on left elbow and right deltoid.
--behavior/attitude guarded ; poor EC while discussing
stressors,
did make EC when discussing less personal issues of pain/medical
history exhibited no PMR, PMA
--speech: ___, low volume slow rate with paucity of speech \
--mood (in patient's words): " I'm depressed"
--affect: blunted; appropriate to the context
--thought content (describe): at times preservative on pain
regimen
--thought process: linear
--perception: significant for without AH, VH, delusions,
paranoia
--SI/HI: significant for without SI with out intent, plan; no
HI;
--insight: fair
--judgment: limited
COGNITIVE EXAM:
--orientation: alert to person, place, time, situation
--attention/concentration: un able to recite MOYB, able to
perform ___ backward
--memory (apple, purple, honesty): immediate intact ___ delayed
recall,
--language: grossly intact
--fund of knowledge: un able to recall the president on
___-
said ___, knew president currently
--similarities/analogies: understood analogy of "apples to
oranges"
PE:
General: Well-nourished, in no distress.
HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear.
Neck: Supple, trachea midline. No adenopathy or thyromegaly.
Back: No significant deformity,
Lungs: coarse rhonchi
CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ pedal
pulses
Abdomen: Soft, nontender, nondistended; no masses or
organomegaly.
Extremities: No clubbing, cyanosis, or edema.
Skin: Warm and dry, bruising s/p fall on right deltoid/left
elbow.
Neurological:
*Cranial Nerves-
I: Not tested
II: Pupils equally round and reactive to light
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally
without
nystagmus.
V, VII: Facial strength and sensation intact and
symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
*Motor- Normal bulk and tone bilaterally. No abnormal
movements, tremors. Strength diminished ___ throughout. No
pronator drift.
*Sensation- Intact to light touch
*Reflexes- B T Pa intact
*Coordination- Normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Pertinent Results:
___ 03:55PM GLUCOSE-113* UREA N-7 CREAT-0.8 SODIUM-141
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-17
___ 03:55PM CALCIUM-8.5 PHOSPHATE-4.4 MAGNESIUM-1.7
___ 03:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:55PM WBC-2.1* RBC-3.28* HGB-10.4* HCT-30.1* MCV-92
MCH-31.5 MCHC-34.5 RDW-14.3
___ 03:55PM NEUTS-58.4 ___ MONOS-8.6 EOS-1.4
BASOS-1.4
___ 03:55PM PLT COUNT-112*
___ CT head without contrast:
1. No acute intracranial process. If clinical concern for stroke
or intracranial mass is high, MRI is more sensitive.
2. Aerosolized secretions in the right maxillary sinus may be
infectious or inflammatory.
Brief Hospital Course:
1. Psychiatric: Mr. ___ is a ___ year old man with multiple
myeloma and gout admitted for depression with neurovegetative
features and decreased self-care in the setting of ongoing
narcotic dependence, strained relationships, and social
stressers.
Mr. ___ expressed strong motivation to decrease his pain
medication and benzodiazepine doses, especially after talking
with the pain consult team. His benzodiazepine dose was
decreased from clonazepam 0.5mg TID to 0.5mg BID. His PRN
opiate was decreased from 30mg QID to 25mg QID. His standing
long-acting opiate (oxycontin 20mg BID) was discontinued over
the course of two days, and Mr. ___ tolerated this well. He
was given comfort medications, including dicyclomine,
methocarbamol, and a clonidine patch, to assist with opitate
withdrawal. Upon discharge, the plan is for Mr. ___ to attend
a detoxification program to finish tapering down his opiates
safely and comfortably and to determine how feasible a plan of
coming off narcotics entirely is vs starting methadone or
suboxone maintainance. He will continue to follow up with his
outpatient psychiatrist and onclogist about this ongoing issue.
Over the course of his hosptialization, the pain consult team
was consulted and given the patients active addiction to opiates
and unclear pain control needs at this time, were also in
support of a detox. He will likely need pain control through
time and they suggested consideration of methadone. They
assisted with the taper of opiates to his current point and
reccommned use of neurontin TID and clonidine weekly patch. They
did not feel that the use of oxycontin and oxycodone through
time would be safe management given the complexity of his
presentation.
For depression, Mr. ___ was started on effexor, which was
titrated to 75mg daily. He was also started on seroquel for
augementation of his antidepressant to assist with depression,
severe anxiety, and rumination that appeared to be a factor even
outside of his addiction. He tolerated the addition of these
medications well. He is motivated for ongoing treatment of his
depression given its comorbidity with his cancer diagnosis and
addiction. He was motivated to begin therapy with his new
therapist that was arranged by his psychiatrist prior to
admission. His therapist is aware of his recent admission. He
will also continue treatment with his psychiatrist, Dr. ___.
After detox from his overuse/abuse of pain medications and
benzos prior to coming to the hosptial, and initiation of
treatment for his depression his neurovegetative features
rapidly improved, and Mr. ___ actively engaged in aftercare
planning. He was bright, social, slept and ate well, and tended
to his hygiene. He was clearly future oriented, was free of
suicidal ideation, plan or intent and denied ever being suicidal
or having a suicide attempt. He expressed a commitment to life
and motivation for sobriety for the good of himself and for his
family. Despite family challanges, he identifies himself as a
father, husband, and provider and this continues to keep him
going in tough times. Over the course of his hospitalization
contact was made with his wife and a meeting was held with his
wife and their son. His wife was open to his return home and was
supportive of his ongoing dual diagnosis treatment. Mr. ___
felt that his move to an apartment within the last few months
was a big factor into his relapse has he felt alone and was
again responsible for managing his own narcotic medications.
When living at home his sister had been distributing and
monitoring his narcotic pills. This remains something he is open
to again. Over the course of his hosptialziation, his sister
___ phone ___ was contacted and if he requires
having pain pills at home, she will assist in the distribution
and coordination with her physicians as in the past. He is
motivated to do what is needed to maintain sobriety and his
functioning.
Other contributors to his relapse recently included stress
regarding his daughter who is pregnant, by someone who is also
strugles with substance dependnece. Also one of his sons that
lives at home with his wife is out of control with narcotic
addiction and they have been actively working to section 35 him
or remove him from the home. Mr. ___ is motivated to maintain
his own sobriety as an example to his children and to reduce the
amount of worry and stress on his wife who has been primarliy
involved in the challanges with the children.
Through out his admission, Mr. ___ was free of suicidal
thoughts, was motivated for recovery and the future and worked
well wiht his treatment team. He had capacity to make decisions
for himself and had an awareness of his risk of relapse into
depression and drug use. As an additional safety measure,
Although Mr. ___ did not express suicidality, he recognized
that given his history of depression and addiction disorder he
was at an elevated risk from the general population of at some
point having impulsive self injury. He agreed with the
treatment team that he would keep his gun at work in a locked
box, rather than at home. He owns a gun due to his profession
as a ___. It was not felt that he was an acute risk
to himself to the degree where removal of the gun from the home
was indicated. In fact, threatening his identity as a police
officer around this issue, would lead to further anxiety and
feelings of being overwhelmed and would threaten his alliance
clear motivation for help and recovery. This was discussed at
length and consultation was sought regarding this issue from Dr.
___ who also evaluated the patient in the emergency
room.
Upon admission Mr. ___ demonstrated some cognitive impairment,
particularly in attention. Possible etiologies included
intoxication from the benzodiazepines and opiates he had been
using at home, depression, or a chemotherapy side effect. His
cognition appeared to improve considerably over the course of
the hospital stay. However, a MOCA performed on ___ had a
score of ___ and showed continuing deficits in attention, with
poor digit repetition and errors on serial 7's, and language,
both repetition and fluency. His cognition should be tracked
closely in the outpatient setting with repeated cognitive
screening over time and more in-depth neuropsychiatric testing
should be considered.
Mr. ___ outpatient psychiatrist, Dr. ___
___ or cell phone ___, was in frequent
communication by phone and included in treatment decisions.
Likewise, his oncologist, Dr. ___, was consulted regarding
tapering the opiate medications and his likley ongoing need for
pain control in the future.
At time of discharge, Mr ___ was anxious about the transfer to
an ___ facility, but remained clearly future
oriented and motivated to "do what it takes to get better." He
expressed remorse for his pain medication seeking behaviors and
misuse of prescription medications. He continued to reflect on
his desire to improve his health and from a physical, mental,
and addiction standpoint for the good of himself and his family.
He appeared safe and appropriate for discharge from a locked
___ facility. He does not present as an acute danger to
himself at this time and has been caring for himself
appropriatley
2. Medical:
#) Multiple myeloma: Per outpatient oncologist Dr. ___
medication changes were indicated, aside from stopping the
prednisone 5mg which was deemed no longer necessary from a
cancer perspective. However, he was restarted on prednisone
when he had a flare of gout (see below) and will be discharged
with a plan to continue the 5mg daily prednisone as he was
taking prior to admission after he finishes the current
prednisone taper. He will continue to follow up with Dr. ___
___ further course of chemotherapy. He should be seen the day
after discharge from detox.
#) ___ esophagus: Mr. ___ was continued on Protonix 40mg
bid.
#) Gout: Mr. ___ suffered a flare in right ankle the day after
his low-dose prednisone -- which he had been taking for multiple
myeloma -- was discontinued. He was started on a prednisone
taper from 30mg with 5mg decreases at 2-day intervals, with a
plan to then continue 5mg daily prednisone chronically as
prophylaxis. He was continued on his home Allopurinol ___
daily. Outpatient follow up with Dr. ___ was scheudled.
3. Safety: Maintained on 15 min checks as he was cooperative
with treatment in hospital and denied sucidal ideation. He was
maintained on fall precautions. While he initially presented as
a risk to self outside of a structured environment due to poor
self-care, his sleeping, eating, hygiene, and cognition all
improved by the time of discharge.
4. Disposition: ___ facility
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ACYCLOVIR - acyclovir 400 mg tablet. 1 Tablet(s) by mouth every
eight (8) hours
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
Aerosol Inhaler. 2 puffs inhaled four times a day as needed for
as needed for wheezing or shortness of breath
ALLOPURINOL - allopurinol ___ mg tablet. 1 tablet(s) by mouth
once a day 90 day supply
CLONAZEPAM - clonazepam 0.5 mg disintegrating tablet. 1
tablet(s)
by mouth three times a day - (Prescribed by Other Provider)
DEXAMETHASONE - dexamethasone 4 mg tablet. 3 tablet(s) by mouth
day after velcade
ONDANSETRON - ondansetron 8 mg disintegrating tablet. 1
Tablet(s)
by mouth every eight (8) hours as needed for nausea
OXYCODONE - oxycodone 30 mg tablet. 1 tablet(s) by mouth -
(Prescribed by Other Provider)
OXYCODONE [OXYCONTIN] - OxyContin 20 mg tablet,extended release.
1 tablet(s) by mouth twice a day as needed for pain
PANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release. 1
Tablet(s) by mouth twice a day
POTASSIUM CHLORIDE [KLOR-CON M20] - Klor-Con M20 mEq
tablet,extended release. 2 tablet(s) by mouth once a day
PREDNISONE - prednisone 5 mg tablet. 1 tablet(s) by mouth once a
day 90 day supply
PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg
tablet.
1 Tablet(s) by mouth every eight (8) hours as needed for nausea
ZOLPIDEM [AMBIEN] - Ambien 5 mg tablet. ___ tablet(s) by mouth
at
bedtime
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by
mouth once a day - (Prescribed by Other Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day as needed for constipation - (OTC)
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheeze
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QTUES
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO TID
8. Pantoprazole 40 mg PO Q12H
9. Quetiapine Fumarate 50 mg PO QHS
10. Senna 1 TAB PO BID:PRN constipation
11. Venlafaxine XR 75 mg PO DAILY
12. Quetiapine Fumarate 25 mg PO BID:PRN severe anxiety
13. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Axis I: Opioid dependence; Benzodiazepine dependence; Major
Depression, recurrent; Cognitive Disorder NOS - intoxication vs
mood related vs related to chemo
Axis II: defer
Axis III: multiple myeloma, gout
Discharge Condition:
MSE:
Appearance: cooperative, appropriately groomed, showered,
casually dressed
Gait: walks steadily
Tone: No evidence of stiffness or tremor
Behavior: adequate eye contact, mild PMR
Speech: soft volume, regular rate
Mood: 'good' and later 'anxious'
Affect: euthymic, fair to good range, congruent
Thought Process: linear to direct questions
Thought Content: no prominent delusions/paranoia. Help seeking.
future oriented.
Perceptions: denies Auditory/Visual/Somatic hallucinations. Does
not appear to be responding to internal stim.
Suicidality/Homicidality: patient continues to deny suicidal
ideation plan, intent. Motivated for recovery.
Insight/Judgment: improving/improving, both appear fair
currently
Discharge Instructions:
During your admission at ___, you were diagnosed with
depression and treatment included medication with venlafaxine.
Please follow up with all outpatient appointments as listed.
Please continue all medications as directed.
Please avoid abusing alcohol and any drugs--whether prescription
drugs or illegal drugs--as this can further worsen your medical
and psychiatric illnesses.
Please contact your outpatient psychiatrist or other providers
if you have any concerns.
Please call ___ or go to your nearest emergency room if you feel
unsafe in any way and are unable to immediately reach your
health care providers.
It was a pleasure to have worked with you and we wish you the
best of health.
If you need to talk to a ___ Staff Member regarding issues of
your hospitalization, please call ___.
Followup Instructions:
___
|
19985545-DS-19 | 19,985,545 | 23,896,005 | DS | 19 | 2140-10-25 00:00:00 | 2140-10-25 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sinus congestion. Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old man with past medical history of multiple
myeloma (diagnosed ___ with IgG lambda multiple myeloma,
Stage
III by ___ at diagnosis, treated with
lenalidomide/bortezomib/dexamethasone then clinical trial
protocol ___ of dendritic cell/fusion vaccine followed by
autologous hematopoietic stem cell transplantation, with day 0:
___, followed by treatment on clinical trial protocol ___
with pomalidomide/bortezomib/dexamethasone from ___ to
___,
resumed pomalidomide/bortezomib/dexamethasone ___, most
recently C5D1 on ___, with subsequent doses held because of
ongoing dyspnea on exertion), hypertension, anxiety/depression,
___ esophagus, arthritis, gout, chronic back pain, and
recent
admissions for dyspnea on exertion of uncertain etiology, who
presents with ongoing dyspnea on exertion, non-productive cough,
myalgias, maxillary sinus pain, and diarrhea for the past day.
His dyspnea on exertion, non-productive cough, and myalgias
remain most concerning for a viral upper respiratory infectious
process and/or maxillary sinusitis. However, other entities to
consider in the differential diagnosis include
obstructive/hypersensitivity lung disease (such as asthma),
interstitial pneumonitis (less likely given normal lung
parenchymal findings on recent chest CT), and medication effect
of pomalidomide or bortezomib.
Regarding his diarrhea, this is most likely related to
antibiotics, specifically Augmentin. However, given his recent
hospitalization and antibiosis, the possibility of C. difficile
colitis or other infectious colitis must be evaluated.
Past Medical History:
PAST ONCOLOGIC HISTORY (per most recent onc note):
diagnosed with stage III multiple myeloma in early ___.
Treated with Velcade, Revlimid, and
dexamethasone. He is now status post autologous stem cell
transplant with stem cells reinfused on ___. Retarted on
Revlimid and dexamethasone in ___. Treated on protocol ___
to include pomalidomide, dexamethasone and Velcade completing
___.
CURRENT TREATMENT PLAN:Pomalyst PO for 14 days; Dex/velcade sc
PAST MEDICAL HISTORY:
MULTIPLE MYELOMA *S/P AUTOLOGOUS SC Tx ___ (see above)
Anxiety/Depression
GOUT
Social History:
SUBSTANCE ABUSE HISTORY:
EtOH: denies use since multiple myeloma diagnosis in ___,
previous heavy use, denies h/o withdrawal, DTs, detox treatment
Illicits: denies, including IVDU, per OMR previous MJ use
Tobacco: none
FORENSIC HISTORY: ___
SOCIAL HISTORY: B/R in ___ and ___. Multiple
sibling, father was ___ ___. Graduated from high
school and completed ___ years at ___. Employed as
___ Officer ___ years. Remains employed, most recently
in administrative capacity but has not worked in many months to
last year. Married for almost ___ years, wife is ___
at ___. They have four adult children. W/ on-and-off
separation from wife since just prior to multiple myeloma
diagnosis in ___. (Pt had just moved out of the home prior to
diagnosis in setting of planned separation, but moved back in w/
wife after
diagnosis.) Most recently moved out again in ___, but
moved back in w/ wife since ___ in setting of on-going
cancer treatment. Notable on-going stressors related to son and
daughter, both in active substance treatment. Daughter w/
notable h/o sexual trauma from patient's father, resulting in
patient being mostly estranged from his family. Identifies as
Catholic but not affiliated with church. Denies h/o trauma.
Family History:
FAMILY PSYCHIATRIC HISTORY:
Father- depression, opiate abuse/dependence (Percocets), per OMR
possible h/o ECT when psychiatrically hospitalized
Sisters, brother- EtOH
Son- opiate abuse/dependence (Percocets)
Daughter- ___ abuse
Multiple family members w/ h/o depression and anxiety. Denies
h/o
suicide.
Physical Exam:
Admission:
Physical Examination:
VS: T 97.6, HR 76, BP 132/76, RR 18, and SpO2 96% on room air
Gen: Pleasant, thin, Caucasian man of normal build, in no acute
distress, breathing comfortably
HEENT: Mild pharyngeal inflammation with some post-nasal drip
noted. Mild tenderness to palpation of bilateral maxillary
sinuses.
Cor: Regular rate and rhythm, S1S2 normal, no murmur/rub/gallops
Pulm: Clear to auscultation bilaterally, no wheezes/rhonci/rales
Abd: Soft, non-tender, non-distended. No hepato/splenomegaly
Ext: Warm and well-perfused, no clubbing/cyanosis/edema
Back: Slight tenderness to palpation in the right mid-scapular
line at approximately the level of T12.
Neuro: A/o x 3, strength/sensation grossly intact
ECOG: 0
Karnofsky: 100
Discharge:
Vitals: 97.5/98.2 120/74 69 20 99RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
Pertinent Results:
Admission:
___ 11:45AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 11:43AM LACTATE-1.6
___ 11:30AM GLUCOSE-93 UREA N-12 CREAT-1.0 SODIUM-143
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
___ 11:30AM estGFR-Using this
___ 11:30AM ALT(SGPT)-12 AST(SGOT)-19 CK(CPK)-49 ALK
PHOS-73 TOT BILI-0.3
___ 11:30AM LIPASE-20
___ 11:30AM cTropnT-<0.01
___ 11:30AM proBNP-116
___ 11:30AM ALBUMIN-4.3 CALCIUM-9.4
___ 11:30AM IgG-445* IgA-43* IgM-50
___ 11:30AM WBC-2.3* RBC-4.04* HGB-13.2* HCT-36.6* MCV-91
MCH-32.6* MCHC-36.0* RDW-14.2
___ 11:30AM NEUTS-39.0* LYMPHS-50.2* MONOS-7.7 EOS-1.2
BASOS-1.8
___ 11:30AM PLT COUNT-140*
___ 11:30AM ___ PTT-31.9 ___
Discharge:
___ 05:41AM BLOOD WBC-1.3* RBC-3.82* Hgb-12.3* Hct-34.0*
MCV-89 MCH-32.4* MCHC-36.3* RDW-13.9 Plt ___
___ 05:41AM BLOOD Neuts-64.7 ___ Monos-5.2 Eos-0.3
Baso-0.6
___ 05:41AM BLOOD Plt ___
___ 05:41AM BLOOD Glucose-146* UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-27 AnGap-13
___ 05:41AM BLOOD ALT-12 AST-13 LD(LDH)-142 AlkPhos-60
TotBili-0.3
___ 05:41AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8
Brief Hospital Course:
#) Dyspnea on exertion, non-productive cough, myalgias, and
maxillary sinus pain: Most likely secondary to viral upper
respiratory infection vs. maxillary sinusitis. Other entities we
considered included asthma, interstitial pneumonia (though
unlikely as CT was negative). He was Flu negative with clear
CXR. He was afebrile. His CRP was 4.9. He had a normal ECHO last
admission with no signs of fluid overload or heart failure. His
tnT is WLN making cardiac Amyloidosis unlikely.
- Although afebrile, we re-broadened antibiotics to
Ceftriaxone.
- Albuterol/ipratropium nebulizer PRN dyspnea.
- After subjective improvement in SOB after two days of IV CTX,
we discharged home on Cefpodoxime.
#) Diarrhea: resolved, most likely antibiotic associated.
- Held Augmentin
- Checked stool C. difficile DNA amplification.
#) Multiple myeloma, complicated by hypogammaglobulinemia:
Disease presently well-controlled, based on recent serum free
light chain assay from ___.
- Repeated quantitative immunoglobulins, which showed low IgG;
we administered IVIg while in house.
- Continued to hold pomalidomide, bortezomib, and dexamethasone.
His WBC was low and we suspect it is d/t to chemo. We advised to
continue holding his chemo on discharge and follow up with Dr.
___ to determine when to restart.
- We Continued acyclovir and Bactrim for prophylaxis.
- Continued aspirin.
#) Anxiety/depression:
- Continued venlafaxine
- Continued clonazepam
#) Chronic back pain
- Continued lidocaine patch, gabapentin, and oxycodone.
#) Fluid/electrolytes/nutrition:
- Regular diet
#) DVT prophylaxis:
- Enoxaparin 30 mg q12h, given normal renal function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, dyspnea
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
4. Aspirin 81 mg PO DAILY
5. Azithromycin 250 mg PO Q24H
6. ClonazePAM 0.5 mg PO TID:PRN anxiety
7. Gabapentin 600 mg PO TID
8. Lidocaine 5% Patch 2 PTCH TD QAM
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN PRN pain
11. Pseudoephedrine 60 mg PO Q6H:PRN confgestion
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Acetaminophen 650 mg PO Q6H:PRN Pain
14. Venlafaxine 225 mg PO DAILY
15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Acyclovir 400 mg PO Q8H
3. ClonazePAM 0.5 mg PO TID:PRN anxiety
4. Gabapentin 600 mg PO TID
5. Lidocaine 5% Patch 2 PTCH TD QAM
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth Q6H:PRN Disp
#*12 Tablet Refills:*0
8. Pseudoephedrine 60 mg PO Q6H:PRN confgestion
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Venlafaxine 225 mg PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
RX *zolpidem [Ambien] 5 mg 1 tablet(s) by mouth QHS:PRN Disp #*3
Tablet Refills:*0
12. Docusate Sodium 100 mg PO BID
13. Guaifenesin ___ mL PO Q6H:PRN cough/congestion
RX *guaifenesin 600 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, dyspnea
15. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 7 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
16. Aspirin 81 mg PO DAILY
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Acyclovir 400 mg PO Q8H
3. ClonazePAM 0.5 mg PO TID:PRN anxiety
4. Gabapentin 600 mg PO TID
5. Lidocaine 5% Patch 2 PTCH TD QAM
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth Q6H:PRN Disp
#*12 Tablet Refills:*0
8. Pseudoephedrine 60 mg PO Q6H:PRN confgestion
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Venlafaxine 225 mg PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
RX *zolpidem [Ambien] 5 mg 1 tablet(s) by mouth QHS:PRN Disp #*3
Tablet Refills:*0
12. Docusate Sodium 100 mg PO BID
13. Guaifenesin ___ mL PO Q6H:PRN cough/congestion
RX *guaifenesin 600 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, dyspnea
RX *albuterol sulfate [Proventil HFA] 90 mcg 2 puff Q6H:PRN Disp
#*1 Inhaler Refills:*0
15. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 7 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
16. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Viral Upper Respiratory Infection
Sinusitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to us with shortness of breath and nasal congestion. We
tested you again for Flu, which was negative and our workup
shows most likely a viral process. However, one can develop
bacterial infections at the same time, so we started you on IV
antibiotics. We gave you breathing treatments to help open your
lungs and help you breath. You improved on the IV antibitoics so
are discharging you home with oral antibitoics to take.
It was a pleasure taking care of you.
Sincerely,
Your ___ team.
Followup Instructions:
___
|
19985545-DS-25 | 19,985,545 | 21,516,111 | DS | 25 | 2144-08-25 00:00:00 | 2144-08-25 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:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
Intubated ___
Extubated ___
___ LP ___
LP ___
Bone marrow biopsy ___
History of Present Illness:
___ with h/o multiple myeloma c/b recent spinal lesions s/p
radiation with recent initiation of clinical trial drug regimen
on ___ (___; ___ and history of opiate withdrawal
with recent decrease in outpatient pain medication regimen who
presented to the ED on ___ with c/o nausea, vomiting and
diarrhea. Shortly after receiving clinical trial medications,
patient developed profuse non-bloody, non-bilious vomiting and
non-bloody diarrhea. Patient called EMS given concern for
symptoms; when EMS arrived they had difficulty obtaining an
SpO2,
with the highest recorded level in the ___ with poor waveform.
En
route to the emergency department, patient developed a sharp,
periumbilical abdominal pain. He otherwise noted subjective
chills and dysuria, but denied any fever, chest pain, SOB,
melena, or BRBPR.
In the ED,
- Initial Vitals: T 98.0 HR 108 BP 96/53 RR 18 SpO2 76% 4L NC
- Exam:
Mottled skin, appears chronically ill
RRR, no murmur, no JVD
Decreased breath sounds in LLL, no wheezing or crackles
Abdomen soft, no focal tenderness, no rebound or guarding
Skin warm and dry
- Labs:
WBC 6.4
Hg 13.3
Plt 67
D-dimer 1718
Fibrinogen 546
INR 1.4
LDH 656
Uric Acid 10.0
K 3.1
Cr 1.5 (baseline 0.9)
HCO3 21
AG 20
VBG @ ___: 7.42 | 42 Lactate 4.0
VBG @ 0000: 7.58 | 26 Lactate 1.4
Trop < 0.01
AST 50
ALT 79
ALP 100
Tbili 1.5
- Imaging:
CTA CHEST:
1. No evidence of pulmonary embolism.
2. Fluid throughout all visualized bowel loops with diffuse
bowel
wall
hyperemia, likely reflecting diffuse enteritis, likely
infectious
or
inflammatory. No bowel wall thickening.
3. New ground-glass opacities within the lower lobes
bilaterally,
compatible with infection.
4. Mild bladder wall thickening anteriorly, which should be
correlated with urinalysis for evidence of cystitis.
5. Known osseous myeloma lesions are better visualized on prior
examinations. Soft tissue within the spinal canal at the level
of
L3 is re-demonstrated, but better evaluated on the MR ___
dated ___.
6. Large hiatal hernia.
___ IMAGING PRELIM READS:****
CT ___ WITHOUT CONTRAST:
No acute intracranial abnormality.
CTA ___:
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:
There are atherosclerotic calcifications of the bilateral
carotid
bifurcations, without evidence of internal carotid stenosis by
NASCET
criteria. The vertebral arteries and their major branches appear
normal with no evidence of stenosis or occlusion.
PERFUSION: No evidence of abnormal perfusion.
- Consults:
Code Stroke: low suspicion for stroke given no evidence large
territory infarct/bleed on CT and non-localizing exam.
Recommended - MRI Brain w/ and ___ contrast, LP for CSF gram
stain/culture, cell count, protein, glucose, HSV PCR,
Cryptococcus antigen, flow cytometry, cytology and CSF
Hold.Recommend empiric treatment with meningitic dosing of
vanc/CTX and acyclovir. Neurology Consult service will follow
along.
- Interventions:
___ 22:05 IVF LR ( 1000 mL ordered)
___ 23:49 IV CefePIME 2 g
___ 00:33 IVF LR ( 1000 mL ordered)
___ 00:33 IV Vancomycin (1500 mg ordered)
Central venous line placed in ED.
LP deferred iso thrombocytopenia and agitation.
In the unit, patient was agitated and attempting to remove
clothing, screaming at staff for help. He was unable to
communicate when asked ROS questions and did not fully
participate in examination. Received 5 mg IV Haldol, placed on
CIWA, reinitiated on opiates to minimize risk of withdrawal,
initiated on IVF, administered morphine IV x2 in s/o likely
withdrawal and ordered for stat TLS labs.
Past Medical History:
Multiple myeloma s/p autologous stem cell transplant, radiation
Orthostatic hypotension
Opiate withdrawal w/ substance use disorder
Depression
Gout
Social History:
___
Family History:
paternal grandmother was institutionalized.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 99.7 HR 63 BP 134/53 RR 23 SPO2 100%
GEN: ___ yo M, sitting up in bed, repeatedly screaming out "god
help please" and trying to get out of bed.
EYES: Pupils equal round reactive and dilated at 5 mm
HENNT: Poor dentition
CV: RRR no M/R/G
RESP: No increased work of breathing. Decreased basilar breath
sounds. No crackles, rhonchi.
GI: Non-distended. Voluntary guarding. Soft with patient unable
to communicate if pain to palpation.
MSK: No peripheral edema.
SKIN: Petechiae over bilateral legs.
NEURO: Unable to follow commands. AAOx0
PSYCH: Agitated.
DISCHARGE PHYSICAL EXAM:
========================
Vitals:24 HR Data (last updated ___ @ 651)
Temp: 98.0 (Tm 98.3), BP: 130/80 (102-177/67-102), HR: 104
(79-113), RR: 18, O2 sat: 97% (96-99), O2 delivery: Ra, Wt:
137.2
lb/62.23 kg
Gen: sitting up in bed, alert and interactive, in no acute
distress
CV: regular rhythm, tachycardic, no m/g/r
LUNGS: CTAB, breathing comfortably on room air
ABD: soft, nontender, nondistended
EXT: warm and well-perfused, no ___ edema.
NEURO: alert, grossly oriented, ___ strength on ankle
dorsiflexion and plantarflexion bilaterally
Pertinent Results:
ADMISSION LABS:
===============
___ 09:31PM BLOOD WBC-6.4 RBC-4.23* Hgb-13.3* Hct-38.6*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.2 RDWSD-41.1 Plt Ct-67*
___ 09:31PM BLOOD Neuts-81.9* Lymphs-10.9* Monos-4.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-5.25 AbsLymp-0.70*
AbsMono-0.26 AbsEos-0.01* AbsBaso-0.01
___ 09:31PM BLOOD ___ PTT-29.0 ___
___ 09:31PM BLOOD ___ D-Dimer-1718*
___ 09:31PM BLOOD Glucose-114* UreaN-19 Creat-1.5* Na-142
K-3.1* Cl-101 HCO3-21* AnGap-20*
___ 09:31PM BLOOD Albumin-4.2 Calcium-9.7 Phos-2.4* Mg-1.9
UricAcd-10.0*
___ 09:31PM BLOOD ALT-50* AST-79* LD(LDH)-656* AlkPhos-100
TotBili-1.5
___ 09:31PM BLOOD Lipase-22
___ 09:31PM BLOOD cTropnT-<0.01
___ 09:31PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 09:42PM BLOOD ___ pO2-19* pCO2-42 pH-7.42
calTCO2-28 Base XS-1
___ 09:42PM BLOOD Lactate-4.0* Na-140 K-3.1*
PERTINENT LABS/MICRO/IMAGING:
=============================
___ 11:19AM BLOOD Osmolal-272*
___ 06:43AM URINE Osmolal-522
___ 06:43AM URINE Hours-RANDOM Na-127
___ 06:14AM BLOOD Osmolal-269*
___ 03:16PM URINE Osmolal-415
___ 03:16PM URINE Hours-RANDOM Na-146
___ 12:00PM BLOOD TSH-3.8
___ 06:35AM BLOOD Cortsol-17.4
___ 07:07AM BLOOD Cortsol-25.5*
___ 07:44AM BLOOD Cortsol-29.5*
___ 06:35
ACTH - FROZEN
Test Result Reference
Range/Units
ACTH, PLASMA 21 ___ pg/mL
___ 12:40PM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:49AM BLOOD cTropnT-0.02*
___ 01:57AM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD PEP-NO MONOCLO FreeKap-1.0* FreeLam-0.9*
Fr K/L-1.1 IgG-394* IgA-18* IgM-22* IFE-NO MONOCLO
___ 00:00 VitB12 155* Folate 4
___ 12:07 Osmolal 281
MICRO:
--------
___ 10:20 am URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
___ 2:41 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Final ___: NO
GROWTH.
___ 2:42 am BLOOD CULTURE Source: Venipuncture.
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 ___ AT
0115.
GRAM POSITIVE COCCI IN CLUSTERS.
___ 9:29 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. CDT ADDED ON ___ AT 0035.
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
___ 12:45 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:20 pm BLOOD CULTURE Source: Line-cvl.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:22 pm URINE Source: ___.
URINE CULTURE (Final ___: NO GROWTH.
___ 4:02 pm CATHETER TIP-IV Source: central line.
WOUND CULTURE (Final ___: No significant growth.
___ 12:34 am BLOOD CULTURE Source: Line-right IJ.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:34 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:31 am URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
___ 05:14PM CEREBROSPINAL FLUID (CSF) TNC-99* ___
Polys-73 ___ ___ 05:14PM CEREBROSPINAL FLUID (CSF) TotProt-___*
Glucose-78
___ 5:14 pm CSF;SPINAL FLUID SOURCE: LP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 04:20PM CEREBROSPINAL FLUID (CSF) TNC-11* ___
Polys-9 ___ ___ 04:20PM CEREBROSPINAL FLUID (CSF) TotProt-255*
Glucose-108
___ 4:18 pm CSF;SPINAL FLUID Source: LP TUBE #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
IMAGING:
---------
CXR ___:
No acute cardiopulmonary abnormality. Moderate-sized hiatal
hernia.
CTA ___ AND NECK ___:
1. No acute intracranial abnormality by unenhanced ___ CT. No
hemorrhage.
2. No large vessel occlusion. Minimal narrowing, left cavernous
ICA.
Otherwise, unremarkable circle of ___.
3. 55 mL volume of elevated MTT, primarily left temporal lobe.
No evidence of
abnormal cerebral blood flow or cerebral blood volume. No
evidence of infarct
core.
4. Calcified atherosclerotic plaque causes 18% proximal right
ICA luminal
narrowing by NASCET criteria. Mild narrowing, bilateral ECA
origins.
Otherwise, widely patent cervical vertebral and carotid
arteries. No left ICA
narrowing.
5. Lytic lesions in the right clavicle and humerus, unchanged in
size,
previously FDG avid on PET-CT from ___, better
evaluated on that
study.
6. Ground-glass opacity in the superior segment, left lower
lobe, better
evaluated on same-day CTA chest.
CTA CHEST AND CT ABDOMEN ___:
1. No evidence of pulmonary embolism.
2. Fluid throughout all visualized bowel loops with diffuse
bowel wall
hyperemia, likely reflecting diffuse enteritis, likely
infectious or
inflammatory. No bowel wall thickening.
3. New ground-glass opacities within the lower lobes
bilaterally, compatible
with infection.
4. Mild bladder wall thickening anteriorly, which should be
correlated with
urinalysis for evidence of cystitis.
5. Known osseous myeloma lesions are better visualized on prior
examinations.
Soft tissue within the spinal canal at the level of L3 is
re-demonstrated, but
better evaluated on the MR ___ dated ___.
___. Large hiatal hernia.
EEG ___:
This continuous ICU monitoring study was abnormal due to 1)
attenuation and continuous focal slowing in the left hemisphere,
indicative of
focal cerebral dysfunction. 2) Generalized background slowing
suggestive of a
mild encephalopathy, non-specific in etiology, however toxic
metabolic
disturbances, infection, or medication effect are possible
causes. There were
no push button events. There were no electrographic seizures or
epileptiform
discharges.
CT ___ WITHOUT CONTRAST ___:
1. No acute intracranial abnormality.
2. Bilateral periventricular and subcortical hypodensities that
are most
likely related to chronic small vessel ischemia.
MR ___ WITHOUT CONTRAST ___:
1. No acute intracranial abnormality.
2. Chronic findings include global parenchymal volume loss and
mild changes of
chronic white matter microangiopathy.
EEG ___:
This continuous ICU monitoring study was abnormal due to: Near
continuous focal slowing in the left temporal and parasagittal
regions
suggestive of focal cerebral dysfunction. There were no push
button events.
There were no electrographic seizures or epileptiform
discharges. Compared to
the previous day there was no significant change.
CHEST X RAY ___:
Probable mild bronchitis lung bases again noted. Hazy opacity
left lung base appears slightly improved.
CXR ___:
No evidence of pneumonia or pleural effusion.
TTE ___:
The left atrial volume index is mildly increased. The inferior
vena cava diateter is normal. There is
normal left ventricular wall thickness with a normal cavity
size. There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 57 %. There is
no resting left ventricular outflow tract gradient. Tissue
Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18mmHg). 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 is mildly dilated. The aortic valve
leaflets (?#) are mildly thickened. There is
mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no
aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is moderate mitral annular
calcification. There is trivial mitral regurgitation. The
tricuspid valve leaflets appear structurally normal.
There is physiologic tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal biventricular function. Mildly thickened
aortic valve leaflets with mild
AS. Mildly thickened mitral valve leaflets with moderate MAC.
Trivial MR.
___ ___:
1. No acute intracranial abnormality. Please note MRI of the
brain is more
sensitive for the detection of acute infarct.
2. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
EEG ___:
This is an abnormal ICU EEG study because of diffuse slowing of
background with periods of diffuse voltage attenuation
indicative of moderate-
severe encephalopathy, which is nonspecific as to etiology.
Frontal rhythmic
delta activity is a nonspecific finding that can be seen with
diffuse
encephalopathies as well as structural disorders involving deep
midline
structure or increased intracranial pressure. There are no
epileptiform
discharges or electrographic changes.
CTA ___ ___:
1. No evidence of mass, hemorrhage or infarction.
2. The major arteries the ___ and neck are patent.
3. Partially imaged left lower lobe collapse. Difficult to
exclude pneumonia
in the appropriate clinical setting. Please see report for
subsequent chest
radiograph dated ___.
EEG ___:
This is an abnormal ICU EEG study because of diffuse slowing of
the background indicative of mild-moderate encephalopathy, which
is
nonspecific as to etiology. Frontal rhythmic delta activity is a
nonspecific
finding that can be seen with diffuse encephalopathies as well
as structural
disorders involving deep midline structure or increased
intracranial pressure.
There are no epileptiform discharges or electrographic changes.
Compared to
the prior day's recording, there is improvement in background.
MR ___ contrast ___:
No acute infarction or evidence of other acute intracranial
abnormalities.
EEG ___:
This is an abnormal ICU EEG study because of diffuse slowing of
background indicative of mild-moderate encephalopathy, which is
nonspecific as
to etiology. Frontal rhythmic delta activity is a nonspecific
finding that can
be seen with diffuse encephalopathies as well as structural
disorders
involving deep midline structure or increased intracranial
pressure. There are
no epileptiform discharges or electrographic changes. Compared
to the prior
day's recording, there is no significant change.
MR ___/ and ___ contrast ___:
1. Multiple T2 hyperintense, T1 hypointense enhancing lesions
throughout the
thoracic and lumbar ___ are consistent with clinical history
of multiple
myeloma. Dominant lesion in the L3 vertebral body has slightly
decreased in
size compared to prior exam with resolution of the soft tissue
component.
2. Subtle enhancement of the cauda equina nerve roots on the
left at the level
of L2 are new compared to prior exam concerning for
leptomeningeal metastatic
infiltration.
3. Multilevel degenerative disc disease in the cervical ___,
most pronounced
at C4-C5 with moderate spinal canal narrowing.
4. Multilevel degenerative disc disease in the lumbar ___,
most pronounced
at L3-L4 with moderate spinal canal narrowing and moderate right
spinal canal
narrowing.
5. Small bilateral pleural effusions with consolidations in the
dependent
portions of the lungs are consistent with worsening
pleural-parenchymal
disease.
CXR ___:
Comparison to ___. Resolution of a pre-existing
left pleural
effusion. Stable normal size of the cardiac silhouette. No
pulmonary edema,
no pneumonia, no pleural effusions. Stable correct position of
a right
internal jugular vein catheter. A previous left lower lobe
consolidation is
still visualized. The consolidation shows air inclusion and
could correspond
to the hiatal hernia, documented on the CT examination from ___.
No pleural effusions. No pulmonary edema.
MRI ___ w/ and ___ contrast ___:
1. Multiple T2 hyperintense, T1 hypointense enhancing lesions
throughout the
lumbar ___ are consistent with clinical history of multiple
myeloma, similar
compared to prior exam.
2. Increasing subtle enhancement of the cauda equina nerve roots
are
concerning for worsening leptomeningeal metastatic infiltration.
3. Moderate to severe spinal canal narrowing at L3-L4 appears
minimally
progressed.
DISCHARGE LABS:
===============
___ CBC: 2.4>10.3/30.4<93 ANC 1.26
___ Coags: ___ 11.0, PTT 31.2, INR 1.0
___ BMP: 136/3.9 | ___ | ___ < 109 Ca 9.0, Phos 4.1,
Mg 2.0
___ LFTs: ALT 15, AST 10, AlkP 82, tBili 0.6
Brief Hospital Course:
PATIENT SUMMARY:
================
___ with history of multiple myeloma c/b recent spinal lesions
s/p radiation with recent initiation of Ninlaro ___ (held on
admission), also with history of opiate/benzo use and
withdrawal, who presented to the ED on ___ with c/o nausea,
vomiting, diarrhea, AMS with aphasia in the setting of taking an
extra dose of Ninlaro. Stroke workup and EEG negative, treated
empirically for meningoencephalitis and mental status back to
baseline within 24 hours (though also in setting of holding
sedating meds). Course c/b persistent thrombocytopenia
refractory to transfusion, persistent pain requiring narcotics,
orthostatic hypotension on midodrine, and hyponatremia. Patient
had unresponsive/hypoxic/hypotensive episode on ___ required
intubation and transfer to the ICU, with ICU course c/b
intermittent hypotensive/unresponsive episodes, Afib with RVR,
and agitation. Stabilized and transferred back to the floor with
ongoing severe orthostasis and pain, now under better control.
Also found to have possible leptomeningeal involvement on MRI
___ discharged on dexamethasone.
ACUTE ISSUES:
=============
#AMS:
#Aphasia:
Per daughter, patient had been intermittently confused since
___. Patient then developed acute change in mental status in
ED, with inability to follow commands and word finding
difficulties/word salad. Given concern for stroke, code stroke
called. NIHSS 4. No evidence of hemorrhage or large territory
infarct on ___. No new abnormalities noted on MRI, and CTA
___ without significant stenosis. Neuro with low suspicion
for stroke as exam did not localize to a particular vascular
territory. EEG showed no epileptiform activity. He was started
on empiric treatment for meningoencephalitis with
vanc/ceftriaxone/acyclovir/ampicillin while awaiting LP.
Unfortunately LP could not initially be done due to
thrombocytopenia that did not improve with transfusions.
Antibiotics were discontinued on ___ after about 5 days of
treatment given low suspicion for infection. Unclear what caused
the acute change in mental status/word finding difficulties.
Potentially related to the Ninlaro, as patient reports taking
two pills instead of one, however nothing like this has been
reported in the literature. He was monitored off antibiotics. LP
was able to be done later in hospital course, which was negative
for infection. He did have further episodes of
AMS/unresponsiveness during hospitalization (see below) which
subsequently improved.
# Unresponsive episodes:
# Hypotension:
# Fever:
Starting on ___, patient had numerous unresponsive episodes.
During these, he did not respond to voice or sternal rub, SBP
was low in 60-80s and HRs were high normal. Basic labs were
checked and no clear etiology was found. There was no evidence
of infection. Differential diagnosis included primary neurologic
process such as autonomic dysreflexia secondary to spinal
radiation vs. multiple myeloma meningeal involvement vs.
metastasis to the ___. These episodes were felt to be less
likely due to drug overdose as narcan did not help, though could
have still been benzo OD given he was found to have pill bottle
in his room earlier in his course. During the first episode, the
patient was intubated due to agonal breathing and transferred to
the ICU. He was then extubated and continued to have
unresponsive episodes. EEG showed no seizures. MRI showed no
acute infarcts or evidence of prior. Infectious workup was
unremarkable. LP done by ___ on ___ was traumatic but
unrevealing. He was then transferred back to the floors. Repeat
LP by Dr. ___ ___ showed no evidence of myeloma, though
repeat MRI ___ showed increasing enhancement around the
cauda equina concerning for leptomeningeal involvement and he
was started on dexamethasone. Overall etiology of these episodes
is still unclear at this point, though the thought is that there
is an element of autonomic dysfunction secondary to prior
myeloma treatment, and now possibly and element of
leptomeningeal involvement.
#Orthostatic hypotension:
On ___ patient noted to be hypotensive to SBP 99 (from SBP
140s a few hours earlier) and on manual repeat SBP 80. HR ___,
no hypoxia, asymptomatic. Positive orthostatic vitals.
Orthostasis did not improve with IVF so unlikely due to
hypovolemia. Sepsis workup negative. No medications on list that
lead to hypotension. ___ stim negative for adrenal
insufficiency. Likely due to autonomic dysfunction in the
setting of Velcade/Ninlaro treatment. Started on midodrine 5mg
TID, which was downtitrated to 2.5mg BID given supine
hypertension.
#Multiple myeloma:
#Pancytopenia:
Pt with relapsed multiple myeloma diagnosed in ___ c/b ___
lesions s/p radiation. Recent ___ PET/CT c/f disease
progression with decision to move forward with triple therapy
with ninlaro, dexamethasone, and revlimid as part of a clinical
trial at ___ in the s/o multiple failed prior
treatments. Received first dose of Ninlaro at 8mg (initial
starting dose usually 4 mg) on ___ with plan to initiate
revlimid if well tolerated at a later date. He reported taking
an extra dose of Ninlaro prior to admission. He was noted to
have worsening pancytopenia, especially thrombocytopenia, which
was though to be due to the Ninlaro. Thrombocytopenia was
minimally responsive to transfusions, and IVIG/hydrocortisone
also had minimal effect. Counts uptrended and plateaued. Bone
marrow biopsy done ___ which showed no disease. LP was also
done on ___ due to c/f leptomeningeal involvement on MRI
___, and this also showed no evidence of myeloma on cytology
(specimen inadequate for flow). However MRI ___ did show
enhancement of cauda equina which was thought to more likely
represent leptomeningeal involvement, though could be
arachnoiditis due to radiation. He was started on dexamethasone
and will follow up with Dr. ___ Dr. ___
for further workup. He was seen by radiation oncology and they
did not feel that he was a candidate for further radiation
should this represent disease.
#DOE, improved:
Patient complaining of increased SOB on exertion since
hospitalization. Lungs clear, no peripheral edema. TTE done
earlier in the hospitalization without any e/o heart failure.
Consider deconditioning vs. symptomatic anemia vs. cardiopulm
etiology. Improved after pRBC transfusion. Continued to work
with ___ while inpatient.
#Afib with RVR, resolved:
Symptomatic AFib with RVR in the ICU without a known history
although prior EKGs have shown frequent ectopy with PVCs and
PACs. Unclear trigger without obvious signs of infection or ACS.
There was concern for autonomic dysfunction and any adrenergic
stimuli could be responsible. Reverted to sinus on diltiazem.
Remained in NSR off nodal agents.
#Hyponatremia, resolved:
Na noted to be 130 (had downtrended daily), asymptomatic. Serum
osm 269 with urine osm and urine Na elevated which would be
consistent with SIADH picture. Had been on IVF and received
boluses, so less likely hypovolemic hyponatremia. No renal
failure, diuretic use, peripheral edema or ascites. ___ stim
and TSH wnl. Placed on fluid restriction 1200cc. After he
returned to the floor from the ICU, fluid restriction lifted and
Na remained within normal range.
#Diarrhea, resolved:
#Enteritis:
#Hypokalemia:
CT scan with diffuse bowel wall hyperemia. Likely infectious vs.
inflammatory in the setting of recent medication introduction.
C.Diff negative and stool cultures negative. Symptomatic
treatment with loperamide. Also may be element of opioid
withdrawal. Resolved about a week into hospitalization.
CHRONIC ISSUES:
===============
#Chronic pain:
#Opiate use:
#Benzodiazepine use:
Patient on significant opiate regimen (oxycodone, morphine) as
outpatient with recent decrease in opiate dosing (oxycodone 10
mg TID to 5 mg TID) on ___ and history of withdrawal in the
past per daughter. On initial exam, patient with pupillary
dilation and recent complaints of diarrhea, concerning for
possible withdrawal. Patient also on significant benzodiazepine
regimen as outpatient with patient completing medications prior
to end of prescription in recent past per family members. During
this hospitalization, found to have empty Klonapin bottle and
bottle with 2 pills of ambien. Reports he last took pills 2 days
prior to being found. He continued to report severe pain while
on oxycodone 10mg TID, so his regimen was changed to oxycodone
15mg q4h prn which he was taking consistently. Klonapin was
decreased from 1mg TID to BID. Pain management intermittently
followed and then palliative care came on board to help optimize
pain regimen. He was ultimately discharged on oxycontin 20mg
q12h, oxycodone 5 mg PO q4h prn BTP, gabapentin
800mg/800mg/1200mg, cymbalta 40mg. He was also discharged on
dexamethasone for presumed cord irritation symptoms.
#Insomnia:
#Anxiety:
#Agitation:
Patient with hx of anxiety and insomnia, multiple prior psych
admissions, most recently ___, who is now complaining of
worsening insomnia and anxiety. Normally takes Ambien and
Klonapin 1mg TID at home. Tried on various regimens inpatient,
including ramelteon, zyprexa, and trazodone. Tried ambien,
however patient had episode of sleepwalking where he felt like
he was in a dream. Required Haldol for agitation in the ICU. Was
placed on Olanzapine standing and PRN with some improvement in
mood and agitation, which was d/c-ed when the above changes were
made to regimen. Psychiatry was briefly involved in medication
management.
TRANSITIONAL ISSUES:
===================
[ ] Discharged on dexamethasone 4mg PO q8h. Up- or down-titrate
as appropriate.
[ ] Will require follow-up with Dr. ___ further
workup/treatment of possible leptomeningeal involvement on MRI.
[ ] Follow-up orthostatic hypotension/autonomic dysfunction. Can
consider up-titrating midodrine (currently on 2.5mg BID) however
be mindful of supine hypertension. Can also consider addition of
fludrocort. Would likely benefit from ___ clinic
follow-up.
[ ] Given frequent PVCs, PACs, and episode of Afib in the ICU,
may consider outpatient Holter monitor.
[ ] Would benefit from follow-up with palliative care for help
with analgesic management given history of opioid use disorder
and chronic pain. The ___ care team ___ MD) is
currently working on scheduling this appointment.
[ ] Patient qualifies for home ___ and OT per inpatient team
recs.
CODE: Full
EMERGENCY CONTACT HCP: ___, daughter
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO TID
2. Doxepin HCl 100 mg PO HS
3. ClonazePAM 1 mg PO TID
4. Morphine SR (MS ___ 60 mg PO Q12H
5. Zolpidem Tartrate 12.5 mg PO QHS
6. Promethazine 25 mg PO Q6H:PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*84 Tablet Refills:*0
2. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
3. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*0
4. Bengay Cream 1 Appl TP BID:PRN knee pain
RX *menthol [Bengay Cold Therapy] 5 % Apply to painful areas
twice a day Refills:*0
5. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight hours
Disp #*90 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. DULoxetine 40 mg PO DAILY
RX *duloxetine 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Gabapentin ___ mg PO TID
Please take 800mg at 8am, 800mg at 3pm, and 1200mg at 11pm.
RX *gabapentin 800 mg ___ tablet(s) by mouth three times a day
Disp #*105 Tablet Refills:*0
11. Midodrine 2.5 mg PO BID
Please check BP in AM. If SBP > 150, please hold both daily
doses and recheck the next morning.
RX *midodrine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
12. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
14. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
15. ClonazePAM 1 mg PO BID
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp
#*20 Tablet Refills:*0
17. Promethazine 25 mg PO Q6H:PRN
RX *promethazine 25 mg 1 tablet by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
18. HELD- Doxepin HCl 100 mg PO HS This medication was held. Do
not restart Doxepin HCl until you speak with your doctor.
19. HELD- Morphine SR (MS ___ 60 mg PO Q12H This medication
was held. Do not restart Morphine SR (MS ___ until you speak
with your doctor.
20. HELD- Zolpidem Tartrate 12.5 mg PO QHS This medication was
held. Do not restart Zolpidem Tartrate until you speak with your
doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Altered mental status/aphasia
-Unresponsive episodes
-Orthostatic hypotension
SECONDARY:
-Multiple myeloma
-Pancytopenia
-Chronic pain/neuropathic pain
-Atrial fibrillation
-Agitation
-Hyponatremia
-Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were vomiting and
having diarrhea, and you were feeling more confused. You were
initially admitted to the ICU, then transferred to the floor
once you were feeling better.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-In the emergency room, you were unable to speak normally.
Imaging of your ___ was done, which did not show any stroke.
You also had an EEG which did not show any seizures. You were
given antibiotics to treat a possible infection.
-No infectious cause of your diarrhea was found. It was probably
due to the extra chemotherapy medication that you took. Your
diarrhea improved.
-Your platelets became low, so you were given a few platelet
transfusions as well as some medications to try to increase your
platelets.
-You were seen by the psychiatry team to help manage medications
for your insomnia. You were also seen by the pain management
team to help manage your pain, and you were started on
gabapentin. You were later seen by palliative care who optimized
your pain regimen.
-You had frequent episodes of low blood pressure, mostly upon
sitting or standing, so you were started on a medication
(midodrine) to help with this.
-You had an episode where you became unresponsive and your
oxygenation level was low, so you were intubated and transferred
back to the ICU. In the ICU you continued to have a few episodes
where your blood pressure dropped. You also were noted to have
an irregular and fast heart rhythm which resolved with
medications.
-You had a lumbar puncture and bone marrow biopsy which did not
show myeloma in the spinal fluid or bone marrow. However, you
had an MRI of your ___ which showed findings that could be
consistent with myeloma of the ___. You were then started on
steroids and you will need to follow up with Dr. ___ Dr.
___ for further workup.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all of your medications as prescribed.
-Have your sister check your BP every morning. If the systolic
BP is greater than 150, hold your midodrine doses for that day.
-Please attend all ___ clinic appointments.
-The inpatient physical and occupational therapy teams evaluated
you and you qualify for home physical therapy (___) and
occupational therapy (OT), which can be set up.
-If you develop sudden weakness in your legs, worsening
numbness/tingling, or you feel you cannot control your urination
or defecation, please immediately go to the ED.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
19985545-DS-27 | 19,985,545 | 29,375,845 | DS | 27 | 2144-10-14 00:00:00 | 2144-10-14 18:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of multiple myeloma, anxiety, and
orthostatic hypotension presenting with weakness,
lightheadedness, shortness of breath, decreased intake by mouth,
and weight loss.
He had 2 falls today ___ when getting up from the bed and
walking to the bathroom. He reports feeling dizzy with SOB,
denies palpitations/CP. He fell on his back denies headstrike.
He
then tried to get back up and fell again. He denies LOC.
Over the past 2 wks he had has progressive SOB. He reports that
4
wks ago he was able to walk over a block, but now is unable to
walk more than a few steps before feeling SOB. Denies any cough,
sputum production, hemoptysis, congestion. He reports that SOB
was not present during his last admission. Pt reports he sleeps
with 4 pillows but is able to lay flat w/o dyspnea, denies PND.
He also mentions that for the past 3 days he has had minimal
oral
intake due to lack of appetite. He reports 6lbs unintentional wt
loss since discharge. Denies n/v/diarrhea. Mentioned that his
appetite has been low since about ___.
Of note, was recently admitted at ___ ___ with similar
symptoms of dizziness, poor oral intake and fall. It was that
that his falls were due to orthostatic hypotension which was
treated with midodrine, compression stockings and salt tabs. It
was also thought that the medications could also be contributing
and a taper was started. He was also instructed to f/u with
___ clinic w/Dr ___ reports that his appointment
was scheduled for today ___ but he presented to the ED for
the fall.
Last saw Dr. ___ on ___ after discharge, pt reported
worsening neuropathy in setting of decreased gabapentin. At that
time it seemed that his MM did not require immediate therapy as
recent evaluation w/o clear evidence of disease.
In the ED:
- Initial vital signs were notable for: afeb, 110, 116/73, 18
95%
RA, lowest BP 81/55
- Exam notable for: oral thrush, tachycardic.
- Labs were notable for:
142 | 106 | 16 / \ 11.1 /
----------- 124 5.5 --- 111
3.9 | 22 | 1.2 \ / 31.5 \
Ca 9 | Mg 2 |Phos 2.4
___ 12 |PTT 23.1 | INR 1.1
Lactate 3.2
Blood cultures pending
- Studies performed include:
CXR, CT Head
- Patient was given:
1L IVF
- Consults: None
Vitals on transfer: 98.4 91 118/69 18 99% RA
Upon arrival to the floor, pt reports that he is hungry and
would
like a diet so that he can order food. He reports that his
symptoms are similar to his last admission but the SOB is new,
again he emphasized that he is unable to ambulate more than a
few
steps before feeling SOB. Again denies fever, chills, n/v,
diarrhea, dysuria, cough, palpitations, CP, orthopnea, PND, leg
swelling. Also mentioned that his sister, who he lives with had
a
cold last week.
Past Medical History:
Multiple myeloma s/p autologous stem cell transplant ___,
radiation
Orthostatic hypotension
Opiate withdrawal w/ substance use disorder
Depression
Gout
Social History:
___
Family History:
paternal grandmother was institutionalized.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals: 24 HR Data (last updated ___ @ 1731)
Temp: 98.1 (Tm 98.1), BP: 115/77, HR: 94, RR: 20, O2 sat:
100%, O2 delivery: Ra, Wt: 129 lb/58.51 kg
Gen: Cachectic, Lying in bed. NAD
HEENT: PERRLA, EOMI, pupils 4mm. No conjunctival pallor. No
icterus. Dry MM. No visible thrush.
NECK: JVP wnl, no hepatojugular reflux
LYMPH: No cervical or supraclav LAD
CV: Tachycardic, irregular rhythm. No MRG.
LUNGS: No incr WOB. reduced air movement B/L. No wheezes,
rales,
or rhonchi. When standing pt becomes dyspneic
ABD: ND, nl bowel sounds, NT, no HSM.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: AOx3. CN ___ intact. Full strength in upper and lower
extremities
DISCHARGE PHYSICAL EXAM:
======================
Gen: Cachectic, Lying in bed. NAD
HEENT: PERRLA, EOMI, No conjunctival pallor. No icterus. Dry MM.
No visible thrush.
NECK: JVP present about mid neck
LYMPH: No cervical or supraclav LAD
CV: regular rhythm . No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: thin,ND, nl bowel sounds, NT, no HSM.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: AOx3. CN ___ intact. Full strength in upper and lower
extremities
GU: normal appearing genitalia. Testes w/o edema or erythema. L
testicle tender, no palpable masses. Unable to appreciate
inguinal hernia. R testicle normal
Pertinent Results:
ADMISSION LABS:
==============
___ 07:35PM ALT(SGPT)-6 AST(SGOT)-7 LD(LDH)-160 ALK
PHOS-47 TOT BILI-1.3
___ 07:35PM TOT PROT-5.1* ALBUMIN-3.9 GLOBULIN-1.2*
___ 07:35PM PEP-HYPOGAMMAG Free K-1.5* Free ___ Fr
K/L-0.25* IgG-292* IgA-16* IgM-12*
___ 07:35PM D-DIMER-824*
___ 03:06PM ___ COMMENTS-GREEN TOP
___ 03:06PM LACTATE-1.4
___ 10:39AM ___ COMMENTS-GREEN TOP
___ 10:39AM LACTATE-3.2*
___ 10:32AM GLUCOSE-124* UREA N-16 CREAT-1.2 SODIUM-142
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
___ 10:32AM estGFR-Using this
___ 10:32AM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-2.0
___ 10:32AM ASA-NEG ACETMNPHN-NEG tricyclic-NEG
___ 10:32AM WBC-5.5 RBC-3.30* HGB-11.1* HCT-31.5* MCV-96
MCH-33.6* MCHC-35.2 RDW-14.3 RDWSD-48.4*
___ 10:32AM NEUTS-56.5 ___ MONOS-11.7 EOS-0.2*
BASOS-0.6 IM ___ AbsNeut-3.08 AbsLymp-1.65 AbsMono-0.64
AbsEos-0.01* AbsBaso-0.03
___ 10:32AM ___ PTT-23.1* ___
___ 10:32AM PLT COUNT-111*
DISCHARGE LABS:
===============
___ 06:40AM BLOOD WBC-2.8* RBC-2.58* Hgb-8.7* Hct-26.3*
MCV-102* MCH-33.7* MCHC-33.1 RDW-14.3 RDWSD-51.5* Plt Ct-63*
___ 06:00AM BLOOD Neuts-49.3 ___ Monos-13.0
Eos-0.5* Baso-0.5 Im ___ AbsNeut-1.02* AbsLymp-0.74*
AbsMono-0.27 AbsEos-0.01* AbsBaso-0.01
___ 06:40AM BLOOD Plt Ct-63*
___ 06:35AM BLOOD ___ PTT-UNABLE TO ___
___ 07:35PM BLOOD D-Dimer-824*
___ 06:40AM BLOOD Glucose-86 UreaN-17 Creat-0.7 Na-142
K-4.6 Cl-104 HCO3-30 AnGap-8*
___ 06:40AM BLOOD ALT-7 AST-9 LD(LDH)-156 AlkPhos-52
TotBili-0.5
___ 06:40AM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.3 Mg-2.0
___ 06:15AM BLOOD VitB12-450 Folate-13 Hapto-<10*
___ 03:20PM BLOOD calTIBC-222* Ferritn-370 TRF-171*
___ 03:40PM BLOOD %HbA1c-4.4 eAG-80
___ 06:00AM BLOOD 25VitD-21*
___ 06:00AM BLOOD Cortsol-1.6*
___ 07:35PM BLOOD PEP-HYPOGAMMAG FreeKap-1.5* FreeLam-5.9
Fr K/L-0.25* IgG-292* IgA-16* IgM-12*
___ 10:32AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 03:40PM BLOOD tTG-IgA-0
___ 10:39AM BLOOD Lactate-3.2*
___ 03:06PM BLOOD Lactate-1.4
___ 03:40PM BLOOD HVY MTL (WHLE BLD NVY/EDTA)-Test
IMAGING:
========
CXR ___: IMPRESSION: No acute intrathoracic process.
CT Head ___: IMPRESSION:1. No acute intracranial process. No
fracture.
TTE ___: EF 60-65% suboptimal study, no change obvious
change
from prior
MRI spine ___:
IMPRESSION:
1. Study is moderately degraded by motion.
2. No definite evidence of fracture.
3. Scattered myelomatous lesions are unchanged.
4. Within limits of study, no definite new or enlarging
myomatous
lesions identified.
5. Previously seen enhancement of the cauda equina nerve roots
is
less
conspicuous.
6. Grossly stable multilevel thoracic and lumbar spondylosis
compared to 3 weeks prior thoracic and lumbar spine contrast MRI
as described, again most pronounced at L3-4 where there is
mild-to-moderate vertebral canal, moderate left and severe right
neural foraminal narrowing.
7. Limited imaging of the lungs suggests bilateral scarring and
probable dependent atelectasis. If concern for lung opacities,
consider dedicated chest imaging for further evaluation.
Sniff test ___:
IMPRESSION: No evidence of diaphragmatic paralysis.
PFTS: ___
FEV1/FVC: 62%
DsbHb 83%
MIP 44%
MEP 33%
Scrotal U/S ___:
IMPRESSION:
1. Heterogeneous echotexture of the right testis without
evidence of focal
mass or abnormal vascularity. Findings may reflect sequelae of
prior injury.
2. Otherwise normal scrotal ultrasound.
MICROBIOLOGY:
=============
___ 3:40 pm Blood (LYME)
Lyme IgG (Pending):
Lyme IgM (Pending):
__________________________________________________________
___ 5:42 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:32 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ with multiple myeloma presents with progressive dyspnea,
failure to thrive, dizziness and mechanical falls after recent
hospitalization for similar symptoms.
TRANSITIONAL ISSUES:
==================
[] New Meds:
Fludrocortisone 0.1mg PO Daily for orthostatic hypotension
Naloxone Inhaler for opioid overdose
Prednisone 10mg PO daily WILL NEED TAPER ONLY GIVEN 7DAY Rx
Multivitamins with minerals daily
Vitamin D3 2000U daily
[] Stopped/Held Meds:
Dexamethasone
Midodrine
[] Discharge weight: 62 kg
[] Consider ADDRESSING POLYPHARMACY to help reduce the risk of
falls: patient on multiple psych/sedating medications as well as
opioid/pain medications
[] f/u orthostatic blood pressure and symptoms consider
uptitrating Fludrocortisone to 0.2mg daily
[] Continue to wear thigh high compression stockings
[] F/u weights for adequate oral intake, encourage fluid intake
___ daily
[] Discharge Creatinine: 0.7
[] Continue BM regimen as on chronic opioids
[] Only new medication Rx's were provided, no opioid, psych,
sleep prescriptions were provided as pt should have enough at
home after reviewing fill history and time in hospital
FOLLOW UP APPOINTMENTS:
[] F/u with urology: Dr. ___ will coordinate f/u for urinary
retention and bladder training
[] f/u with ___ clinic: Request placed for Dr. ___,
___ will f/u on HBA1c, B1, B6, ___, Ro, La, ACE, heavy metals,
tTG IgA, lyme, HIV, urine PBG, BNP
[] f/u with palliative care: Dr. ___ ___ 9am
[] f/u PCP: Dr. ___ ___ 10AM
ACTIVE ISSUES:
=============
#POLYPHARMACY:
Pt is on many medications that may be contributing to his
recurrent falls which include Clonazepam, gabapentin, oxycodone,
oxycontin, tramadol, zolpidem, and mirtazepapine. We would
highly suggest that his polypharmacy burden be reduced given
recurrent admissions.
#dyspnea: Pt with 4wk hx of dyspnea that has been progressively
worsening now he can only take a couple steps. Modified Wells
score 2.5/unlikely. CXR clear. Denies hemoptysis. On exam Tachy,
with reduced air movement. Dyspnea upon standing. CTA negative
for PE. Monitored on Tele which was NSR. PFTs were done showing
obstructive pattern with reduced MIP. Sniff test nl diaphragm
movement. Pulmonology was consulted. Dyspnea improved with IVF
and nutrition, thus it was thought to be secondary to underlying
orthostatic hypotension. This improved prior to discharge
#Falls
#Orthostatic hypotension
Pt has long hx of falls which are likely multifactorial:
orthostatic hypotension, polypharmacy (including opioids),
non-compliance with walker, and possible large fiber sensory
neuropathy. Pt with hx of orthostatic hypotension. Recently has
also had poor PO intake which may further exacerbate orthostatic
hypotension. Other possibilities include adrenal insufficiency,
POEMS syndrome, autonomic dysfunction ___ Parkinsonism (no
signs/symptoms). Was instructed to f/u with Dr ___
___ clinic. Neurology was consulted and suggested a
panel of labs for small fiber polyneuropathy, most of which are
pending, we have requested f/u with Dr. ___ will f/u on
the labs. We continued compression stockings. Stopped home
midodrine and started Fludrocortisone 0.1 mg po daily for
orthostatic hypotension in the hopes of better home compliance.
#urinary retention
#testicular pain
During admission pt had intermittent urinary retention requiring
straight catheterization. Urology was consulted, they
recommended foley placement and will f/u with him as an
outpatient for straight cath education and urodynamic testing.
MRI was done to evaluate his thoracic and lumbar spine which
revealed no change in known lesions. Pt then complained of
testicular pain, testicular U/S was reassuring and it was likely
due to tension on foley, this resolved when foley was addressed.
#Multiple Myeloma
MM studies were stable. He was admitted on dexamethasone 2mg po
daily and was transitioned to prednisone 10mg PO daily. He
continued home acyclovir, atovaquone and omeprazole.
#FFT
#severe MALNUTRITION:
Likely multifactorial given multiple chronic issues outlined
above. As well as psychosocial stressors at home. Psych was
consulted and helped to clarify medications. Palliative was
consulted as they followed him during the last admission.
Nutrition was consulted. We continued B12, folate, and MVI. GI
was consulted and suggested stool elastase and calprotectin both
remain pending. SW was consulted to help with resources.
___ (resolved): Creatine on admission was 1.2 with rehydration
decreased to 0.5, suggesting it was likely pre-renal in setting
of poor PO intake. Urine culture was negative. PO intake was
encouraged. Creatinine upon discharge was
#CHRONIC MALIGNANCY ASSOCIATED PAIN
#Opiate use
Per OMR, Management previously complicated by history of opiate
misuse. Recently transitioned from morphine to oxycodone. Stable
pain in knees and back. Has narcotic contract with ___,
however this was discontinued due to violation on ___. Has
been Rx OxyCONTIN and Oxycodone by Dr. ___ filled ___
with one month supply. Serum and urine tox screen were as
expected. No prescriptions for controlled substances were
provided on discharge. Home oxyCONTIN, oxycodone, lorazepam were
continued as inpatient. Please consider reducing opioid
medications as may contribute to fall risk. Also on discharge
was given inhaled naloxone as a precaution for opioid overdose.
#pancytopenia
#thrombocytopenia
#anemia
On arrival counts were low normal, however with IVF counts
decreased and remained low. Unclear etiology but counts were
stable. MM may be contributing however MM labs do not suggest
active disease. There was was appears to be a spurious low
platelet count to 15, upon repeat was back up to 57, HIT abs
were checked and were negative. Smear was also done, no
schistocytes were seen.
#hypophos
was repleted per scale
#Thrush
Pt reports 2 wks of stomach pain, denies odynophagia. On exam no
oral thrush. Pt may continue home nystatin as needed.
#lactic acidosis (Resolved)
Likely secondary to hypovolemia as improved with IVF
CHRONIC ISSUES:
==============
#DEPRESSION: Continued home clonazepam BID (pt reports he takes
it TID), home gabapentin, home Escitalopram and mirtaz
#insomnia: continued home ?tramadol, home zolpidem
# CODE: Presumed Full
# EMERGENCY CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Alternate HCP: ___ (son) ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Acyclovir 400 mg PO Q12H
3. Atovaquone Suspension 1500 mg PO DAILY
4. Bengay Cream 1 Appl TP BID:PRN knee pain
5. ClonazePAM 1 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Dexamethasone 2 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 600 mg PO BID
11. Gabapentin 900 mg PO QHS
12. Midodrine 5 mg PO TID
13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
14. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
16. Senna 8.6 mg PO BID
17. Nystatin Oral Suspension 10 mL PO QID:PRN thrush
18. Omeprazole 40 mg PO DAILY
19. Sodium Chloride 2 gm PO TID W/MEALS
20. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
21. TraMADol 50 mg PO QHS
22. Escitalopram Oxalate 20 mg PO DAILY
23. Mirtazapine 15 mg PO QHS
24. Zolpidem Tartrate 12.5 mg PO QHS
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily in the
morning Disp #*30 Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose
Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal spray once
Disp #*1 Spray Refills:*0
4. PredniSONE 10 mg PO DAILY
RX *prednisone 5 mg 2 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
5. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
RX *cholecalciferol (vitamin D3) 2,000 unit 1 capsule(s) by
mouth daily Disp #*30 Capsule Refills:*0
6. Acetaminophen 1000 mg PO Q8H
7. Acyclovir 400 mg PO Q12H
8. Atovaquone Suspension 1500 mg PO DAILY
9. Bengay Cream 1 Appl TP BID:PRN knee pain
10. ClonazePAM 1 mg PO BID
11. Cyanocobalamin 1000 mcg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Escitalopram Oxalate 20 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Gabapentin 900 mg PO QHS
16. Gabapentin 600 mg PO BID
17. Mirtazapine 15 mg PO QHS
18. Nystatin Oral Suspension 10 mL PO QID:PRN thrush
19. Omeprazole 40 mg PO DAILY
20. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
21. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
22. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
23. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
24. Senna 8.6 mg PO BID
25. Sodium Chloride 2 gm PO TID W/MEALS
26. TraMADol 50 mg PO QHS
27. Zolpidem Tartrate 12.5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Orthostatic hypotension
SECONDARY DIAGNOSIS:
===================
Failure to thrive
malnutrition
acute kidney injury
urinary retention
dyspnea without hypoxia
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 ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You fell, lost weight, had low blood pressure, and was short
of breath
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We gave you fluid through your IV for hydration
- We made sure you were eating 3 meals a day
- We had neurology see you they recommended some lab testing and
the results are pending, you will follow up with Dr. ___ in
the ___ clinic to follow up on those results.
- We had urology see you because you were having difficulty
urinating, we placed a foley to drain your bladder. You will
follow up with urology as an outpatient they will come up with a
plan regarding the foley
- We had our pulmonology (lung) doctors ___ for your
shortness of breath, we did imaging and testing which came back
reassuring.
- We monitored your orthostatic blood pressures and your
symptoms. Similar to prior hospital admissions your blood
pressure dropped when you stood up, when you first arrived you
would become dizzy and short of breath. This improved but you
were still orthostatic after you were hydrated and well fed.
- You complained of testicular pain we did an ultrasound which
was normal
- We had psychiatry see you to help us with your medications.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below) We
ARE VERY CONCERNED ABOUT YOUR MEDICATION LIST. There are
multiple medications that you take that may be contributing you
your recurrent falls. It would be beneficial to reduce the
amount of sedating medications that you take.
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
of falls, dizziness, or shortness of breath.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19985545-DS-29 | 19,985,545 | 23,469,336 | DS | 29 | 2145-07-21 00:00:00 | 2145-07-21 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea and subacute SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ year old M
admitted for dyspnea, n/v, and abdominal pain found to have ___,
pancytopenia and klebsiella bacteremia. His PMH is significant
for multiple myeloma s/p auto SCT in ___, afib, asthma,
depression, substance abuse in remission, orthostatic
hypotension, and other co-morbidities.
He was in his usual state of health until approximately two
weeks
prior to admission when he began to feel more SOB. This was on
exertion and began to become more prominent. No CP, leg
swelling,
fevers or chills. Notably, he has been having exertional dyspnea
episodically since approximately ___. He has seen Pulmonology
and Cardiology as well as Hem/Onc. Studies have included PFTs,
TTE, EKG, and routine imaging with no definitive cause found.
Per
Pulm, suspicion for deconditioning. Infectious workup on
admission showed pan-sensitive klebsiella bacteremia and
pseudomonas aeruginosa UTI.
Past Medical History:
[ONCOLOGIC & TREATMENT HISTORY]:
Per primary hemoncologist Dr. ___: Diagnosed with multiple
myeloma in acute renal failure in ___. He was found to be
anemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on
CT
of the abdomen. Bone marrow biopsy and aspirate on ___
showed that CD138 positive cells replaced 90% of his marrow with
abnormal plasma cells seen. Cytogenetics showed a normal male
karyotype and skeletal survey done on ___ showed
degenerative disease in the cervical and lumbar spine and a
question of a ___ versus a lytic lesion in the frontal
skull. He had an elevated serum free lambda of 1140 mg/L, beta
2
of 10, IgG of 2.3 g/dL, calcium of 10.1, creatinine of 1.18 and
albumin of 3.6. However, over the span of ___ weeks he
developed
renal failure and ultimately was admitted for plasmapheresis and
Velcade.
TREATMENT HISTORY:
--___: Cycle 1 Plasmapheresis + Velcade
Cycle 2 Velcade + Dexamethasone(severe
neuropathy)
Cycle 3 - 5 Revlimid/Dexamethasone
--___: High Dose Cytoxan for Mobilization
--___: Autologous Stem cell Transplant
--Treated on Protocol ___ vaccination with DC/Tumor fusion
vaccine in patients with multiple myeloma
--___: Completed ___ fusion vaccines
--___: Found modest rise in paraprotein. Started on Revlimid
but tolerated poorly due to nausea and loose stools and
ultimately stopped in ___.
--Slow rising paraprotien over the following year
--___: Started on Protocol ___ A Phase I multicenter,
open label, dose-escalation to determine the maximum tolerated
dose for the combination of Pomalidamide, Velcade and low dose
dexamethasone in subject with relapsed or refractory multiple
myeloma.
--Lost to follow up for one year, re-presented in ___ with
a rising light chain. M protein was found to be 780 with a max
of 1110 and a free light chain of 270. His free lambda did rise
to as high as 447 in ___ prior to initiating treatment.
--___: Placed back on pomalidomide at 4 mg daily;
decreased to 2mg due to cytopenias.
--___: Found to have a small rise in his light chain,
and SPEP revealed a monoclonal protein of 910 and a free light
chain of 293. Reinitiated treatment with Velcade and
dexamethasone and increased the pomalidomide to 3 mg daily.
--Received four cycles of Velcade, pomalidomide and
dexamethasone with great disease control, then placed on
pomalidomide maintenance for close to ___ years. Dose was
decreased from 3mg to 2mg ___ due to fatigue and
nausea.
--___: Presented with right sacral pain unrelieved by
Tylenol. Pelvic and lumbar sacral MRI obtained. Clear
progression of disease including L3 and L5 lesions.
--___: Daratumumab added to current pomalidomide
treatment.
--Treatment plan: Daratumumab 16 mg/kg weekly for 8 weeks
Pomalidomide 2 mg p.o. daily for 21 out of 28
days will increase to 3 mg next cycle
Dexamethasone 20 mg p.o. day of and day
following Daratumumab
___: Week 2 ___
___: Week 3 ___
___: Week 4 ___
___: Week 5 ___
___: Week 6 ___
___: Week 7 ___
___: Week 8 ___ (Dexamethasone decreased to 10
mg on day of ___ and ___ 4 mg on following 2 days)
___: Treatment held and admitted for respiratory work up
___: Started Daratumumab/Dexamethasone alone
___: T7-T8 lesions. RT therapy started
___: Retuned to Daratumumab Monthly
___: Pet shows progression of disease. RT to L spine and
femur
___: started Ninlaro/Dex but accidently took two Ninlaro
pills in two subsequent days. Admitted for MS changes.
___: PET CT shows interval resolution uptake in the
bones,
now demonstrating background uptake. No new suspicious uptake.
___ 2. Mild uptake along the thoracic esophagus, likely
representing mild esophagitis secondary to hiatal hernia.
Problems (Last Verified ___ by ___:
*S/P AUTOLOGOUS STEM CELL TRANSPLANT
ACUTE RENAL FAILURE
AUTO HPC, APHERESIS INFUSION
GOUT
MULTIPLE MYELOMA
STEM CELL COLLECTION
STUDY ___
THERAPUTIC PLASMAPHERESIS
MULTIPLE MYELOMA
DEPRESSION
ADVANCE CARE PLANNING
BACK PAIN
ASTHMA
NARCOTICS AGREEMENT
DYSPNEA
Social History:
___
Family History:
paternal grandmother was institutionalized.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
============================
General: Sitting upright, in no acute distress
Skin: No obvious rashes/lesions, pale
HENT: Normocephalic, atraumatic. Oropharynx clear with moist
mucous membranes, no lesions
Eyes: Extraocular movements intact, non-injected, no scleral
icterus.
Lymph: No palpable cervical, submandibular, or supraclavicular
lymphadenopathy.
CV: Regular rate and rhythm, S1, S2, systolic murmur noted, no
audible rubs, ___
Resp: CTAB with diminishment in bases, no inc WOB
Abd: Bowel sounds present, soft, nondistended. Tender in RUQ and
LUQ to deep palpation. No palpable hepatosplenomegaly
Extremities: Warm, without edema
Neuro: Grossly normal, moving all limbs
Psych: Alert & oriented to conversation, euthymic, appropriately
conversant
ECOG performance status: 2
DISCHARGE PHYSICAL EXAMINATION
===================================
24 HR Data (last updated ___ @ 1114)
Temp: 97.8 (Tm 98.4), BP: 144/81 (134-175/69-91), HR: 60
(55-73), RR: 20 (___), O2 sat: 98% (97-98), O2 delivery: RA,
Wt: 161.4 lb/73.21 kg
GEN: A&Ox3, NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular
lymphadenopathy.
CV: Irregularly irregular sometimes but currently in sinus
bradycardia. No murmurs, rubs or gallops
PULM: non-labored, fine crackles at bases. No rhonchi or
wheezing
ABD: BS+, soft, NT/ND, no masses or hepatosplenomegaly. No
rebound or guarding.
MUSC: No edema or tremors
SKIN: Dry. Pink papules with concave yellow center noted on
right
chest. No other lesions
ACCESS: PIV C/D/I
Pertinent Results:
ADMISSION LABS
======================
___ 08:54PM URINE HOURS-RANDOM TOT PROT-9
___ 08:54PM URINE U-PEP-ALBUMIN IS
___ 08:54PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:54PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG*
___ 08:54PM URINE RBC-1 WBC-33* BACTERIA-FEW* YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 07:11PM LIPASE-31
___ 07:11PM TOT PROT-6.3*
___ 07:11PM PEP-ABNORMAL B Free K-19.4 Free L-76.7* Fr
K/L-0.25* b2micro-6.5*
___ 10:58AM cTropnT-<0.01
___ 07:55AM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 07:52AM ___ PTT-34.2 ___
___ 07:52AM D-DIMER-871*
___ 07:29AM GLUCOSE-83 UREA N-24* CREAT-1.8* SODIUM-136
POTASSIUM-3.4* CHLORIDE-101 TOTAL CO2-20* ANION GAP-15
___ 07:29AM estGFR-Using this
___ 07:29AM ALT(SGPT)-14 AST(SGOT)-29 ALK PHOS-70 TOT
BILI-0.5
___ 07:29AM LIPASE-17
___ 07:29AM proBNP-670*
___ 07:29AM cTropnT-<0.01
___ 07:29AM ALBUMIN-3.8 CALCIUM-8.0* PHOSPHATE-3.4
MAGNESIUM-1.8
___ 07:29AM WBC-1.4* RBC-3.12* HGB-10.0* HCT-29.8* MCV-96
MCH-32.1* MCHC-33.6 RDW-14.2 RDWSD-49.2*
___ 07:29AM NEUTS-32.4* ___ MONOS-33.1* EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-0.45* AbsLymp-0.47* AbsMono-0.46
AbsEos-0.00* AbsBaso-0.00*
___ 07:29AM PLT COUNT-58*
IMAGING STUDIES
============================
___ CT abd/pelv
IMPRESSION:
No acute intra-abdominal pathology to account for patient's
symptoms, within the limitations of this unenhanced scan.
___ RUQ U/S
IMPRESSION:
No cholelithiasis or evidence of acute cholecystitis. No
biliary
ductal dilatation.
"Laboratory pulmonary function tests from ___ show total
lung
capacity 7.4 (107% predicted and residual volume 3.5 (138%
predicted with an RV/TLC of 130% predicted. Slow vital capacity
is 88% predicted and forced vital capacity is 3.96 (91%
predicted). FEV1 to vital capacity ratio is 74% (99% predicted).
Diffusing capacity is 16.8 (66% predicted) DL divided by
alveolar
volume is 2.9 (77% predicted)."
DISCHARGE LABS
___ 07:10AM BLOOD WBC: 2.9* RBC: 2.76* Hgb: 8.6* Hct: 27.1*
MCV: 98 MCH: 31.2 MCHC: 31.7* RDW: 15.3 RDWSD: 49.2* Plt Ct: 57*
___ 07:10AM BLOOD Neuts: 48.9 Lymphs: ___ Monos: 16.0*
Eos: 0.7* Baso: 0.7 Im ___: 3.1* AbsNeut: 1.44* AbsLymp: 0.90*
AbsMono: 0.47 AbsEos: 0.02* AbsBaso: 0.02
___ 07:10AM BLOOD Glucose: 88 UreaN: 13 Creat: 0.8 Na: 145
K: 4.2 Cl: 106 HCO3: 29 AnGap: 10
___ 07:10AM BLOOD ALT: 8 AST: 12 LD(LDH): 204 AlkPhos: 53
TotBili: 0.5
___ 07:10AM BLOOD Calcium: 8.6 Phos: 3.7 Mg: 1.9
___ 9:00 BLOOD CULTURE: KLEBSIELLA PNEUMONIAE.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CTA ___:
1. No evidence of pulmonary embolism centrally through the
segmental pulmonary
arteries. Evaluation of the subsegmental pulmonary arteries is
limited due to
timing of the contrast bolus.
2. Trace right nonhemorrhagic pleural effusion is new from
prior.
3. Stable to slightly improved diffuse bronchial wall
thickening.
4. Stable right upper lobe 4 mm pulmonary nodule.
5. Severe coronary artery and mitral annular calcifications.
6. Moderate hiatal hernia and patulous esophagus, which may
predispose to
aspiration.
bil LENIs ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CT chest ___:
No evidence of pneumonia in the present examination.
Stable right upper lobe 4 mm nodule (5:34).
Moderate bronchial wall thickening reflecting chronic
bronchitis.
Severe coronary artery atherosclerotic disease.
Severe mitral annulus calcification.
___: CT abd/pelvis
1. No acute intra-abdominal pathology to account for patient's
symptoms,
within the limitations of this unenhanced scan.
Brief Hospital Course:
ASSESSMENT AND PLAN: Mr. ___ is a ___ year old male admitted
with dyspnea, N/V/D, and abdominal pain found to have ___,
pancytopenia as well as klebsiella bacteremia and pseudomonas
UTI. His PMH is significant for MM (s/p auto SC in ___, afib,
asthma, depression, substance abuse in remission, orthostatic
hypotension, and other comorbidities.
Acute Conditions
========================
#Bacteremia (Klebsiella Pneumoniae):
#UTI (Pseudomonas Aeruginosa, initial culture < 100K):
Presented with SOB, N/V/D and abdominal discomfort. CT Torso and
CXR ___ without evidence of infection. Blood culture
(___) grew GNR. Started on cefepime while awaiting culture
data - which showed klebsiella. Additionally, UA showed 33 WBC
with culture growing pseudomonas A. Of note, patient left ___ with PIV which may have been likely source of
bacteremia
but source of UTI is unclear (imaging did not show enlarged
prostate, recent PSA ___ = 0.6). He did have urinary
symptoms
(urgency and dysuria on presentation) but since these have
resolved.
-PIV Culture No growth
-Repeat UA improved and Ucx without growth
-Cefepime (___) x7 days then transitioned to
Ciprofloxacin x7 days ___ - ___ with plan for a 14
day
course per ID
-Surveillance cultures NGTD
-ID signed off
#Multiple Myeloma:
#Pancytopenia (Improving):
Diagnosed in ___ with anemia, ___ showing CD138 cells in 90% of
marrow with abnormal plasma cells. He is status post
plasmapharesis, velcade, auto transplant, ___, and
other
therapies with his last treatment being in ___. His counts the
day of admission showed pancytopenia with neutropenia and a Cr
of
1.8. His recent numbers over the past few months when trended
(see above) showed a worsening free kappa/lambda since ___
with rising IgG. His ___ SPEP was deemed monoclonal. Given
this change, plan was to obtain PET scan to further evaluate
whether he has evidence of disease progression. Unclear if his
pancytopenia is related to progression of disease or infection
(counts improving now so presume likely infection related).
Received x1 dose of GSCF on ___. Has mild LDH elevation
which may be due to counts recovery/recent GSCF. Free Lamdba
trending up modestly. Bone marrow biopsy done ___ (results
pending).
-Continue infectious prophylaxis: acyclovir
-Transfuse if plts < 10 and/or hgb < 7
-B12 & folate normal; F/U zinc & copper
-Plan for PET scan ___ outpatient.
- follow up bone marrow bx results.
#Asthma:
#AS:
#DOE/SOB:
Improving overall since admission but persists. His SOB is
subacute, has been ongoing episodically with exertion since
approximately ___. He has had workup with cardiology,
pulmonary, and hem/Onc with PFTs, TTE, EKG, and myeloma
restaging. Overall, he has known asthma and AS; however, his
other studies do not point to a clear cause. Per Pulmonary,
concern raised for deconditioning. As suspicion for myeloma
recurrence looms, his SOB may be a constitutional symptom
reflecting brewing underlying disease. EKG and troponins are
appropriate. CXR x2 without evidence of infection. No evidence
of
clot on CTA or LENIs. Of note, patient has been recently on
apixaban (~ 2 weeks) as part of afib management but this has
been
on hold in s/o TCP.
-Consider restarting apixaban if plts remains > 50K.
-Continue supportive care
#Epigastric & Chest Pain: Largely resolved but occasionally
reports symptoms. Chest pain is sharp in intensity but does not
refer elsewhere. No worsening of SOB or hypoxia. No exacerbating
factors. Suspect GERD related. Current cardiac workup negative
(no new arrhythmias, cardiac enzymes flat and repeat chest
imaging without acute pulmonary infection). Improved with H2
blocker and continues on home PPI.
-Remains on telemetry
-Trend examination
___ (Resolved):
#Abdominal Pain (Resolved):
#N/V/D (Largely resolved):
Resolved since admission but with recrudescence of diarrhea on
___ (? due to IV ABX). On admission, BUN/Cr = ___ was
above his usual of 0.9 significantly. His bicarb is low
reflecting metabolic acidosis. Previous values from ___ show
a rising trend: Cr 0.9 on ___ and Cr 1.2 on ___. Thus,
this has been a protracted process again, consistent with
multiple myeloma. Contribution may also be from vomiting and
diarrhea; Notably, RUQ U/S and CT A/P did not reveal abnormality
so fundamental reason for his GI symptoms is unclear. ___
resolved with IVF. Overall stool studies have been unrevealing.
-Repeat stool studies if persists
-Loperamide prn
-IVF prn
-Lipase normal
#Atrial Fibrillation with RVR: History of a-fib (on metoprolol
ER
25mg). Held apixaban in setting of low plts. On telemetry and
had
been in NSR until ___ when he was in afib with rvr (rates
in
170s, no recurrence since then). He was asymptomatic and
maintaining BPs.
-Continue metoprolol
-Continue telemetry
-Holding apixaban as above
#Hypertension: Improved. SBPs ranging between 150-170s since
admission, asymptomatic. Besides BB (metoprolol) for rate
control
in s/o known afib, patient is not on anti-HTNs. Unclear
exacerbating factor at this point but will hold off on
initiating
new regimen.
-Monitor and trend BPs
#Hypophosphatemia: Suspect ___ decreased PO intake, repleting
prn
Chronic/Stable/Resolved Conditions
==========================================
#Substance Use Disorder:
#Depression:
Has had issues in the past with improper use of benzodiazepines
and opiates. Follows OSH Psychiatry and states he has been in
remission for months.
-Continue clonazepam as 1mg QID
-Continue home escitalopram
-Takes cannabinoid at home - but holding inpatient
-B12 & folate normal as above
#Lesion on Chest:
#History of Basal Cell:
Patient has lesion on chest which should be biopsied. However,
given low counts, we will hold but will likely pursue
dermatology
follow up (could be done as an outpatient).
#Orthostatic Hypotension: Continues florinef.
-Hold off on daily orthostatic VS as stable
-Held midodrine as he only takes it PRN.
Transitional Issues
========================
[ ] Bone marrow biopsy results pending
[ ] Stable right upper lobe 4 mm nodule
[ ] follow up with cardiology
[ ] consider restarting anticoagulation depending on platelet
count.
[ ]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Acyclovir 400 mg PO Q12H
3. ClonazePAM 1 mg PO BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Escitalopram Oxalate 20 mg PO DAILY
6. Fludrocortisone Acetate 0.2 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 900 mg PO QHS
9. Gabapentin 600 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. PredniSONE 10 mg PO DAILY
13. Zolpidem Tartrate ___ mg PO QHS:PRN sleep
14. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose
15. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
16. Midodrine 2.5 mg PO TID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
Continue as ordered until ___
2. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild
3. ClonazePAM 1 mg PO QID:PRN anxiety
4. Acyclovir 400 mg PO Q12H
5. Cyanocobalamin 1000 mcg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. Fludrocortisone Acetate 0.2 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 900 mg PO QHS
10. Gabapentin 600 mg PO BID
11. Midodrine 2.5 mg PO TID:PRN orthostasis
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose
14. Omeprazole 40 mg PO DAILY
15. PredniSONE 7.5 mg PO DAILY
16. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
17. Zolpidem Tartrate ___ mg PO QHS:PRN sleep
18. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until instructed to restart by your healthcare
provider (due to low platelet count).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
=====================
Klebsiella Bacteremia
Pseudomonas UTI
Dyspnea without Hypoxia
Hypertension
Secondary Diagnoses
===========================
Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted due to worsening shortness of breath, nausea,
vomiting and diarrhea. Extensive workup showed infection in your
blood and urine which were treated with IV antibiotics. You will
complete treatment for your infections with oral antibiotics,
ciprofloxacin.
Please continue to take all of your medications as prescribed.
Your appointment with Dr. ___ is as listed below. It was an
absolute pleasure taking care of you.
Sincerely,
Your ___ TEAM
Followup Instructions:
___
|
19986107-DS-20 | 19,986,107 | 27,203,962 | DS | 20 | 2171-06-29 00:00:00 | 2171-07-14 12:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LUQ pain
Major Surgical or Invasive Procedure:
___: Gel-Foam embolization of the left gastric artery.
___: Upper endoscopy
History of Present Illness:
___ PMHx for alcoholism, DM, vasculitis and a remote hx of a
rupture splenic artery pseudoaneurysm that was embolized
___ who was admitted from OSH with concerns for
hemoperitoneum. Of significance, patient was seen by the
surgical
service in ___, for an acute onset of UGI bleed, with
subsequent
findings significant for ruptured pseudoaneurysm into the lesser
sac of the stomach. CT scan back in ___ characterized two
splenic ( proximal, distal) aneurysms. The proximal
pseudoaneurysm that was ruptured was coiled. Patient did have a
prolonged hospital course, but was eventually discharged in
stable condition. Patient now states that she has been
complaining of significant " bilateral rib pain" since ___
that have progressed. She now complains of colicky sharp left
upper quadrant abdominal pain, as well as difficulty with PO
intake. She states that she hasn't passed gas for ___ days.
Denies fevers, BRBPR or UGB. She went to OSH where she was
scanned, and was found to have a three pockets of
hemoperitoneum,
perihepatic, pelvic, and near the stomach.
Past Medical History:
PAST MEDICAL HISTORY:
Autoimmune hepatitis
Vasculitis
HTN
IBS
Depression
DM
Alcoholism
Migraines
.
PAST PSYCHITATRIC HISTORY:
Pt sees a psychiatrist and a therapist
for likely depression, with possibility of mania, per patient
report. This is to be confirmed with her Psychiatrist (Dr
___ and therapist (Dr ___.
She denies ever being hospitalized for such depressions. She
states that she has contemplated suicide but has bot been really
serious about it. She has poor sleep, treated with sleeping
medicines, and feels guilty about not feeling good and letting
her family down by not taking care of herself. Her mother's
death
___ years ago, remains a source of her depression.
Social History:
SOCIAL HISTORY:
Pt is older of two children, describes happy childhood. Denies
abuse. One year of college. Works as a ___ for
the fourth grade. Married with ___ old twins and is happy that
she has coinciding holidays with them.
SUBSTANCE USE:
-Denies tobacco.
-History of ETOH abuse though claims sobriety from ETOH for past
___ years. Used -to drink 1 qt whisky qday x years; denies ___. +
blackouts,
no seizures, no severe withdrawal. History of 2 detoxes at
least, including
___ in ___.
-History of fairly heavy marijuana use x years between ages
___
-History of heavy daily cocaine use x years between ages ___
-Denies IVDU
Family History:
FAMILY PSYCHIATRIC HISTORY: Sister and Grandmother diagnosed
with
depression. Her grandmother had been hospitalized for this.
Physical Exam:
Admission Physical exam:
Vitals: Stable
General: AAOx3
Cardiac: Normal S1, S2
Respiratory: Breathing comfortably on room air
Abdomen: Soft, distended, tenderness in LUQ, mid tenderness RUQ.
No rebound or guarding. No signs of peritonitis.
Skin: No lesions
Discharge Physical Exam:
VS: 98.2, 99, 171/87, 18, 98%
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 03:15PM BLOOD Hct-29.9*
___ 03:11AM BLOOD WBC-11.2* RBC-2.88* Hgb-9.0* Hct-28.1*
MCV-98 MCH-31.3 MCHC-32.0 RDW-12.9 RDWSD-45.1 Plt ___
___ 07:22PM BLOOD WBC-11.5* RBC-2.76* Hgb-8.9* Hct-26.9*
MCV-98 MCH-32.2* MCHC-33.1 RDW-12.9 RDWSD-45.0 Plt ___
___ 05:10PM BLOOD WBC-11.7* RBC-2.72* Hgb-8.8* Hct-26.5*
MCV-97 MCH-32.4* MCHC-33.2 RDW-12.9 RDWSD-45.2 Plt ___
___ 12:50PM BLOOD WBC-12.7* RBC-2.80* Hgb-8.8* Hct-27.2*
MCV-97 MCH-31.4 MCHC-32.4 RDW-12.9 RDWSD-45.2 Plt ___
___ 11:06PM BLOOD WBC-10.3* RBC-2.55* Hgb-8.1* Hct-25.2*
MCV-99* MCH-31.8 MCHC-32.1 RDW-13.0 RDWSD-46.2 Plt ___
___ 07:44PM BLOOD WBC-11.0* RBC-2.36* Hgb-7.6* Hct-23.3*
MCV-99* MCH-32.2* MCHC-32.6 RDW-12.9 RDWSD-45.1 Plt ___
___ 02:27PM BLOOD WBC-13.3* RBC-2.66* Hgb-8.4* Hct-26.2*
MCV-99* MCH-31.6 MCHC-32.1 RDW-12.8 RDWSD-45.3 Plt ___
___ 05:26AM BLOOD WBC-9.9 RBC-2.97* Hgb-9.4* Hct-29.0*
MCV-98 MCH-31.6 MCHC-32.4 RDW-12.8 RDWSD-45.2 Plt ___
Imaging:
___ CT A/P:
1. No evidence of aneurysm, pseudoaneurysm or active
extravasation.
2. Small volume hemoperitoneum in the upper abdomen and pelvis,
little changed from the outside hospital CT performed several
hours earlier.
3. More localized fluid with surrounding stranding along the
greater curvature of the stomach, raising the possibility that
the source of bleeding is from the gastroepiploic territory.
However, an underlying lesion cannot be excluded, and an MRI is
recommended for further evaluation when clinically appropriate.
___ MESENTERIC ARTERIOGRAM:
Abnormal appearance of the left gastric artery treated with
Gel-Foam
embolization. Otherwise, normal arteriograms of the celiac,
gastroduodenal artery, gastroepiploic artery, and superior
mesenteric artery, without active extravasation.
___ MRI Abdomen:
1. Limited exam due to the artifact from splenic artery
embolization coils. Diffusion, and pre and post contrast
sequences cannot be used to assess for tumor given this
artifact. However, no obvious signal abnormality or other
finding is seen in the gastric wall on other T1 or T2 weighted
sequences.
2. Similar appearance of hematoma along the greater curvature of
the stomach, intimately associated with the gastric wall, again
raising the possibility of a gastroepiploic artery or gastric
wall vascular abnormality as the etiology of this finding.
3. Main pancreatic ductal dilation to 6 mm without extrahepatic
or
intrahepatic biliary dilation. A ___ at the ampulla or
ampullary stenosis is not excluded.
4. Bibasilar atelectasis, right greater than left.
5. 4 mm gallbladder polyp. No specific follow-up is needed for
this finding.
Brief Hospital Course:
Ms. ___ was admitted to spontaneous hemoperitoneum with
unknown etiology. CTA did not reveal any extravasation. ___ was
consulted and an angiogram was performed. They did not see any
extravasation but noted the left gastric to be abnormal in
appearance. The left gastric was then gel-foam embolized given
it's abnormal appearance. An MRI was obtained to rule out any
gastric masses. It revealed a possibly abnormal gastric wall and
a possibly stenotic ampulla. Given these findings GI was
consulted. During this time, she was admitted to the ICU with
the following course.
Neuro: Her pain was controlled with IV and then subsequently PO
pain medication.
CV: hemodynamics were monitored closely. She was intermittently
tachycardic upon arrival which shortly resolved.
Resp: She remained stable on room air
GI: Please see above imaging and intervention course. Her diet
was advanced once her Hcts were stable.
GU: UOP was adequate with a foley in place
Heme: Serial hematocrits were obtained without need for
transfusions.
ID: no acute issues
She was stable for transfer to the floor on ___. Hematocrit
was stable and subcutaneous heparin was restarted for DVT
prophylaxis. On HD5 the patient was triggered for hypotension,
hypoxia, and downtrending hematocrit. Repeat CT of abdomen /
pelvis showed mild interval decrease in the amount of small
volume hemoperitoneum. Chest xray and cardiac enzymes were
normal. The following day the hematocrit came up on its own. GI
was consulted for endoscopic evaluation to rule out a gastric
malignancy that may have led to her bleed. on HD7, the patient
underwent an EGD, which was normal and showed no findings to
explain the bleeding.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
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:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraZODone 200 mg PO QHS:PRN insomnia
2. Verapamil 360 mg PO Q12H
3. Venlafaxine XR 150 mg PO DAILY
4. PredniSONE 7 mg PO DAILY
5. Metoclopramide 10 mg PO DAILY
6. Pramipexole 1 mg PO QHS
7. Omeprazole 20 mg PO BID
8. MethylPHENIDATE (Ritalin) 20 mg PO TID
9. NovoLIN 70/30 (insulin NPH and regular human) 8 units
subcutaneous DAILY
10. Gabapentin 1200 mg PO BID
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Fluoxetine 20 mg PO DAILY
13. Celebrex ___ mg oral BID
14. Atenolol 25 mg PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
2. NovoLIN 70/30 (insulin NPH and regular human) 8 units
subcutaneous DAILY
3. Celebrex ___ mg oral BID
4. Senna 8.6 mg PO BID
5. Atenolol 25 mg PO DAILY
6. Fluoxetine 20 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 1200 mg PO BID
9. MethylPHENIDATE (Ritalin) 20 mg PO TID
10. Metoclopramide 10 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Pramipexole 1 mg PO QHS
13. PredniSONE 7 mg PO DAILY
14. TraZODone 200 mg PO QHS:PRN insomnia
15. Venlafaxine XR 150 mg PO DAILY
16. Verapamil 360 mg PO Q12H
17. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
18. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoperitoneum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to ___ with complaints of abdominal pain
and CT imaging concerning for blood in your peritoneum but did
not show any active bleeding. You were admitted for close
monitoring for any sign of continued bleeding. Your hematocrit
and vital signs have been stable and you did not require any
blood transfusions or interventional procedure to stop the
bleeding. The Gastroenterology doctors were ___, and they
performed an endoscopic exam of your stomach, which showed no
findings on EGD to explain the bleeding. You are now tolerating
a regular diet and your pain is improved. You are ready to be
discharged home to continue your recovery. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
19986183-DS-12 | 19,986,183 | 28,820,683 | DS | 12 | 2193-08-12 00:00:00 | 2193-08-22 08:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / pseudoephedrine
Attending: ___
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with past medical history
notable for Type 1 DM and NHL who presented with hyperglycemia
in
the setting of taking steroids.
Patient states it all began ~ 2 weeks prior to admission where
she noticed LLE>RLE. She was sent to ___ where significant
workup
was done to rule out PE (with CTA and LENIs). It was concluded
she had no clot, however she was found to have worsening of her
Non-Hodgkin's lymphoma.
Her oncologist prescribed dexamethasone for 4 days which she
started taking 2 days prior to admission (with plan for
initiation of rituximab in 1 week - ___. Both patient and
providers were aware of hyperglycemia and thus she was closely
monitoring her sugars. Of note patient is very knowledgeable
about her sugars and diabetes management. She uses an insulin
pump with Humalog and noticed elevated sugars as expected.
However when sugars started being uncontrolled and instructions
by phone from ___ did not resolve them (with basal insulin
adjustment), she presented to the emergency room.
She denies any symptoms except a cough for the past month. She
denies dizziness, increased urinary frequency, chest pain,
N/v/Diarrhea
In the ED
- Initial vitals: 96.6 74 110/66 16 100% on RA
- Labs:
+ WBC 13.4 Hgb 10.8 Plt 267
+ Na 123, K 6.5 (hemolyzed) creatinine 1.2
- Imaging: Cxray with no findings
- Patient was given ceftriaxone for a question of UTI and
regular
insulin 10units, followed by 8 units humalog
Transfer vitals HR 77 BP 126/93 RR 16 98% on RA. Patient's ___ on
arrival to the floor is ~ 180
Past Medical History:
- Type I DM (on insulin pump)
- Non-Hodgkin's Lymphoma (diagnosed ___ and never treated)
- Hyperlipidemia
- Hypertension
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission physical exam:
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, oral
mucosa is dry
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. Insulin pump attached to RLQ - area is
clean with no erythema
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, 2+ BLE with LLE>RLE
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 physical exam:
___ 0818 Temp: 98.5 PO BP: 107/58 HR: 93 RR: 18 O2 sat: 99%
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, oral
mucosa is dry
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. Insulin pump attached to RLQ - area is
clean with no erythema
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, 3+ BLE with LLE>RLE
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
Pertinent Results:
Admission labs
===============
___ 04:17AM BLOOD WBC-13.4* RBC-4.03 Hgb-10.8* Hct-32.6*
MCV-81* MCH-26.8 MCHC-33.1 RDW-13.8 RDWSD-40.4 Plt ___
___ 04:17AM BLOOD Glucose-441* UreaN-45* Creat-1.2* Na-123*
K-6.5* Cl-87* HCO3-19* AnGap-17
___ 04:17AM BLOOD Calcium-12.2* Phos-4.6* Mg-1.6
___ 05:55AM BLOOD 25VitD-10*
___ 06:42AM BLOOD PTH-20
___ 05:55AM BLOOD PEP-NO MONOCLO IgG-628* IgA-90 IgM-31*
IFE-NO MONOCLO
Discharge labs
================
___ 05:55AM BLOOD WBC-6.6 RBC-3.93 Hgb-10.6* Hct-31.8*
MCV-81* MCH-27.0 MCHC-33.3 RDW-14.2 RDWSD-41.3 Plt ___
___ 05:55AM BLOOD Glucose-60* UreaN-37* Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-23 AnGap-14
___ 05:55AM BLOOD TotProt-4.8* Albumin-2.9* Globuln-1.9*
Calcium-12.4* Phos-4.3 Mg-1.8
___ 04:31AM BLOOD Lactate-2.1* K-4.2
Brief Hospital Course:
Ms. ___ is a ___ female with past medical history
notable for Type 1 DM and NHL who presented with hyperglycemia
in the setting of taking steroids.
ACUTE/ACTIVE PROBLEMS:
# Hyperglycemia:
# Type 1 DM: Patient with Type I DM and presenting with elevated
sugars in the setting of taking dexamethasone for treatment of
advancing NHL. No evidence of DKA currently. Patient uses an
insulin pump and very experienced with its use, and given
ability to manage her own sugars with well controlled numbers we
continued to use the pump with her direction and ___ support.
No evidence of infection. No chest pain/cardiac symptoms.
# Hyponatremia: Resolved/ likely in the setting of high sugars.
Na was 123 on admission but corrected for sugars was ~130.
Discharge Na was 140
# Hypercalcemia: Currently asymptomatic and stable. We reviewed
___ records where her last calcium in ___ was ~10.1. This is
likely new in the setting of malignancy. In order not to anchor
on that, work up done to rule out other etiologies (workup
pending at the time of discharge): PTH, Vitamin D, SPEP and UPEP
given trace anemia. Patient educated to avoid factors that can
aggravate hypercalcemia, including thiazide diuretics, volume
depletion (to drink ___ glasses of water daily given risk of
dehydration in the setting of diabetes, avoid high calcium diet
(>1000 mg/day).
# Leukocytosis: Resolved. No evidence of infection despite
intermittent cough for ~ 1 month (patient states was treated for
Pneumonia ~ 1 month ago). Leukocytosis likely due to steroids.
# NHL: Significantly advanced per patient report and CT image
records patient presented. LLE>RLE worked up and DVT ruled out
at ___ ~ 2 weeks earlier with suspicion for malignancy as
etiology.
TRANSITIONAL ISSUES
======================
- F/u on workup sent for hypercalcemia
- Continue to monitor calcium as outpatient and ensure it is
mild or moderate
>30 minutes spent on discharge planning and coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 4 mg PO DAILY
2. Probiotic (B. coagulans) (Bacillus coagulans) 10 billion cell
oral DAILY
3. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
4. Simvastatin 20 mg PO QPM
5. Aspirin EC 81 mg PO DAILY
Discharge Medications:
1. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
2. Aspirin EC 81 mg PO DAILY
3. Probiotic (B. coagulans) (Bacillus coagulans) 10 billion
cell oral DAILY
4. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia
Hypercalcemia
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Miss ___,
___ were admitted due to uncontrolled sugar in the setting of
taking steroids. ___ improved significantly managing your sugars
with your insulin pump. Please DO NOT take anymore steroids and
follow up with your doctor.
Your calcium levels were also found to be moderately elevated.
___ had no symptoms and ___ were also hydrated significantly in
the hospital. We sent labs to understand what caused this (which
were pending by discharge) though we also suspect the Lymphoma
could be the cause.
Please follow up with your doctor to ensure your calcium levels
are rechecked.
It was a pleasure being part of your team
Your ___ team
Followup Instructions:
___
|
19986230-DS-16 | 19,986,230 | 21,266,234 | DS | 16 | 2188-12-16 00:00:00 | 2188-12-18 22:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Oxycodone / Naprosyn
Attending: ___.
Chief Complaint:
L flank pain
Major Surgical or Invasive Procedure:
cystoscopy, L ureteral stent
History of Present Illness:
This is a ___ year old female who
presents with right lower quadrant pain. She reports sudden
onset
of RLQ pain starting 2 days ago that radiated to her right
flank.
This was associated with nausea, emesis x1, and chills. Denies
dysuria, hematuria, fevers. She denies history of
nephrolithiasis.
Past Medical History:
PGynHx: No abl paps, regular menses until ___, no STIs
PObHx: G5P4, 1 TAB
PMH: Reported no current medical issues, though in reports found
notes re. ___ right breast granular cell tumor found on bx but
no f/u from pt. Also h/o back pain.
PSH:
___ - laparoscopically assisted vaginal hysterectomy with
cystoscopy
___: Operative hysteroscopy with myomectomy and endometrial
ablation with rollerball
___: R breast bx
Social History:
___
Family History:
FamHx: no breast, gyn, colon malignancy. + fam history of
fibroids.
Physical Exam:
On discharge:
NAD
No cardiopulmonary distress
Abd soft nt nd
Pertinent Results:
___ 06:15AM BLOOD WBC-7.4 RBC-4.35 Hgb-11.8 Hct-37.8 MCV-87
MCH-27.1 MCHC-31.2* RDW-15.6* RDWSD-49.5* Plt Ct-94*
___ 06:15AM BLOOD Glucose-110* UreaN-11 Creat-1.1 Na-142
K-3.8 Cl-108 HCO3-21* AnGap-13
Brief Hospital Course:
This is a ___ yF who presented with obstructive uropathy and SIRS
(fevers, leukocytosis) due to a L ureteral calculus. She
underwent a cystoscopy, R ureteral stent placement by Dr. ___
on ___.
Post-operatively, the patient's hospitalization stay involved
treating septicemia (Proteus, pan-sensitive) that grew in her
blood on presentation. She stayed until ___ when she
de-effervesced. Her Foley was removed prior to discharge. When
it was demonstrated that she was afebrile x 24 hours on oral
therapy and voiding without issues, she was discharged on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Ibuprofen 600 mg PO Q8H:PRN pain/fever
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*22 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*1
6. TraMADol 50-100 mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
7. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis secondary to obstructed ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take antibiotic as prescribed for 11 days.
Drink 8 or more glasses of water daily.
Go to emergency room if you develop any of the following:
fevers
nausea/vomiting leading to inability to tolerate fluids
worsening pain
persistent shakes and chills
The urology office phone number is ___. Call office on
___ to confirm your surgery date.
Followup Instructions:
___
|
19986309-DS-19 | 19,986,309 | 21,193,364 | DS | 19 | 2117-06-01 00:00:00 | 2117-06-01 15:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left sided weakness and tingling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ yo right handed man with a history
of metastatic SCLC with solitary left cerebellar brain met s/p
gamma knife radiosurgery in ___ (gets care at ___) who
presents with transient left arm weakness, as well as abnormal
sensation in his face.
The day of presentation he tried to pick up a glass of juice
with his left hand at around 6:30 pm but found he was unable. He
could reach to the glass and wrap his fingers around it, but
couldn't bring it to his mouth. He denies having shaking in his
arm. At the same time his left face began to "feel funny" like a
swollen numb feeling. The arm was weak for ___ minutes. The left
face was numb for ~7 minutes. Then, the sensation he had on his
left face moved to his right face. He walked to the kitchen and
told his daughter about his symptoms, who called an ambulance.
He was taken to ___ where ___ was read as having a SAH
vs. laminar necrosis with edema in the right parietal cortex. He
was transferred to ___ for neurology evaluation. He denied
trouble talking or walking. He doesn't know if his face was
drooping. This morning, he feels back to normal apart from a
mild headache, though this is similar to his chronic headaches
which are a pressure like sensation in his forehead bilaterally.
He gets care at ___ for "brain cancer and lung cancer". He's
had radiation treatment for the brain cancer. He doesn't know
what type of cancer it is, but denies it being a metastasis from
his lung cancer. He says he was treated for his cancer ___ years
ago and he's been told he is currently cancer free.
Review of Systems: + for recent cough w/ SOB, chronic dizziness,
chronic memory problems, and headache;
The pt denies loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, tinnitus or new hearing
difficulty. Denies difficulties producing or comprehending
speech. No bowel or bladder incontinence or retention. Denies
new difficulty with gait. The pt denies recent fever or chills.
Denies chest pain or palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies rash.
Past Medical History:
-metastatic small cell lung cancer diagnosed ___ - s/p chemo
and radiation (___, metastatic to L1, adrenal
gland, and brain
-solitary brain met to left cerebellum s/p gamma knife
radiosurgery ___
-diabetes
-HLD
-hypothyroidism
-HTN
Social History:
___
Family History:
history of cancer in family
Physical Exam:
Admission Exam:
Vitals: 97.1 69 136/77 15 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: breathing comfortably on RA
CV: RRR
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
Neuro:
-Mental Status: Awake, not oriented to ___ but knows he's in a
hospital. Has difficulty relating details of his medical
history.
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. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Inattentive, unable to name ___ backward (stuck at
___. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: in light: left pupil 3.5->2.5, right 2.5->1.5mm; pupillary
asymmetry is more pronounced in the dark. VFF to confrontation
with finger counting.
III, IV, VI: EOMI without nystagmus. slightly smaller palpebral
fissure on right
V: Facial sensation intact to light touch and pin in all
distributions
VII: Subtle decreased activation of left lower face with
flattening of the NLF.
VIII: hard of hearing.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: Normal bulk throughout. No pronator drift bilaterally.
No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
___ Tri ___ Pat Ach
L 1 tr tr 1+ 0
R 1 tr tr 1+ 0
- Toes were downgoing bilaterally.
-Sensory: left arm and leg with 50% pinprick sensation compared
to right. Decreased temperature sensation in left arm.
Temperature gradient in the legs. Vibration absent in the feet.
-Coordination: ?subtle dysmetria on FNF bilaterally. Rapid
alternating movements are slower on the left.
-Gait: Good initiation. Narrow-based, normal stride, appears
mildly unsteady. Romberg absent but with subjective
unsteadiness.
Discharge Exam:
Vitals: 97.9 155/95 66 17 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: breathing comfortably on RA
CV: RRR
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
Neuro:
-Mental Status: Awake, initially not oriented to date, but
recalled that it was
___ and ___ is fluent with
intact repetition and comprehension. Normal prosody. Pt. was
able to name high but not low frequency objects ("pen" but not
"tip", "glasses" but not "lens"). Speech was not dysarthric.
Able to follow both midline and appendicular commands.
Inattentive, unable to name ___ backward (stuck at ___.
There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: in light: left pupil 3->2, right 2->1mm; pupillary asymmetry
is more pronounced in the dark. VFF to confrontation with finger
counting.
III, IV, VI: EOMI without nystagmus. slightly smaller palpebral
fissure on right (pseudoptosis, R eye inverse ptosis)
V: Facial sensation intact to light touch and pin in all
distributions
VII: face symmetrical with mild flattening of NLF on left
VIII: hard of hearing.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: Normal bulk throughout. No pronator drift bilaterally.
No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
___ Tri ___ Pat Ach
L 1 tr tr 1+ 0
R 1 tr tr 1+ 0
- Toes were downgoing bilaterally.
-Sensory: intact to light touch throughout
-Coordination: subtle dysmetria on FNF bilaterally with
pass-pointing.
Pertinent Results:
OSH Labs:
Na 143
K 4.6
Cl 103
Glu 90
bicarb 28
Cr 1.2
BUN 18
ALT 10
AST 17
trop <0.01
WBC 4.6
Hb 13.1
___ 12.8
INR 1.15
PTT 31.6
Admission Labs ___ @12:15am:
WBC-3.3* RBC-3.84* Hgb-12.9* Hct-38.5* MCV-100* MCH-33.6*
MCHC-33.5 RDW-12.7 RDWSD-46.8* Plt Ct-72*
Neuts-47.3 ___ Monos-10.1 Eos-1.8 Baso-0.6 Im ___
AbsNeut-1.55* AbsLymp-1.31 AbsMono-0.33 AbsEos-0.06 AbsBaso-0.02
___ PTT-30.4 ___
Glucose-92 UreaN-18 Creat-1.0 Na-139 K-4.1 Cl-103 HCO3-24
AnGap-16
Discharge Labs ___ @07:45am
WBC-3.9* RBC-3.96* Hgb-13.2* Hct-39.6* MCV-100* MCH-33.3*
MCHC-33.3 RDW-12.4 RDWSD-46.4* Plt ___
Glucose-80 UreaN-15 Creat-0.9 Na-141 K-3.7 Cl-105 HCO3-25
AnGap-15
Calcium-9.1 Phos-2.7 Mg-1.6
Images:
NCHCT ___
- ___ PRIMARY READ: ribbon-like high density in the right
parietal lobe superiorly with surrounding mild intra-axial
edema. Finding is nonspecific may be secondary to small
subarachnoid hemorrhage or possibly laminar necrosis secondary
to recent infarct in this area.
- ___ SECOND READ:
1. Right frontal subarachnoid hemorrhage.
2. Reported brain tumor not visualized on this non-contrast
enhanced study and review of prior imaging is recommended.
CTA HEAD & CTA NECK: WET READ ___
Non con head: Stable to perhaps minimal increase in right
frontal
subarachnoid hemorrhage. Otherwise no significant change from
prior.
CTA: Final read pending 3D recons. The carotid and vertebral
arteries and
their major intracranial branches are patent with no aneurysm
greater than 3mm, high-grade stenosis or other vascular
abnormality. Numerous pulmonary
nodules bilaterally. Comparison with prior imaging would be
helpful to
evaluate stability.
MR HEAD W & W/OUT CONTRAST: ___
1. Sulcal FLAIR hyperintensity and leptomeningeal enhancement
involving the right central, precentral and superior frontal
sulci. Additional focus of leptomeningeal enhancement at the
left frontal superior gyrus. Findings may represent reactive
changes secondary to subarachnoid hemorrhage versus
leptomeningeal carcinomatosis, given clinical history of lung
cancer.
Consider correlation with CSF cytology and/or follow up imaging
to
characterize the evolution of these findings.
2. Extensive bilateral cortical siderosis consistent with prior
subarachnoid hemorrhages.
3. No discrete parenchymal lesion.
CXR PA & LAT: ___
The lungs are mildly hyperinflated. The cardiomediastinal
contour is within normal limits. The heart is not enlarged.
There is a slightly prominent epicardial fat pad along the right
heart border. No consolidation, pneumothorax or pleural
effusion seen. There are moderately severe multilevel
degenerative changes in the thoracic spine.
Brief Hospital Course:
___ is an ___ yo R-handed man with a history of
metastatic SCLC (with a single cerebellar met s/p knife
radiosurgery) who presented to OSH with transient left arm
weakness, as well as left followed by right face numbness. A
___ at ___ demonstrated a right frontal convexal
subarachnoid hemorrhage, which may have prompted a seizure
leading to his transient symptoms. The etiology of his SAH is
unclear; the differential includes metastatic lesion from his
known expanding primary lung cancer (no current evidence of
MRI), amyloidosis (no evidence on MRI), AVM (no evidence on
CTA), traumatic (no history but patient poor historian),
aneurysm (not seen on CTA), or RCVS.
Upon admission to ___, all of his labs were within normal
limits; he was given Keppra 1000mg PO for seizure prophylaxis. A
CTA of the head and neck showed no aneurysms with patent carotid
and vertebral arteries. An MRI did not show any discrete masses
or evidence of amyloid. It did show sulcal FLAIR hyperintensity
and leptomeningeal enhancement involving the right central,
precentral and superior frontal sulci. Additional focus of
leptomeningeal enhancement at the left frontal superior gyrus.
This could be consistent with reactive changes secondary to SAH
versus leptomeningeal carinomatosis. The MRI also showed
evidence of extensive bilateral sidersosis from prior SAHs. He
improved over the course of his admission, and his neurological
exam was unremarkable the day after admission. He was discharged
home on 1g Keppra BID with plans to follow-up with his
oncologist at ___ for further workup regarding the etiology of
his SAH including outpatient LP once SAH resorbs and plans to
have his PCP refer him to a neurologist for outpatient titration
of Keppra.
Transitional Issues:
-Spoke with outpatient ___ on-call oncologist, Dr. ___
agreed to pursue further work-up for etiology of ___ as
outpatient
- Will need to follow-up with oncologist, Dr. ___ evidence of mass or amyloid on MRI
- Will need outpatient referral by PCP to neurologist in home
network for titration of Keppra; currently on 1g Keppra BID due
to concern for seizure
- Will need outpatient monitoring of blood pressure (goal
BP<140/90)
-CTA final read pending (wet read only)
-Numerous pulmonary nodules on CTA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 750 mg PO TID
2. Pioglitazone 15 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Pioglitazone 15 mg PO DAILY
5. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 750 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a brain bleed ("subarachnoid
hemorrhage"). There was no evidence of a new mass on your MRI.
It will be important for you to buy a blood pressure cuff and
measure your blood pressure once daily at home and keep a diary
of blood pressures. Bring this diary to your primary care
doctor. Your goal blood pressure should be less than 140 for the
top number and less than 90 for the bottom number.
We are concerned that your symptoms may have been due to a
seizure due to irritation of your brain by the blood. We have
started you on a seizure medication (Keppra); you will need to
take 1 gram twice a day.
We spoke with the on-call oncologist at the office at ___ that
follows you for your cancer. It will be very important that you
call them to make a follow-up appointment due to the growing
cancer in your lungs and for further work-up to make sure you do
not have a new mass in your brain.
It was a pleasure meeting you!
Your ___ Neurology Team
Followup Instructions:
___
|
19986341-DS-19 | 19,986,341 | 25,942,220 | DS | 19 | 2169-10-20 00:00:00 | 2169-10-20 21:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
___ with PMHx aortic stenosis s/p AVR(#23MM Magna Ease) and
coronary artery disease s/p coronary artery bypass graft x 2
(LIMA-LAD, SVG-D) ___, alcohol use disorder, T2DM, gout, HLD,
HTN, a-fib on apixiban admitted to the CCU for management of
pericardial tamponade and cardiogenic shock. He presented with 1
day of significant shortness of breath, inability to lay flat
and
extreme weakness. The patient denies any chest pain or abdominal
pain. He also has hyperglycemia and metabolic acidosis
concerning
for DKA. Bedside ultrasound showed a large pericardial effusion
with significant right ventricular collapse consistent with
pericardial tamponade. The patient received K-Centra.
In the ED,
- Initial vitals were: 96.0 100 ___ 95% 2L NC
- Labs notable for:
-H/H 12.1/41.8, WBC 15.0, plt 239
-Na 128, BUN 22, Cr 1.7, glucose 390
-___ 19.9, PTT 27.1, INR 1.8
-Trop-T < 0.01
-VBG 7.18/42
- Studies notable for:
CXR: Low lung volumes with mild retrocardiac atelectasis and
trace left pleural effusion. Possible mild pulmonary vascular
congestion without frank pulmonary edema.
- Patient was given: IV Kcentra, 1L NS
Bedside ECHO performed by cardiology fellow notable for large
pericardial effusion. Patient subsequently taken to the cath lab
for emergent pericardiocentesis.
Per procedural report, "The pericardial space was accessed from
the subxiphoid approach with echocardiographic and fluoroscopic
guidance. The initial mean pericardial pressure was 35 mm Hg
with
an amber fluid dripping back. After removal of 865 mL of dark
amber (slightly reddish brown fluid: 60+60+20 mL in syringes,
725
in vacuum bottle), the pericardial effusion was minimal on
echocardiogram with marked symptomatic improvement and closing
pericardial pressure of 3 mm Hg. The pericardial drainage
catheter was secured in place."
On arrival to the CCU, the patient feels much improved and was
sitting comfortably in bed. He denied any dizziness, LH, CP,
SOB,
abdominal pain, n/v/d, or urinary symptoms.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
Alcohol Abuse
Aortic Stenosis
Diabetes Mellitus Type II
Gout
Hyperlipidemia
Hypertension
Social History:
___
Family History:
No family history of heart disease
Physical Exam:
ADMISSION EXAM:
===============
VS: Reviewed in MetaVision
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP 10 at 60 degrees.
CARDIAC: rrr, ___ holo-systolic murmur, no g/r
CHEST: Healing sternotomy scar; mild-moderate bibasilar
crackles,
no wheeze.
ABDOMEN: NTND, bowel sounds present
EXTREMITIES: WWP, no pitting edema
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: CNII-XII intact
DISCHARGE LABS:
===============
24 HR Data (last updated ___ @ 316)
Temp: 98.0 (Tm 98.8), BP: 147/83 (123-147/62-88), HR: 97
(75-97), RR: 18, O2 sat: 96% (96-99), O2 delivery: Ra
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP 8 at 60 degrees.
CARDIAC: rrr, ___ holo-systolic murmur, no g/r
CHEST: Healing sternotomy scar; mild-moderate bibasilar
crackles,
no wheeze.
ABDOMEN: NTND, bowel sounds present
EXTREMITIES: WWP, no pitting edema
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: CNII-XII intact
Pertinent Results:
ADMISSION LABS
==============
___ 06:55PM BLOOD WBC-15.0* RBC-5.92 Hgb-12.1* Hct-41.8
MCV-71* MCH-20.4* MCHC-28.9* RDW-18.6* RDWSD-42.3 Plt ___
___ 06:55PM BLOOD Neuts-72.0* ___ Monos-4.6*
Eos-0.2* Baso-0.9 NRBC-0.2* Im ___ AbsNeut-10.78*
AbsLymp-3.18 AbsMono-0.69 AbsEos-0.03* AbsBaso-0.13*
___ 06:55PM BLOOD ___ PTT-27.1 ___
___ 06:55PM BLOOD Glucose-390* UreaN-22* Creat-1.7* Na-128*
K-7.5* Cl-95* HCO3-11* AnGap-22*
___ 01:52AM BLOOD ALT-261* AST-186* AlkPhos-76 TotBili-0.5
___ 06:55PM BLOOD cTropnT-<0.01
___ 10:01PM BLOOD Calcium-8.6 Phos-5.8* Mg-1.7
___ 07:05PM BLOOD Lactate-9.2*
DISCHARGE LABS
==============
___ 07:27AM BLOOD WBC-7.7 RBC-5.92 Hgb-12.0* Hct-40.5
MCV-68* MCH-20.3* MCHC-29.6* RDW-17.3* RDWSD-38.7 Plt ___
___ 07:27AM BLOOD Glucose-239* UreaN-19 Creat-0.9 Na-136
K-4.6 Cl-100 HCO3-22 AnGap-14
___ 06:55AM BLOOD ALT-182* AST-25 AlkPhos-102 TotBili-0.5
___ 07:27AM BLOOD Calcium-9.8 Phos-4.1 Mg-1.9
PERTINENT LABS
==============
___ 05:06AM BLOOD CK-MB-2 cTropnT-0.05*
___ 06:55PM BLOOD Beta-OH-0.2
___ 05:06AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV
Ab-POS*
___ 06:27AM BLOOD CRP-18.7*
___ 05:06AM BLOOD HCV Ab-NEG
___ 10:19PM BLOOD Lactate-5.8*
___ 02:14AM BLOOD Lactate-2.8*
___ 12:19PM BLOOD Lactate-1.3
___ 05:06AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV
Ab-POS*
___ 02:56PM BLOOD IgM HAV-NEG
___ 06:27AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 05:06AM BLOOD HCV Ab-NEG
IMAGING
=======
CXR - ___
Low lung volumes with mild retrocardiac atelectasis and trace
left pleural
effusion. Possible mild pulmonary vascular congestion without
frank pulmonary edema.
TTE - ___
EF > 60%. Well seated, normal functioning bioprosthetic AVR with
normal gradient and no aortic regurgitation. Normal left
ventricular wall thickness and biventricular cavity sizes and
regional/global systolic function. Small circumferential
pericardial effusion without echocardiographic evidence for
tamponade physiology. Compared with the prior TTE (images
reviewed) of ___ , the pericardial effusion is now
slightly larger but remains small and without echo evidence of
hemodynamic compromise.
CXR - ___
In comparison with the study of ___, following
pericardiocentesis the
cardiac silhouette is now essentially within normal limits.
Pericardial drain is in place. Blunting of the left
costophrenic angle is consistent with pleural fluid. No
evidence of appreciable vascular congestion or acute focal
pneumonia.
RUQUS - ___
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Mild splenomegaly.
3. Cholelithiasis.
Focused TTE - ___
The estimated right atrial pressure is ___ mmHg. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
The visually estimated left
ventricular ejection fraction is 60%. Normal right ventricular
cavity size with depressed free wall motion. The mitral valve
leaflets are mildly thickened. There is moderate mitral annular
calcification. Due to acoustic
shadowing, the severity of mitral regurgitation could be
UNDERestimated. There is a small posterior pericardial effusion.
The effusion is echo dense, c/w blood, inflammation or other
cellular elements. There are
no 2D or Doppler echocardiographic evidence of tamponade.
Compared with the prior TTE (images reviewed) of ___,
there is no obvious change, but the suboptimal image quality of
the studies precludes definitive comparison.
CT abdomen/pelvis without contrast - ___
1. Punctate, subpleural nodules in the right lower lobe are
nonspecific, but likely infectious versus inflammatory in
etiology.
2. Trace residual pericardial effusion with a pericardial drain
in situ.
3. Incidentally noted are multiple healing right-sided rib
fractures.
TTE - ___
Small posterior loculated pericardial effusion without
tampoande.
Compared with the prior TTE ___ , small posterior
effusion not echolucent. Appears slightly larger (see apical 4
and apical long axis views).
MICRO
=====
PERICARDIAL FUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
PATH
====
Pericardial fluid - ___: NEGATIVE FOR MALIGNANT CELLS.
Predominantly lymphocytes, with scattered admixed reactive
mesothelial cells.
Brief Hospital Course:
___ with PMHx aortic stenosis s/p AVR(#23MM Magna Ease) and
coronary artery disease s/p coronary artery bypass graft x 2
(LIMA-LAD, SVG-D) ___, alcohol use disorder, T2DM, gout, HLD,
HTN, a-fib on apixiban admitted to the CCU for management of
pericardial tamponade and cardiogenic shock.
ACUTE ISSUES
============
# Pericardial effusion w/ effusoconstrictive physiology
Patient presented to ED on ___ with 1-month cough and 2-day
worsening dyspnea on exertion. Bedside TTE in the ED showed
large effusion with normal global LV function and signs of RV
collapse. Had an emergent pericardiocentesis with mean
pericardial opening pressures of 35 mmHg and closing pressures
of 3 mm Hg. 875 mL of dark amber fluid was removed and a
pericardial drainage catheter was secured in place. He was
transferred to the CCU where he continued to be monitored. The
drainage catheter was removed on ___ after 24-hour
collection was <50cc. Pericardial fluid fluid cell count,
chemistry, cytology, culture was c/w post surgical/inflammatory
pericardial effusion. CRP was 18.7. Patient was started on
colchicine 0.6mg BID for 3 months (End date ___. The
patient's apixaban was held at discharge. Would consider
restarting after repeating TTE in 1 week.
#Post surgical cough
#Dysphonia
Patient has noticed a chronic cough after his CABG. Despite
being euvolemic, the patient continues to have a cough. CT Chest
was done without evidence of cause. The patient was started on
cough suppressants and had a SNIFF test given L diaphragm was
slightly elevated on CXR. This showed no evidence diaphragmatic
weakness. He was started on pantoprazole for empiric treatment
of GERD. Planned for ENT referral as an outpatient.
# Lactic acidosis
# Hypotensive shock
Pt presented with lactic acidosis to 9.2 which down-trended to
2.8; pH of 7.18 and PCO2 42, Bicarbonate of 16. Labs were
initially concerning for DKA given FBG of 390 so pt was placed
on insulin gtt which was weaned to SSI after urine ketones and
serum beta-hydroxybutyrate resulted negative. Lactic acidosis
likely in the setting of poor cadiac perfusion d/t tamponade
physiology which responded to therapeutic pericardiocentesis.
# ___
Cr baseline 0.9-1.2; peak 1.7, down-trended to 0.9. Likely
pre-renal given hypoperfusion iso tamponade. Cr on discharge 0.9
# Paroxysmal AF
Metoprolol succinate was held initially iso temponade and
hypotension. Patient had one episode of afib with RVR and was
started on metoprolol tartrate that was consolidated to
metoprolol succinate 100mg daily. Apixaban was held initially
due to concerns that the pericardial effusion was hemorrhagic.
Patient was discharged on metop succinate 100mg daily and held
apixaban 5mg BID.
# Transaminitits (improving):
on ___, ALT was 542 and AST of 187 with normal total
Bilirubin. No clear etiology; however, this coincidenced with
starting colchicine. RUQUS showed hepatic steatosis without
obstruction. Hep. B serology showed immunity due to previous
infection. Hep B viral load was pending. Hep A antibodies were
negative and Hep C antibodies were negative. Atorvastatin was
switched to Crestor 20mg. LFTs came down. On discharge, ALT was
182 and AST was 25.
#Gout Flare
Pt had gout flare in R second PIP joint on ___, was given three
days of PO prednisone 20 mg.
CHRONIC ISSUES
==============
#NIDDM
The patient was placed on insulin sliding scale while inpatient.
His home oral regimen was continued on discharged. Would
consider switching to SGLT2 for cardiovascular benefit.
- home Amaryl (glimepiride); pt not taking
- home Januvia (SITagliptin) 100 mg oral daily
- home MetFORMIN (Glucophage) 500 mg PO BID
#Aortic Stenosis s/p Aortic valve replacement
#Coronary Artery Disease s/p coronary artery bypass graft x 2
- Cont ASA 81.
- Cont Atorvastatin 40mg qHS
TRANSITIONAL ISSUES
[] repeat CRP after treatment. CRP was 18.7 while inpatient
[] Will need repeat echo in ___ weeks to ensure no
reaccumulation. Would consider restarting apixaban if stable.
[] Consider switching from glimepiride to SGLT2 given
cardiovascular benefit
[] Ensure ENT follow up for chronic cough
[] f/u HBV and HCV VL
#CODE: Full code (confirmed)
#CONTACT/HCP: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. GuaiFENesin ER 1200 mg PO Q12H
4. Ranitidine 150 mg PO DAILY
5. Senna 17.2 mg PO QHS
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
7. Apixaban 5 mg PO BID
8. Amaryl (glimepiride) 4 mg oral BID
9. Januvia (SITagliptin) 100 mg oral DAILY
10. Losartan Potassium 25 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Thiamine 100 mg PO DAILY
14. TraZODone 25 mg PO QHS:PRN insomnia
15. Furosemide 40 mg PO DAILY
16. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
2. GuaiFENesin-Dextromethorphan ___ mL PO Q6H Cough
3. Pantoprazole 40 mg PO Q24H
4. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
5. Amaryl (glimepiride) 4 mg oral BID
6. Aspirin 81 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. GuaiFENesin ER 1200 mg PO Q12H
9. Januvia (SITagliptin) 100 mg oral DAILY
10. Losartan Potassium 25 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Senna 17.2 mg PO QHS
15. Thiamine 100 mg PO DAILY
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
17. TraZODone 25 mg PO QHS:PRN insomnia
18. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until you see your cardiologist
19. HELD- Furosemide 40 mg PO DAILY Duration: 7 Days This
medication was held. Do not restart Furosemide until you are
told to by your heart doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Pericardial Effusion with tamponade physiology
SECONDARY DIAGNOSES:
====================
Atrial fibrillation
Chronic cough
transaminitis
Gout
Type 2 diabetes mellitus
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
trouble breathing.
WHAT WAS DONE IN THE HOSPITAL?
- You had an ultrasound of your heart. This showed that there
was a collection of fluid surrounding your heart.
- You had a procedure called a pericardiocentesis to remove the
extra fluid surrounding your heart.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Continue to take all your medications as prescribed.
- Make sure to follow-up with your heart doctor and primary care
doctor.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19986589-DS-25 | 19,986,589 | 27,690,011 | DS | 25 | 2192-02-21 00:00:00 | 2192-02-21 18:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ Cardiac Cath
History of Present Illness:
___ y.o. male w/ h/o CAD
w/anomalous RCA, prior NSTEMI w/BMS to anomalous RC and CABG
w/SVG to anomalous dRCA ___ and s/p PCI ___ with DES to
distal OM1 on ASA and plavix, DM2, HTN, and HLD presenting with
chest pain. He says he has been having chest pain intermittently
since discharge that he describes as sharp stabbing pains. He
has
been taking SL nitro which improved his pain except for today.
This morning the patient developed substernal CP at rest that
lasted 10 secs. At 4 ___ he developed L sided chest pressure ___
at rest that was non-radiating and worsened with talking and got
better with resting. The pain was also associated with
lightheadness and he said it felt like pressure/squeezing. He
tried NTG x3 and full-dose ASA with slight improvement. Denies
nausea, vomiting, diaphoresis, abdominal pain, SOB. Initial
reports from EMS was that the patient had ST depressions on EKG.
He was discharged to rehab ___ after undergoing PCI. He saw
his cardiologist on ___ as an outpatient at which point he
reported frequent presyncopal episodes with standing and
reported
that his blood pressure has been low. His lisinopril was
stopped
by the rehab but his symptoms continued. Dr. ___
his metoprolol and Imdur dosing.
In the ED...
- Initial vitals: 96.9F, BP 120/80, RR 16, 100% on RA
- EKG: Slight horizontal flattening of inferior leads, otherwise
not significantly changed from prior
- Labs/studies notable for: Trop neg x1
- Patient was given: SL nitro x2
- Vitals on transfer: HR 81, BP 98/59, RR 25, 95% on RA
On the floor he reports that his chest pain improved from ___
to
___ since receiving 2 SL nitro in the ED. He said the pain
never
went away completely. He received a ___ SL nitro during the
interview with ultimate resolution of chest pain. He reports
that
he was feeling lightheaded at his rehab when getting up to be
washed and reports that his SBP was as low as 74 during these
episodes. He says that once his Imdur and metoprolol doses were
reduced he noticed improvement in those symptoms.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (+)
- Hypertension (+)
- Dyslipidemia (+)
2. CARDIAC HISTORY
- CABG: ___
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal
anomalous RCA), ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Osteoarthritis
- Constipation
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
VS: 97.4F, 122/78, HR 81, RR 18, 96% on RA
GENERAL: Sitting on the edge of the bed, in no acute distress
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: pain not reproducible to palpation
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 828)
Temp: 98.6 (Tm 98.7), BP: 106/62 (103-128/62-80), HR: 84
(79-94), RR: 17 (___), O2 sat: 96% (94-100)
GENERAL: Sitting on the edge of the bed, in some pain.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: NR, RR. Nl S1, S2. No m/r/g.
CHEST: Pain not reproducible to palpation
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION/PERTINENT LABS
========================
___ 06:43PM BLOOD WBC-5.0 RBC-4.38* Hgb-13.4* Hct-40.5
MCV-93 MCH-30.6 MCHC-33.1 RDW-12.8 RDWSD-43.8 Plt ___
___ 06:35AM BLOOD WBC-3.9* RBC-4.28* Hgb-12.9* Hct-39.7*
MCV-93 MCH-30.1 MCHC-32.5 RDW-13.0 RDWSD-44.2 Plt ___
___ 06:43PM BLOOD Neuts-56.3 ___ Monos-8.5 Eos-3.0
Baso-0.6 Im ___ AbsNeut-2.83 AbsLymp-1.57 AbsMono-0.43
AbsEos-0.15 AbsBaso-0.03
___ 06:43PM BLOOD ___ PTT-26.8 ___
___ 06:35AM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-140
K-4.4 Cl-103 HCO3-25 AnGap-12
___ 06:43PM BLOOD cTropnT-<0.01
___ 12:58AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:31AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:35AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0
STUDIES
=======
Cath ___
LM: The left main coronary artery had mild plaquing.
LAD: The left anterior descending coronary artery had an ostial
30% stenosis. The mid LAD had a slightly hazy 30% stenosis
unchanged from prior angiogram. The distal LAD wrapped well
around the apex. Flow in the LAD was delayed and pulsatile,
consistent with microvascular dysfunction.
Circ: The circumflex coronary artery had a near ostial 20%
plaque. The retroflexed OM1 had an origin 40% stenosis. The mid
OM1 was angulated with some dynamic bending during systole. The
angulated OM2 had mild proximal plaquing. The AV groove CX was
retroflexed after OM2 with mild plaquing
before supplying 2 LPLs. Flow in OMs and LPLs was delayed,
consistent with microvascular dysfunction.
RCA: The right coronary artery arose anomalously adjacent to the
LMCA and had mild luminal irregularities. The proximal stent had
mild in-stent restenosis. There was competitive flow in the mid
RCA from the SVG.
SVG-RCA: The saphenous vein graft to the distal RCA had luminal
irregularities. There was antegrade perfusion into the RPDA and
retrograde perfusion into the native mid RCA.
Complications: There were no clinically significant
complications.
Findings
1. Stable native coronary atherosclerosis with patent recent OM1
stent and mild restenosis of the prior
stent in the anomalous RCA arising adjacent to the LMCA.
2. Patent SVG-distal RCA.
3. Diffuse slow pulsatile flow consistent with microvascular
dysfunction.
Brief Hospital Course:
Mr. ___ is a ___ year-old man w/ h/o CAD w/anomalous RCA, prior
NSTEMI w/BMS to anomalous RC and CABG w/SVG to anomalous dRCA
___ and s/p PCI ___ with DES to distal OM1 on ASA and
plavix, DM2, HTN, and HLD presenting with chest pain.
# CORONARIES: Patent SVG-distal RCA, patent recent OM1 stent and
mild restenosis of prior stent in anomalous RCA arising adjacent
to LMCA, diffuse slow pulsatile flow consistent with
microvascular dysfunction,
# PUMP: EF 55%
# RHYTHM: NSR
ACTIVE ISSUES
=============
# Unstable Angina
# CAD
H/o DES to OM1 last month, with remainder of vessels relatively
patent. Had decreased Imdur and Metoprolol I/s/o presyncope at
last visit with Dr. ___. Presented with multiple intermittent
episodes of CP, initially atypical and mostly stabbing, then
progressive to more of a pressure sensation, which responded to
NTG. Trops negative x3. EKGs unchanged. Started on NTG drip due
to persistent pain. Underwent cath via RRA with no evidence of
new/progressive disease and all grafts and vessels similarly
patent to prior study in ___. Increased imdur to 30mg.
Continued on ASA, Plavix, Metoprolol, Atorvastatin.
# Pre-syncope
Reports several episodes at rehab of orthostasis and pre-syncope
and reports low systolic blood pressures. His lisinopril was
discontinued but symptoms persisted. Imdur and metroprolol doses
were reduced at recent outpatient cardiology visit as above and
since then symptoms have resolved. Orthostatics here negative.
Increased imdur without recurrence in symptoms.
CHRONIC ISSUES
==============
# Type 2 diabetes
On lantus, metformin, byetta, and glipizide as an outpatient.
A1c 10.1% in ___ and since then has been started on
insulin. Continued on Lantus and ISS.
# Severe osteoarthritis of bilateral knee status post
replacement
Wheelchair bound. Continued lidocaine patches, APAP, tramadol,
gabapentin.
TRANSITIONAL ISSUES
===================
[ ] Increased Imdur due to persistent CP though most likely
small-vessel I/s/o no intervenable lesions on cath. Monitor for
presyncope/syncopal symptoms.
[ ] ___ likely continue with some CP; can take SL nitroglycerin
for pain that lasts more than a few seconds. If pain persists
despite SL nitro, should come to ED for evaluation.
[ ] Patient brought up desire for surgery for OA of knees.
Discussed that orthopedics can communicate with Dr. ___
___ regarding ___ risk evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. GlipiZIDE 10 mg PO BID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
10. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
11. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line
14. Multivitamins 1 TAB PO DAILY
15. Gabapentin 300 mg PO TID
16. melatonin 3 mg oral QHS
17. Glargine 18 Units Bedtime
18. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
19. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Glargine 18 Units Bedtime
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
7. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
8. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
9. Gabapentin 300 mg PO TID
10. GlipiZIDE 10 mg PO BID
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. melatonin 3 mg oral QHS
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line
16. Multivitamins 1 TAB PO DAILY
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. Senna 17.2 mg PO DAILY
19. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1.5 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Unstable Angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We gave you medicine to treat your chest pain.
- We did a cardiac catheterization to look at the stents and the
blood vessels in your heart, which showed no new disease.
- We changed your medications to try and reduce the frequency of
your chest pain.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19986589-DS-27 | 19,986,589 | 20,368,763 | DS | 27 | 2192-03-18 00:00:00 | 2192-03-18 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with PMH notable for CAD s/p CABG, BMS and DES
as well as DM and HTN. ___ has had four admissions since
___ with complaints of chest pain. He underwent a PCI to
OM1 with DES in ___. He
underwent angiography again on ___ which showed stable
nonobstructive CAD with evidence of diffuse microvascular
disease. At discharge ___, added amlodipine, increased
isosorbide from 15mg to 30mg and added protonix. He again
presents with c/o CP. Per EMS report, was distraught and crying
in the ambulance. He was admitted through the ED to rule out for
MI.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (+)
- Hypertension (+)
- Dyslipidemia (+)
2. CARDIAC HISTORY
- CABG: ___
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal
anomalous RCA), ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Osteoarthritis
- Constipation
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission exam:
Physical Examination:
General: chronically ill appearing man looking older than stated
age sitting up in bed in NAD
Neuro: alert and oriented w/o focal deficit, speech clear and
coherent
Cardiac: RRR, no M/R/G
Lungs: diminished bilat, breathing regular and unlabored
Abd: +BS, soft NT ND
Extremities: Warm and dry w/o edema, +2 palpable peripheral
pulses. Bilateral knees with long scars because of BKA. No
obvious swelling or tenderness to palpation.
Admission weight:109.2 kg
Discharge exam:
VS: 97.9, 112/73-118/73, HR 64-98, RR 16, 02 sat 96% RA
WEIGHT: 108.9 kg
I/O: 120/1000cc
TELEMETRY: SR 70's, no alarms per telemetry review
Physical Examination:
Gen: Patient is comfortable, in no acute distress.
HEENT: Face symmetrical, trachea midline.
Neuro: A/Ox3. Speaking in complete, coherent sentences. No face,
arm, or leg weakness.
Pulm: Breathing unlabored. Breath sounds clear bilaterally.
Cardiac: No JVD. No thrills or bruits heard on carotids
bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs,
S3, S4 or friction rubs heard.
Vasc: No edema noted in bilateral upper or lower extremities. No
pigmentation changes noted in bilateral upper or lower
extremities. Skin dry, warm. Bilateral radial, ___ pulses
palpable 2+.
Abd: Rounded, soft, non-tender.
Diagnostic studies:
CXR ___:
No focal consolidations. No pneumothorax.
Pertinent Results:
___ 07:27PM cTropnT-<0.01
___ 11:11AM cTropnT-<0.01
___ 05:00AM cTropnT-<0.01
___ 04:45AM cTropnT-<0.01 proBNP-47
___ 11:11AM GLUCOSE-165* UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
Brief Hospital Course:
Mr. ___ is an ___ gentleman with a history of coronary
artery disease status post CABG and multiple PCI's,
hypertension, hyperlipidemia, type 2 diabetes who has had
multiple admissions for chest pain in recent months. He resides
at the ___ in ___,
___ due to chronic disability and being
wheelchair-bound at this time. His last cardiac catheterization
was in ___ showing stable CAD and chest pain
thought to be secondary to micro vascular disease. On ___, he was residing at the rehab when he was anxious and upset
and reports a delay in response to complaints of chest pain. He
then called ___ himself and was brought to the emergency
department by EMS. His troponins were negative x5 with no new
EKG changes. We increased his metoprolol succinate to 50 mg
daily as his heart rate was initially in the ___, which he has
tolerated well. On day of discharge his heart rate was 60-80.
We did not increase isosorbide mononitrate due to blood
pressure; he has been running SBP 112-118. That might be a
consideration in the future if his blood pressure is higher and
he tolerates the increased dose of beta-blocker. We also
considered introducing Ranexa but felt he may benefit from
maximizing beta blockade (goal HR 60 bpm as BP tolerates) and
having his anxiety managed first and see if that helps decrease
chest pain. He had a few transient episodes of chest pain in
the setting of anxiety and in the absence of EKG changes while
admitted. He was given Ativan 0.5 mg on 2 separate occasions
which was very effective and chest pain resolved without any
further intervention. He admits to high anxiety and stress
being a trigger for his multiple episodes of chest pain
requiring hospital admission. He is anxious about his
disability, being wheelchair-bound, and needing knee surgery
which he reportedly has not been cleared to undergo. He is
willing to follow-up with his PCP and willing to trial
medication in attempt to better manage his anxiety which seems
to be consistently a trigger for these chest pain episodes. For
now, we will prescribe Ativan 0.5 mg up to twice daily for
anxiety. He was instructed not to drive while taking this
medication. (He is currently wheelchair-bound and in a long-term
care facility so this should not impact him at this time.) We
requested that the rehab make a hospital follow-up appointment
with his PCP ___ 1 week of discharge to address ongoing
anxiety and stress. We are hopeful that managing this will
decrease his episodes of chest pain. He may also benefit from
additional support services such as social work. For cardiac
medications, he will continue atorvastatin, Plavix, aspirin,
isosorbide, metoprolol succinate, amlodipine and as needed
nitro. He may benefit from an ACE given prior NSTEMI with
hypertension and diabetes, though we will not start it now given
recent reported orthostasis prior to this hospitalization and
soft BP. He has a follow-up appointment with Dr. ___ who is
his primary cardiologist in ___ and continues to be followed
by orthopedics for his ongoing knee issue. Also to note, there
was some report of pyuria prior to admission and reportedly was
ordered for Cipro at the rehab but never took it. A urine
culture done here this admission was negative for growth . He
was afebrile and had no urinary complaints and did not get any
antibiotics during this admission. He is voiding without
difficulty. We will discharge him back to rehab today via chair
car.
>30 minutes spent on discharge planning/coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Gabapentin 300 mg PO TID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Docusate Sodium 100 mg PO BID
7. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third Line
8. amLODIPine 5 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID
11. Glargine 18 Units Bedtime
12. Senna 17.2 mg PO QHS:PRN Constipation - First Line
13. Multivitamins 1 TAB PO DAILY
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
17. melatonin 3 mg oral HS
18. Clopidogrel 75 mg PO DAILY
19. Pantoprazole 40 mg PO Q24H
20. Aspirin 81 mg PO DAILY
21. Tamsulosin 0.4 mg PO QHS
22. GlipiZIDE 10 mg PO BID
Discharge Medications:
1. LORazepam 0.5 mg PO Q12H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every twelve (12) hours
Disp #*30 Tablet Refills:*0
2. 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
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. amLODIPine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID
11. Gabapentin 300 mg PO TID
12. GlipiZIDE 10 mg PO BID
13. Glargine 18 Units Bedtime
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. melatonin 3 mg oral HS
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
19. Pantoprazole 40 mg PO Q24H
20. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
21. Senna 17.2 mg PO QHS:PRN Constipation - First Line
22. Tamsulosin 0.4 mg PO QHS
23. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Chest pain, coronary microvascular disease
Discharge Condition:
See discharge summary
Discharge Instructions:
You were admitted to ___ with chest pain. You EKG and blood
work showed that you did not have a heart attack. You had a
recent cardiac catheterization in ___ during prior
admission which showed stable coronary arteries. It is felt that
you have "microvascular" disease which involves the very small
branches off the main coronary arteries. We have optimized your
medical management to treat this and attempt to prevent chest
pain. There also appears to be a component of stress/anxiety
which precipitates the chest pain episodes. You were given a
dose of Ativan during one of your episodes here at the hospital
which worked well to decrease the stress and the chest pain
resolved at that time without further intervention. We request
that you see your PCP within one week of discharge in order to
discuss medication options and perhaps start on something daily
to help decrease your baseline anxiety. If your stress/anxiety
was better managed, it may decrease your episodes of chest pain.
Meanwhile we have prescribed Ativan/Lorazepam 0.5mg by mouth to
take up to twice daily as needed for anxiety. PLEASE ONLY TAKE
WHEN NEEDED TO MANAGE ACUTE ANXIETY. YOU CAN NOT DRIVE WHILE
TAKING THIS MEDICATION.
You should continue your current medications with the following
changes:
1. Increase Metoprolol Succinate to 50mg daily
2. Start Ativan (Lorazepam) 0.5mg every 12 hours AS NEEDED for
anxiety.
If you have any urgent questions that are related to your
recovery from your hospitalization or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
You will follow-up with PCP within one week of hospital
discharge. We have asked the rehab to scheduled this appointment
and necessary transportation to and from.
You will follow-up with your cardiologist as scheduled below.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
19986589-DS-28 | 19,986,589 | 21,321,609 | DS | 28 | 2192-05-30 00:00:00 | 2192-05-31 07:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with history of CAD s/p CABG,
Type II diabetes, hypertension, and chronic knee pain, who
presents from rehab with chest pain.
Patient states at rehab he had to use the bathroom and called
for
assistance, but nobody would come to help him. He then called
___. EMS helped him to the restroom. During this interaction he
developed sudden-onset moderate chest pain, which he describes
as
a left-sided heaviness, that then radiated to the right side.
This is in the setting of coronary artery disease and is typical
for his episodes of angina. He was therefore brought to the ED.
Denies any associated shortness of breath, cough, fever,
diaphoresis, nausea, vomiting. Denies abdominal pain. Denies
dizziness or lightheadedness.
Patient states that his typical chest pain will start on the
left
side. He will often try SL nitro at this point, which most often
relieves the pain. However, at times it does not and radiates to
the right side and will become squeezing. He states that this
happened a lot in ___ and ___, but has been doing
better. He feels that it is triggered by stress.
Regarding his UTI, he notes that had he has had two urinary
tract
infections this past month. The one he is being treated for now
he did not have any symptoms, but it was found on testing.
Regarding his knee pain, he notes that he both knees hurt,
especially the left, which will buckle sometimes, causing him to
fall. This was worse after knee replacements ___ years ago. Uses
a
wheelchair. He has discussed an operation to help repair his
knees, but states that his cardiologist doesn't feel that a
surgery would be safe until can go a year without a cardiac
event.
He states that being in rehab has been very difficult. He notes
that he is there with many people who are much older than him,
and this has taken a mental toll. He has seen many things that
have made him uncomfortable and feel that the care he gets is
often very poor. He also struggles with the idea of being stuck
in a wheelchair at a rehab at such a young age.
He also reports that he used to see Dr ___, who is now at
___. Would like to see her again, previously limited by
insurance.
On review of records, patient has had around five admissions
since ___ with chest pain, and several additional ED
visits. He underwent a PCI to OM1 with DES in ___.
He underwent angiography again on ___ which showed stable
nonobstructive CAD with evidence of diffuse microvascular
disease. He most recently underwent a nuclear stress on ___
which was normal.
In the ED:
Initial vital signs were notable for: T 97, HR 95, BP 133/86, RR
20, 97% RA
Exam notable for: well-appearing on exam. He has tenderness to
palpation of the anterior chest wall. He is breathing
comfortably
on room air and lungs are clear to auscultation. Radial pulses
intact. Abdomen soft and nontender.
Labs were notable for:
- CBC: WBC 4.8, hgb 12.9, plt 354
- Lytes:
139 / 103 / 11 AGap=12
-------------- 242
4.4 \ 24 \ 0.8
- trop <0.01 x2
Studies performed include: CXR with no acute intrathoracic
process.
Patient was given:
___ 06:40 IV Ketorolac 15 mg
___ 08:02 PO/NG amLODIPine 5 mg
___ 08:02 PO/NG Clopidogrel 75 mg
___ 08:02 PO/NG Gabapentin 300 mg
___ 08:02 PO Isosorbide Mononitrate (Extended Release) 30
mg
___ 08:02 PO Metoprolol Succinate XL 25 mg
___ 08:02 PO Pantoprazole 40 mg
___ 08:03 SC Insulin 2 Units
___ 08:04 PO/NG Aspirin 81 mg
___ 08:04 PO TraMADol 75 mg
___ 15:19 PO/NG Gabapentin 300 mg
___ 17:08 SC Insulin 6 Units
___ 18:10 PO TraMADol 75 mg
Plan was initially for patient to return to rehab. However, he
declined to go with plan to go to Motel. After multiple
discussions with ___, CM, SW, plan to admit patient to medicine
for further physical therapy and discuss returning to rehab.
Patient amenable with this plan.
Vitals on transfer: T 98.3, HR 81, BP 134/70, RR 18, 95% RA
Upon arrival to the floor, patient recounts history as above. He
has no chest pain now.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (+)
- Hypertension (+)
- Dyslipidemia (+)
2. CARDIAC HISTORY
- CABG: ___
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal
anomalous RCA), ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Osteoarthritis
- Constipation
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
====================
VITALS: T 98.2, HR 79, BP 120/70, RR 18, 99% 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
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 suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities. Lower extremities with
knee pain to flexion and extension
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:
====================
GENERAL: Alert and in no apparent distress, sitting up in CHAIR
EYES: Anicteric, pupils equally round
CV: RRR no m/r/g
LUNGS: CTAB
ABD: obese, normal bowel sounds.
NEURO: Alert, oriented, face symmetric, speech fluent
PSYCH: Calm
Pertinent Results:
ADMISSION LABS:
___ 12:14AM BLOOD WBC-4.8 RBC-4.50* Hgb-12.9* Hct-40.8
MCV-91 MCH-28.7 MCHC-31.6* RDW-12.4 RDWSD-41.1 Plt ___
___ 12:14AM BLOOD Neuts-53.8 ___ Monos-7.6 Eos-3.1
Baso-1.0 Im ___ AbsNeut-2.60 AbsLymp-1.66 AbsMono-0.37
AbsEos-0.15 AbsBaso-0.05
___ 12:14AM BLOOD Glucose-242* UreaN-11 Creat-0.8 Na-139
K-4.4 Cl-103 HCO3-24 AnGap-12
___ 12:14AM BLOOD cTropnT-<0.01
___ 03:24AM BLOOD cTropnT-<0.01
___ 03:24AM BLOOD cTropnT-<0.01
======================================
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain// eval pna
COMPARISON: Chest radiograph ___
FINDINGS:
AP and lateral views of the chest.
Mid sternotomy wires are again seen and appear similarly
positioned. Low lung
volumes bilaterally, particularly on the right where there is
unstable right
hemidiaphragm elevation. No areas of focal consolidation,
pulmonary edema,
pneumothorax or pericardial effusion. Cardiac size is normal.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
Mr. ___ is a ___ male with history of CAD s/p CABG,
type II diabetes, hypertension, and chronic knee pain, who
presents from rehab with recurrent chest pain with negative
workup for acute cardiac cause, admitted as declined to return
to nursing facility. Patient was ultimately discharged to a
hotel as patient refused to return to prior SAR.
# Coronary artery disease/Microvascular coronary disease:
# Chest Pain:
# Chronic stable angina:
Patient with significant history of CAD and what is felt to be
angina from microvascular disease. Multiple troponins negative
and EKG without ischemic changes. No chest pain since arrival,
and extensive recent workup, including nuclear stress last
month. This was thought to be exacerbated by anxiety. patient
also complained of pleuritic chest pain and lightheadedness and
underwent a CT chest that was negative.
# Osteoarthritis:
# Knee pain:
Patient is unable to ambulate as knees buckle, which has
currently left him wheelchair-bound and previously in rehab.
This is reportedly due to prior failed knee surgery. Plan for
eventual surgery, though first would need to be improved from a
cardiac standpoint. Discharged with wheelchair and bedside
commode.
#UTI
-previously treated with cefpodoxime for a Klebsiella UTI,
patient unaware if he received the antibiotics as he was in
rehab. UA suggestive of infection. Culture pending at discharge.
Given Cipro for 10day course.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. LORazepam 0.5 mg PO BID:PRN anxiety
3. Clopidogrel 75 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. amLODIPine 5 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. melatonin 3 mg oral QHS
10. Tamsulosin 0.4 mg PO QHS
11. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
14. Gabapentin 300 mg PO TID
15. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
16. GlipiZIDE 10 mg PO BID
17. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
18. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second
Line
19. Cefpodoxime Proxetil 100 mg PO Q12H
20. MetFORMIN (Glucophage) 1000 mg PO BID
21. Acetaminophen 975 mg PO Q6H:PRN Pain - Mild/Fever
22. Aspirin 81 mg PO DAILY
23. Multivitamins 1 TAB PO DAILY
24. Senna 17.2 mg PO QHS
25. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
26. Mylanta 30 ml oral Q4H:PRN dyspepsia
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen [8HR Muscle Aches-Pain] 650 mg 1 tablet(s) by
mouth q8 Disp #*30 Tablet Refills:*0
3. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [Blood Glucose Test] use for blood
sugar monioring 4x dialy Disp #*200 Strip Refills:*0
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) ___ Units before BED; Disp #*3 Syringe Refills:*0
RX *blood-glucose meter [Blood Glucose Monitoring] blood sugar
monitoring 4X day Disp #*1 Kit Refills:*0
RX *lancets [BD Microtainer Lancet] 30 gauge use for glucose
monitoring Disp #*200 Each Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 81 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
7. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
RX *exenatide [Byetta] 10 mcg/0.04 mL per dose (250 mcg/mL) 2.4
mL 10 mcg twice a day Disp #*1 Syringe Refills:*0
8. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
10. GlipiZIDE 10 mg PO BID diabetes
RX *glipizide 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
11. 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
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. LORazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
14. melatonin 3 mg oral QHS
15. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin [Fortamet] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
16. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate [Kapspargo Sprinkle] 50 mg 1 capsule(s)
by mouth once a day Disp #*30 Capsule Refills:*0
17. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second
Line
18. Multivitamins 1 TAB PO DAILY
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp
#*15 Tablet Refills:*0
20. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30
Tablet Refills:*0
21. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime
Disp #*30 Capsule Refills:*0
22. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
RX *tramadol [Ultram] 50 mg 1.5 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
23.bedside Commode
Drop arm, no diagnosis: ambulatory dysfunction
physical function: good
length of need: 13 months
24.Standard Manual Wheelchair
Standard Manual Wheelchair, Seat and back cushion, Elevating
leg rests, Anti tip and brake extensions
Dx: Ambulatory dysfunction
Px: good
___ 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetes, type II
Coronary artery disease
Anxiety
Knee osteoarthritis
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:
Mr. ___,
You were admitted to the hospital for chest discomfort and
anxiety while at rehab. We made adjustments in your blood
pressure regimen to help in case the chest pain was due to heart
disease. We also adjusted your insulin regimen since you had
elevated blood sugars. You should continue your home regimen at
discharge.
Your urine studies revealed elevation in WBC concerning for a
urinary tract infection. You are prescribed 10 days of
Ciprofloxacin antibiotics.
Followup Instructions:
___
|
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