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19986589-DS-29

DS

2192-06-08 00:00:00

2192-06-08 20:06:00

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: From admitting H&P: ___ male with history of CAD s/p CABGx1 SVG-dRCA (___), BMS to anomalous RCA ___, DES to OM ___, T2DM, HTN and chronic knee pain from OA wheelchair-bound, multiple recent admissions for chest pain, who presents with chest pain. On day of admission, he reports waking up with ___ chest pain from sleep at 7 am, no shortness of breath, nausea or vomiting. He says the pain has been persistent over the day and has not improved with sublingual nitro. He does not notice any change with inspiration, position, or with exertion. Of note, he's had 6 admissions over the last 6 months for chest pain, and several additional ED visits. In ___ he presented with unstable angina and underwent DES to OM ___. On the subsequent admissions, chest pain was thought to be related to either anxiety or microvascular disease, as he's had negative troponins and no ischemic changes on EKG. 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. His recent admission was ___ to ___ with chest pain thought to be related to anxiety. After his last admission, he was discharged to a hotel rather than to a skilled nursing facility. Per the note, "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 reports that he's very anxious regarding his ability to care for himself. He feels he made a mistake by requesting discharge to hotel and he has trouble getting in and out of bed and getting to the bathroom. He has not been taking Ativan recently but he reports that the Ativan appears to help his chest pain. In the ED while he was getting an EKG, he suddenly became confused and complained of sudden onset headache. Then had weakness and inattentiveness. A code stroke called. CTA head showed no hemorrhage or large vessel occlusion. Neurology evaluated him and found no neurologic deficits, exam notable for anxiety, and treated his headache with IVF and migraine cocktail. He reports he's never had these types of symptoms before. - In the ED, initial vitals were: 97.8 90 135/71 18 96% RA - Exam was notable for: Confused, in pain, unable to state name, location, date, inattentive on the right. Weakness RUE > LUE, weakness RLE > LLE, inattentive on right, not able to follow exam commands for CN, able to wiggle toes. - Labs were notable for: trop negative x2, negative serum tox/urine tox, normal CBC, Cr, lytes, LFTs. - Studies were notable for: 4 EKG's obtained showing NSR, normal intervals, no ischemic changes - The patient was given: SL nitro x 3, ASA 325, Tylenol, prochlorperazine, 1L LR, plavix, atorvastatin 80 mg, tramadol 50 mg, insulin 4 U - cardiology was consulted, recommended admission for medication titration given his recurrent presentations to the ED for chest pain. On arrival to the cardiology service, he endorses history above. He reports constant chest pain which is ___ and unchanged from prior. He does appear comfortable and has been mostly concerned with anxiety surrounding inability to complete ADLs." Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes (+) - Hypertension (+) - Dyslipidemia (+) 2. CARDIAC HISTORY - CABGx1 SVG-dRCA (___) - BMS to anomalous RCA ___, DES to OM ___ - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY - chronic knee pain from OA wheelchair-bound - anxiety Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: On day of discharge: Vitals: 24 HR Data (last updated ___ @ 800) Temp: 98.3 (Tm 98.4), BP: 119/73 (108-143/64-89), HR: 74 (70-78), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra Weight: 113kg Weight on admission: 110.3 kg Telemetry: sinus rhythm General: Well appearing, no apparent distress HEENT: Normocephalic, atraumatic. EOMI. Neck: Supple, trachea midline. Lungs: Decreased breath sounds throughout, but otherwise clear to auscultation bilaterally in all lung fields. CV: RRR. Normal S1, S2. No murmurs, rubs or gallops. Abdomen: Bowel sounds present throughout. Nontender to palpation in 4 quadrants. Ext: Warm, well perfused. No cyanosis Neuro: CN II-XII intact. UE strength ___ bilaterally. ___ strength ___ bilaterally. Sensation intact and symmetric throughout. Tone normal. Pertinent Results: At admission: ___ 01:10PM BLOOD WBC-5.9 RBC-4.43* Hgb-12.8* Hct-39.4* MCV-89 MCH-28.9 MCHC-32.5 RDW-13.1 RDWSD-42.7 Plt ___ ___ 01:10PM BLOOD ___ PTT-28.0 ___ ___ 05:28AM BLOOD Glucose-153* UreaN-11 Creat-0.6 Na-141 K-3.9 Cl-101 HCO3-28 AnGap-12 ___ 01:10PM BLOOD ALT-22 AST-19 AlkPhos-104 TotBili-0.3 ___ 01:10PM BLOOD Lipase-18 ___ 01:10PM BLOOD cTropnT-<0.01 ___ 05:05PM BLOOD cTropnT-<0.01 ___ 01:10PM BLOOD Albumin-3.7 Interim labs: At discharge: CTA head/neck: 1. No evidence of acute territorial infarction or intracranial hemorrhage. 2. CT perfusion is nondiagnostic due to poor bolus timing. 3. No evidence of large vessel occlusion, stenosis, aneurysm, or dissection. MRI brain: 1. There is no evidence of hemorrhage, edema, mass, or infarction. The ventricles and sulci are age-appropriate. There is no mass effect or midline shift. 2. Scattered T2 and FLAIR hyperintense foci in the periventricular and subcortical white matter are nonspecific, but likely reflect chronic small vessel ischemic changes. 3. There is mild mucosal thickening of the paranasal sinuses. There is mild fluid signal in the left mastoid air cells. The intraorbital contents are unremarkable. Brief Hospital Course: #Chest Pain The patient presented with chest pain similar to previous multiple admissions over the last 6 months. Patient has known CAD and microvascular disease. Workup in the ED for ischemia was negative. No pleurisy. Chest pain not responsive to sublingual nitroglycerin and the pain persisted through 2 sets of negative biomarkers and repeated EKGs. During his most recent admission, ___, his chest pain was thought to be related to anxiety. He was given small dose Ativan to see if the chest pain would improve on anxiolytics, and although the pain improved, it did not go away. The cause of the chest pain remains unclear, with anxiety vs microvasular disease both possible. Low suspicion for ACS. Given his known CAD, he was continued on Imdur, but the timing of the dose was changed to nightly for improved antianginal effect in the morning. #CAD Patient is s/p CABGx1 SVG-dRCA (___), BMS to anomalous RCA (___), and DES to OM (___). Additionally, coronary angiography on ___ showed stable nonobstructive CAD with evidence of diffuse microvascular disease. Nuclear stress on ___ was normal. Troponin negative x 2 this admission. EKG without ischemic changes x4. Initially, it was thought that the chest pain could be due to microvascular disease, but the pain did not improve after nitroglycerin administration, making this unlikely. He was continued on his aspirin and Plavix, as well as Toprol XL. His Imdur was changed to nightly, as stated above. #Anxiety Patient has a hx of anxiety, however, he is not followed by a therapist or a psychiatrist as an outpatient and is not on an SSRI. His stress is worsened by his inability to perform his ADLs. Pt denies anxiety specifically but endorses significant worry and stress. He was trialed on Ativan 0.5mg prn on prior admission and currently, with some relief, and discharged with limited course. Recommend trial of longer acting anxiolytic, SSRI or a TCA for anxiety symptoms. Social work was consulted for assistance with discharge planning and coping. It was felt that discharging the patient back to a hotel was unsafe given failure of this strategy requiring rehospitalization. He was set up with a complex case manager and discharged to a SNF. #Code stroke in ED While in the ED, the patient had an episode where he felt unable to speak. A code stroke was called. NIHSS 0. The episode was brief and the symptoms resolved by time the patient was evaluated by neurology. CT head and CTA head/neck showed no evidence of hemorrhage. The patient had no residual deficits or recurrence of his symptoms. He was monitored on telemetry for the duration of his hospital stay and no arrhythmias were recorded. MRI brain was obtained with no evidence of bleed or acute ischemia. The transient speech difficulty was felt highly unlikely to represent TIA, and was not due to stroke given lack of findings on imaging. His symptoms, given his underlying psychiatric symptoms, are more consistent with a functional neurologic symptom disorder. Neurology recommended 1 month of outpatient heart monitoring, but this was deferred given lack of MRI findings and no recorded arrhythmias on telemetry, suggesting a low likelihood of arrhythmia leading to an embolic event. This should be readdressed by the PCP. #T2DM Home ___ held while hospitalized, but restarted at discharge. Patient covered with sliding scale insulin while in hospital. #Osteoarthritis Patient reports history of work injury and is s/p bilateral knee replacement complicated by chronic knee pain. Patient is unable to bear weight and is wheelchair-bound. Patient is reportedly planning for surgery however, needs to be stable from cardiac perspective. He was continued on his home analgesic regimen without changes. #Prior UTI Patient was found to have Klebsiella UTI at last admission ___. He remained on ___ with plan to finish course ___. 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 650 mg PO Q8H: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. Clopidogrel 75 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. GlipiZIDE 10 mg PO BID diabetes 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. LORazepam 0.5 mg PO BID:PRN anxiety 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Metoprolol Succinate XL 50 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. TraMADol 75 mg PO Q6H:PRN Pain - Moderate 16. Tamsulosin 0.4 mg PO QHS 17. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 18. melatonin 3 mg oral QHS 19. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second Line 20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 21. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection Discharge Medications: 1. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 6. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 7. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection Duration: 2 Doses 8. Clopidogrel 75 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. GlipiZIDE 10 mg PO BID diabetes 11. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. LORazepam 0.5 mg PO BID:PRN anxiety 14. melatonin 3 mg oral QHS 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Metoprolol Succinate XL 50 mg PO DAILY 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 20. Pantoprazole 40 mg PO Q24H 21. Tamsulosin 0.4 mg PO QHS 22. TraMADol 75 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Chest pain Coronary artery disease Transient aphasia Urinary tract infection 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 of chest pain WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - In the emergency room, you had an episode where you were unable to speak, so you were evaluated by the neurology team - Your chest pain was evaluated with EKGs and lab work, all of which was reassuring and not indicative of a cardiac cause of your chest pain. Your pain was felt to be most likely related to anxiety - You were evaluated by the physical therapists who felt you would benefit from a rehab facility. We agreed, so you were discharged to a skilled nursing facility to help you with self-care and medication administration WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - 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. We wish you the best! Your ___ Care Team Followup Instructions: ___

19986589-DS-30

DS

2192-06-14 00:00:00

2192-06-15 05:56:00

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 ___ year old M w/ hx of CAD s/p CABG x1 SVG-dRCA, DES to OM, and BMS to RCA; HTN; DM; and anxiety who was recently discharged from the hospital who presents from rehab with chest pain. He was at ___ but left ___ after a dispute over a TV. He was supposed to be picked up by a family member but they did not come. He then started to complain of chest pain and was brought to ___. He was given aspirin in the ambulance. In the ED, initial vitals were notable for tachycardia to 104 with BP 148/90. A code stroke was called as the patient was non-verbal in the ED with lack of movement in his RUE. He was evaluated by Neurology who felt his exam had many functional features and he was noted to intermittently able to speak in full sentences and move LUE and LLE antigravity. CTA head/neck and NCHCT were unremarkable. Further history was limited by minimal patient participation regarding his chest pain. Troponin negative x1 and EKG showed sinus tachycardia. He was not given any medications. Of note, on his last admission, he also had a code stroke which showed no evidence of TIA or stroke and were more consistent with a functional disorder. He also had chest pain felt to be secondary to microvascular disease vs. anxiety. He has had multiple admissions with complex care involved, as he is unable to care for himself at home. On arrival to the floor, the patient complains of right-sided headache that he describes as similar to "someone sticking needles" in his head. He denies nausea, vomiting, lightheadedness, dizziness, blurry vision. He also complains of chest pain which he said has been ongoing since his fight at rehab on day prior to admission. He describes it as a squeezing, pulling pain. He also notes that he intermittently "can hear but can't respond or move as directed". He notes that when this happens, he cannot move his RUE. Past Medical History: Diabetes HTN HLD CABGx1 SVG-dRCA (___) BMS to anomalous RCA ___, DES to OM ___ Chronic knee pain Anxiety Wheelchair bound Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: 24 HR Data (last updated ___ @ 721) Temp: 98.3 (Tm 98.3), BP: 118/77, HR: 90, RR: 18, O2 sat: 98%, O2 delivery: Ra, Wt: 253.31 lb/114.9 kg GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. mild TTP on left chest wall. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. did not participate in CN exam. Strength ___ in ___ upper extremities, ___ in LLE and ___ in RLE at the time of my exam. Normal sensation. DISCHARGE PHYSICAL EXAM ======================= GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. mild TTP on left chest wall. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. did not participate in CN exam. Strength ___ in ___ upper extremities, ___ in LLE and ___ in RLE at the time of my exam. Normal sensation. Pertinent Results: ADMISSION LABS ============== ___ 03:07AM BLOOD WBC-6.7 RBC-4.71 Hgb-13.4* Hct-42.5 MCV-90 MCH-28.5 MCHC-31.5* RDW-14.0 RDWSD-45.4 Plt ___ ___ 03:07AM BLOOD Neuts-58.8 ___ Monos-5.6 Eos-3.2 Baso-0.8 Im ___ AbsNeut-3.93 AbsLymp-2.07 AbsMono-0.37 AbsEos-0.21 AbsBaso-0.05 ___ 03:25AM BLOOD ___ PTT-22.5* ___ ___ 03:07AM BLOOD Glucose-161* UreaN-10 Creat-0.8 Na-138 K-4.5 Cl-101 HCO3-22 AnGap-15 ___ 03:07AM BLOOD ALT-21 AST-23 AlkPhos-96 TotBili-0.4 ___:07AM BLOOD cTropnT-<0.01 ___ 03:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG ___ 03:25AM BLOOD Glucose-160* Creat-0.7 Na-140 K-4.7 Cl-105 calHCO3-34* STUDIES ======= ___ ___ No evidence of intracranial hemorrhage, acute large territorial infarction, edema, or mass. CTA HEAD AND NECK ___ No evidence of dissection, occlusion, high-grade stenosis, or aneurysm greater than 3 mm within the great vessels of the head or neck. The vessels of the circle of ___ and their principal intracranial branches appear patent. Brief Hospital Course: Mr. ___ is a ___ year old M w/ hx of CAD s/p CABG x1 SVG-dRCA, DES to OM, and BMS to RCA; HTN; DM; and anxiety who was recently discharged from the hospital who presents from rehab with chest pain and a code stroke in the ED with concern for functional neurological disorder. TRANSITIONAL ISSUES: ==================== []Will need psychiatry outpatient follow up and consideration of initiation of SSRI for anxiety []Patient will need ongoing management with social work and case management as he has had numerous recent hospitalizations []He would benefit from ongoing outpatient workup for etiology of headache []Please consider referral to Dr. ___ at ___ for suspect functional neurological disorder ACUTE/ACTIVE ISSUES: ==================== # Chest pain While patient certainly has a history of CAD and risk factors, trop negative x1 and EKG shows no signs of ischemia (although could be microvascular disease). In addition, constant pain for >24hrs with TTP on exam is not consistent with cardiac etiology. Most likely Ddx at this point includes malingering given no place to reside vs. anxiety. Patient was continued on home aspirin, Plavix, atorvastatin, metoprolol and nitroglycerin prn chest pain. # Unresponsiveness # Functional neurological deficit Patient had a code stroke in the ED with inconsistent neurologic exam, more consistent with functional neurological deficit. All head imaging including NCHCT and CTA were negative for intracranial etiology. In addition, exam changed between ED exam and admission exam. Neurology was consulted and agree with diagnosis of likely functional neurological deficit. He was continued on home tramadol, gabapentin and lorazepam. Recommend followup with Dr. ___ at ___ for further evaluation. # Headache All imaging was negative for intracranial etiology. He was seen by neurology in the ED who felt that this was less likely a complex migraine. More likely ___ medication overuse given ongoing headache and numerous recent hospitalizations and rehab stay. Tylenol was discontinued. He should be considered for bridge therapy (with NSAIDS vs steroids vs DHE) if he continued to experience severe headaches despite holding likely culprit. Possibly also a component of left sided occipital neuralgia. Recommend warm compresses to back of head, followup with neurology if headache fails to improve. CHRONIC/STABLE ISSUES: ====================== # Anxiety Social work was consulted. He was continued on home lorazepam. He should have outpatient f/u with psychiatry and should consider initiation of an SSRI. # Type II DM Held home exanetide, placed on ISS while inpatient. # Knee osteoarthritis Continued home lidocaine patch, gabapentin and tramadol. Held home Tylenol. # BPH Continued home Tamsulosin # GERD Continued home pantoprazole Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H: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. Clopidogrel 75 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. LORazepam 0.5 mg PO BID:PRN anxiety 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second Line 12. Multivitamins 1 TAB PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Tamsulosin 0.4 mg PO QHS 15. TraMADol 75 mg PO Q6H:PRN Pain - Moderate 16. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 17. GlipiZIDE 10 mg PO BID diabetes 18. melatonin 3 mg oral QHS 19. MetFORMIN (Glucophage) 1000 mg PO BID 20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 21. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Glargine 18 Units Bedtime 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 5. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 6. Clopidogrel 75 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. GlipiZIDE 10 mg PO BID diabetes 9. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. LORazepam 0.5 mg PO BID:PRN anxiety 12. melatonin 3 mg oral QHS 13. MetFORMIN (Glucophage) 1000 mg PO BID 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second Line 16. Multivitamins 1 TAB PO DAILY 17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 18. Pantoprazole 40 mg PO Q24H 19. Tamsulosin 0.4 mg PO QHS 20. TraMADol 75 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Functional neurological deficit SECONDARY DIAGNOSIS Chest pain (non-cardiac) Headache Anxiety 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 part in your care here at ___! Why was I admitted to the hospital? - You were admitted for chest pain and a headache. What was done for me while I was in the hospital? - We did tests of your heart and your chest pain was determined to not be coming from your heart - You had trouble moving your arm and leg but we took images and determined you did not have a stroke - You complained of a headache which we think may be because you take so many medications or an irritated nerve What should I do when I leave the hospital? - Take all of your medications as prescribed - Go to all of your appointments Sincerely, Your ___ Care Team Followup Instructions: ___

19986715-DS-5

DS

2153-07-24 00:00:00

2153-07-25 16:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue, decreased voice, globus sensation, drooling, diplopia: Myasthenia ___ Flare Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ woman with medical history of MuSK positive myasthenia ___ with predominantly bulbar symptoms MGFA classification II-B followed in neurology clinic by Dr. ___ presents to the ED for evaluation of worsening bulbar symptoms in the setting of a cold and medication noncompliance. She reports was in her usual state of health which includes independence in all activities of daily living until ___. Of note she stopped taking her prednisone around ___ for the space of 2 weeks and felt well, so she discontinued the use of her azathioprine (last filled in ___ as well). She then developed an upper respiratory tract infection in ___ and has not been feeling like herself. Subsequently she has been complaining of progressive fatigue which is especially worse at the end of the day or when climbing up stairs. She has also noted her voice has a different quality as she is somewhat hypophonic and describes that her tongue is very slow. She has to repeat what she wants to say several times as people have trouble comprehending her. Additionally she has been complaining of upper back pain like she is carrying camping bag. She reports a sensation like something is caught in her throat however denies choking. She does complain that her throat is dry but has persistent drooling. She is concerned that the sweating palms have returned. Her eyes are also tearing excessively which is unusual for her and 2 days ago she developed horizontal diplopia which resolves when covering either eye. She denies any breathing difficulties, nausea vomiting or diarrhea but reports poor appetite which has been a problem in the past. She initially presented in ___ with acute respiratory failure requiring intubation and was found to have Musk antibody positive myasthenia ___ with predominantly bulbar features. Her initial symptoms were fluctuating diplopia, left eyelid ptosis, dysphagia, dysarthria, lightheadedness and generalized weakness. She was treated with 5 days of plasma exchange and subsequently prednisone. She had also been prescribed a BiPAP machine upon discharge for overnight respiratory support. She has been managed in neurology clinic by Dr. ___ has slowly tapered her prednisone from 5060 mg p.o. daily down to 5 mg p.o. daily and continued her on azathioprine 50 mg every morning and 100 mg every afternoon. Neurologic review of systems notable for the above-mentioned symptoms otherwise unremarkable. On general review of systems, the patient reports recent upper respiratory tract infection. Otherwise denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. --------------- --------------- --------------- --------------- ALLERGIES: Allergies (Last Verified ___ by ___: Patient recorded as having no known allergies to drugs Past Medical History: PMH/PSH: Problems (Last Verified ___ by ___, MD): MYASTHENIA ___ OSTEOPENIA PREDIABETES VITAMIN D DEFICIENCY HEADACHE Social History: ___ Family History: FAMILY HISTORY: Reports no family history of neurologic conditions Physical Exam: ADMISSION EXAMINATION: Vitals: 98.0 81 128/67 16 100% RA NIF > -60 FVC 2.5L General: NAD HEENT: NCAT, LT proptosis without scleral irritation, no oropharyngeal lesions ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive. Speech is fluent with full sentences, but mildly hypophonic. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. Cranial Nerves: PERRL 4->2 brisk. VF full to confrontation. EOMI, but notable for saccadic pursuit. Horizontal diplopia worse on LT gaze. Outer image disappears when covering her right eye. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. There is mild upgaze fatigability with frontalis activation, left greater than right orbicularis oculi weakness on forced eye closure, full strength in her orbicularis oris, jaw and tongue. Does exhibit some weakness when trying to keep her cheeks puffed. Neck flexion and extension full-strength. Motor: Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 4+ 5 5 5 5 5 R 5 ___ ___ 4+ 5 5 5 5 5 Sensory: No deficits to light touch bilaterally. No extinction to DSS. DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. Coordination: No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. Gait: Normal initiation. Narrow base. Normal stride length and arm swing. Stable without sway. Negative Romberg. DISCHARGE EXAMINATION: Vitals: T 98.6 BP 111 / 75 HR 71 RR 16 spO2 100 RA General: thin ___ female, appears well, in no acute distress HEENT: NCAT, LT proptosis without scleral irritation, no oropharyngeal lesions, mild soft tissue swelling in anterior neck on left, no LAD ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes, breathing comfortably without use of accessory respiratory muscles, counts to 30 in one breath Abdomen: soft, NT, ND, +BS, no guarding Extremities: warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive. Speech is fluent with full sentences, but mildly hypophonic. Normal prosody. Able to follow both midline and appendicular commands. Cranial Nerves: PERRL 6->4 brisk. VF full to confrontation. EOMI, but notable for saccadic pursuit. There is subtle hyper and exotropia on the left and exotropia on the right on cover-uncover tests. Lower lid retraction bilaterally. No reported diplopia on resting gaze and left gaze. Horizontal diplopia on far right gaze with outside image disappearing with covering right eye. Upgaze intact, with fatigability after 10 seconds. Mild bifacial weakness, left slightly greater than right, with decreased forehead wrinkling and orbicularis oris strength, orbicularis oculi is ___ bilaterally. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. Motor: Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 Neck flexion and extension ___. There is fatigability to 4+ on the right deltoid. Sensory: No deficits to light touch bilaterally. No extinction to DSS. DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. Coordination: No dysmetria with finger to nose testing bilaterally. Gait: Good initiation, narrow based gait with normal arm swing. Can ascend 2 flights of stairs with minimal dyspnea. Pertinent Results: IMAGING: Noncontrast head CT with look at the orbits with No acute intracranial process. CXR without acute intrathoracic process ___ 07:10AM BLOOD WBC-4.9 RBC-3.89* Hgb-11.5 Hct-35.5 MCV-91 MCH-29.6 MCHC-32.4 RDW-12.4 RDWSD-41.1 Plt ___ ___ 07:00PM BLOOD WBC-4.7 RBC-4.29 Hgb-12.7 Hct-39.6 MCV-92 MCH-29.6 MCHC-32.1 RDW-12.7 RDWSD-42.7 Plt ___ ___ 07:10AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-140 K-4.1 Cl-100 HCO3-23 AnGap-17 ___ 07:00PM BLOOD Glucose-89 UreaN-15 Creat-0.6 Na-140 K-4.9 Cl-100 HCO3-26 AnGap-14 ___ 07:00PM BLOOD ALT-11 AST-21 AlkPhos-68 TotBili-0.2 ___ 07:00PM BLOOD Lipase-19 ___ 07:00PM BLOOD TSH-2.2 ___ 07:00PM BLOOD T4-7.8 ___ 07:00PM BLOOD antiTPO-LESS THAN Brief Hospital Course: The patient is a ___ year old woman with history of MUSK-ab positive myasthenia ___ who presents with a few weeks of fatigue, blurred vision, and hypophonia in the setting of a recent respiratory viral illness, and after self-tapering her antimyasthenic medications several months ago. Her respiratory status was stable and inspiratory force/vital capacity in the normal ranges. She had mild anterior neck swelling that was Her neurologic examination was notable for bilateral proptosis, diplopia in horizontal endgaze and upgaze, mild bifacial weakness, and full motor power in skeletal muscles (including neck flexors/extensors) though with mild fatigability. An active infection was excluded with negative CXR and UA. She was started on prednisone 10mg daily and azathioprine 50mg BID and mestinon 30 mg TID. Her fatigue and neurologic examination improved with these interventions, and her respiratory status remained stable, with consistent ability to count to 30 in one breath and daily respiratory mechanics Nif -60 and VC 2.75. For neck swelling, TSH was negative, anti-TPO antibodies were also negative; she will be ordered for outpatient thyroid ultrasound. Given her good social supports with family to monitor her, she was deemed safe to discharge with follow up in the ___ clinic with her provider ___. Transitional issues: [ ] Consider uptitrating her prednisone to 20mg this week- patient will contact Dr. ___ to discuss this. [ ] Follow up with Dr. ___ on ___. [ ] Follow up thyroid ultrasound to be performed outpatient. Medications on Admission: MEDICATIONS: See the prescribed medication list below, however she reports has not been taking any medications since ___ ___. As per pharmacy records she last filled her as a therapy and prednisone in ___. --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription AZATHIOPRINE - azathioprine 50 mg tablet. 1 tablet(s) by mouth twice daily ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 unit capsule. 1 (One) capsule(s) by mouth weekly for 12 weeks FOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth once a day Medications - OTC ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (OTC; as needed) CALCIUM CITRATE-VITAMIN D3 - calcium citrate-vitamin D3 315 mg-250 unit tablet. 2 (Two) tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 2,000 unit capsule. 2 (Two) capsule(s) by mouth once a day TOLNAFTATE [TINACTIN] - Tinactin 1 % topical spray. Apply to affected areas twice a day Discharge Medications: 1. AzaTHIOprine 50 mg PO BID RX *azathioprine 50 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*1 2. PredniSONE 10 mg PO DAILY RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 3. Pyridostigmine Bromide 30 mg PO TID RX *pyridostigmine bromide [Mestinon] 60 mg/5 mL 2.5 mL by mouth three times daily Refills:*1 4. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: MUSK myasthenia ___ flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted because of recent fatigue, blurred vision, and voice changes, which we felt was likely symptoms of a myasthenia flare, which probably resulted from a recent viral infection. Because this is now your second presentation of myasthenia, we restarted you on your medications, including Azathioprine at 50mg twice daily, and prednisone, at a low dose of 10mg daily. You will need to remain on these medications for a prolonged length of time in order to prevent another myasthenia flare. For symptomatic relief, we also started on you a medication called Mestinon (pyridostigmine), at a dose of 30mg, which you may take three times a day. Fortunately, you responded well to the above treatments. Your respiratory status was monitored and you showed no sign of any weakness in your breathing muscles. Your neurologic examination was also improved. Therefore, we will discharge you home as long as you remain well monitored by your family members and come back to the Emergency Department for any signs of worsening or development of difficulty breathing. You should call Dr. ___ and keep your follow up appointment with her on ___ in order to address next steps. It was a pleasure taking care of you. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___

19986744-DS-22

DS

2132-04-04 00:00:00

2132-04-04 16:05:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Clindamycin Hcl Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with Hx recent carpal tunnel surgery, T2DM, osteoarthritis, s/p PDA repair presents following fall this morning. Shortly after waking this morning he went to the bathroom. After standing up from the toilet he fell on his left side, striking his ribs, shoulder, and head. He does not recall if he urinated or not, but does recall standing up, feeling "funny" or drugged, and then falling to the ground. He denies any prodrome, no chest pain, no palpitations, no diaphoresis or tunnel vision, no lightheadedness or vertigo. His wife heard a thud and went to the bathroom. She attempted to convince him to stand up, but he refused. She observed that he was lethargic and his speech was slow. She did not see any asymmetry in his face, he was moving all extremities, and his speech was not slurred. She was concerned for hypoglycemia and gave him mango juice and sugar packets. After a few minutes he improved and was speaking normally, at which point he stood up. He denies history of falls. Denies fever, chills, N/V/D/C, headache, lightheadedness, vertigo, melena, BRBPR, CP, dyspnea, palpitations. He is taking Tylenol #3 QHS following his surgery ___. . Of note, the patient notes that over the last 3 months he has lost 20 pounds due to decreased appetite. He initially had a chronic cough, typical for him in the ___, that reduced his appetite. He then noted dyspepsia on eating meals, which he addressed by eating several small meals over the course of the day. His cough resolved a few weeks ago, but his appetite did not improve and he has not returned to eating meals of the same size as previous. A colonoscopy ___ was normal, however he had prior polypectomy. PSA ___ 0.9. . In the ED, initial VS were: 97.3 86 103/56 16 100% RA. He had an episode where his pressure dropped to 65/40 although he was asymptomatic. Guaiac negative. Labs were remarkable for lactate of 2.3, WBC count 8.3 with 90% PMN. CT head showed no acute process. CXR and XR rib, shoulder were performed with no acute injury shown. Thought to be dehydrated, provided 2L IVF. . On the floor he complains of his chronic left shoulder pain, exacerbated due to missing his dose of ibuprofen. He also notes pain of the left ribcage at approx the 7th rib in the mid-axillary line. This is new since his fall. Finally he notes pain behind his right ear, also new. He does not recall falling on this ear. Past Medical History: PAST MEDICAL HISTORY: - Carpal tunnel syndrome s/p bilateral release - Left rotator cuff tears and impingement syndrome - Cervical spondylosis - Benign prostatic hypertrophy s/p TURP - Diabetes mellitus type 2 - Osteoarthritis - Erectile dysfunction - Hearing loss - Hyperlipidemia - Calcified submandibular gland s/p resection - Hemorrhoids - Anemia PAST SURGICAL HISTORY: - Tonsillectomy - TURP - Arthroscopic knee surgery, ___ and ___ - Surgical resection of calcified submandibular gland, complicated by infection, ___ - Carpal tunnel release (right ___, left ___ - PDA repair, ___ Social History: ___ Family History: Notable for diabetes mellitus Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.6 90/58 112 16 99% RA General: Alert, oriented, no acute distress HEENT: EOMI, PERRL, sclera anicteric, MMM, OP clear Neck: supple, JVP not elevated, no LAD, no thyromegaly Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: many brown SKs on back, no rash Neuro: CN II-XII tested and intact, strength ___ throughout, ROM limited in left shoulder ___ pain, gait not tested . DISCHARGE PHYSICAL EXAM: Vitals: Tm/c 98.8 109-62 (90-108/50-62) 102 (86-112) 18 98%RA (96-99%RA) FSBS: 171-329 General: Alert, oriented, no acute distress HEENT: EOMI, PERRL, sclera anicteric, MMM, OP clear Neck: supple, JVP not elevated, no LAD, no thyromegaly Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Back: No palpable muscle spasms, some TTP at ~T8 on the left, jsut under scapula Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: many brown SKs on back, no rash Neuro: CN II-XII tested and intact, strength ___ throughout, ROM limited in left shoulder ___ pain, gait not tested Pertinent Results: Admission Labs: ___ 08:17AM BLOOD WBC-8.1 RBC-3.88* Hgb-10.4* Hct-33.7* MCV-87 MCH-26.9* MCHC-30.9* RDW-14.2 Plt ___ ___ 08:17AM BLOOD Neuts-90* Bands-2 Lymphs-7* Monos-0 Eos-1 Baso-0 ___ Myelos-0 ___ 08:17AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-NORMAL Acantho-OCCASIONAL ___ 08:17AM BLOOD Plt Smr-NORMAL Plt ___ ___ 08:17AM BLOOD Glucose-193* UreaN-18 Creat-0.8 Na-137 K-4.1 Cl-103 HCO3-23 AnGap-15 ___ 08:17AM BLOOD ALT-43* AST-38 AlkPhos-65 TotBili-0.7 ___ 08:17AM BLOOD Lipase-42 ___ 08:17AM BLOOD cTropnT-<0.01 ___ 08:17AM BLOOD Albumin-3.5 Calcium-9.3 Phos-2.9 Mg-1.8 ___ 08:24AM BLOOD Lactate-2.3* . Relevant Labs: ___ 01:10PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:10PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 01:10PM URINE RBC-2 WBC-78* Bacteri-NONE Yeast-NONE Epi-<1 . Discharge Labs: ___ 06:10AM BLOOD WBC-12.6*# RBC-3.52* Hgb-9.5* Hct-30.5* MCV-87 MCH-27.2 MCHC-31.3 RDW-14.2 Plt ___ ___ 06:10AM BLOOD Neuts-80.0* Lymphs-13.3* Monos-4.8 Eos-1.8 Baso-0 ___ 06:10AM BLOOD Glucose-145* UreaN-10 Creat-0.8 Na-137 K-4.0 Cl-103 HCO3-24 AnGap-14 ___ 06:10AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9 ___ 06:10AM BLOOD Cortsol-16.9 . Microbiology: ___ Urine culture: pending at the time of discharge . Imaging: CT Head ___: No acute intracranial process. . Left forearm and shoulder ___: (prelim) No acute fracture or dislocation is seen. There are degenerative changes at the acromioclavicular joint as well as spur formation at the glenoid and in the region of the supraspinatus tendon. IMPRESSION: No acute fracture or dislocation. . Left chest wall, rib and CXR ___: (prelim) No focal opacity to suggest pneumonia is seen. No pleural effusion, pulmonary edema or pneumothorax is present. The heart size is top normal. There is tortuosity of the aorta and calcification at the aortic arch. Adjacent to the marker along the left lower hemithorax, there is a possible minimally displaced fracture along the left lateral seventh rib. Brief Hospital Course: ___ with Hx recent carpal tunnel surgery, T2DM, osteoarthritis, s/p PDA repair presents following fall, possible syncope. Admission complicated by transient hypotension and a leukocytosis. . . ACTIVE ISSUES: # Syncope: The patient describes a fall, however it seems he may have had LOC. The differential is broad, including medication effect, hypoglycemia, orthostasis, vasovagal, and mechanical fall. There is no evidence of seizure activity or stroke. No chest pain or dyspnea, and troponin negative. However, given his history of PDA repair, there is the possibility of cardiac etiology. There is no sign of GIB, no Hct drop, and he is guaiac negative. Medication effect is possible, as he has been using Tylenol #3 QHS following his recent surgery. As juice partially resolved his symptoms, and given his use of a sulfonylurea, hypoglycemia is possible. Micturition syncope is also possible, although largely a diagnosis of exclusion. Patient was noted to be hypotensive on admission. He was given IV fluids on arrival. Shortly thereafter, orthostatic vital signs were negative. X-rays showed possible minimally displaced fx of left 7th rib (will heal on its own). Morning cortisol was within normal limits, ruling out adrenal insufficiency. He was stabilized, and able to ambulate around the floor without difficulty. . # Hypotension: He had an episode of asymptomatic hypotension in the ED and was SBP 90 on admission to the floor. He was clinically dehydrated on presentation and his BP did increase with fluids, although not to baseline. He reports poor PO intake recently, and per report his PCP thought he was dehydrated at a recent visit. There was no sign of infection; he was afebrile. No Hct drop or sign of GIB. Oral intake was encouraged, and SBPs increased to low 100s. . # Leukocytosis: WBC 12.9 noted on day of discharge, with a neutrophilic predominance. Patient was afebrile, with no localizing symptoms of infection. leukocytosis may have been secondary to possible rib fracture. ___ also be a component of atelectasis, if not as mobile overnight. UA showed 72 WBC, so patient began empiric treatment for uncomplicated cystitis with ciprofloxacin. UCx was pending at the time of discharge. . . CHRONIC ISSUES: # T2DM: Currently well-controlled on oral regimen. He was covered with a sliding scale while in house. . # Pain s/p carpal tunnel: Recently post-op on ___. Continues to have pain post-op. Patient was treated with standing Tylenol, along with home ibuprofen, and small doses of oxycodone. . # Hemorrhoids: Continued Anusol cream. . # Hyperlipidemia: Continued atorvastatin and ASA. . . Transitional Issues: - Would recommend TTE as outpatient to evaluate for cardiac causes of syncope. - Code: full - Urine culture pending at the time of discharge. Medications on Admission: acetaminophen-codeine 300 mg-30 mg Tablet ___ Tablet(s) Q6H PRN pain atorvastatin 20 mg Tablet daily glipizide 5 mg daily hydrocortisone [Anusol-HC] 2.5 % Cream Apply rectally tid PRN ibuprofen 600 mg TID metformin 1500 mg daily aspirin 81 mg daily Discharge Medications: 1. acetaminophen-codeine 300-30 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Anusol-HC 2.5 % Cream Sig: One (1) application Rectal three times a day. 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a day. 6. metformin 1,000 mg Tablet Sig: 1.5 Tablets PO once a day. 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Through ___. Disp:*6 Tablet(s)* Refills:*0* 9. oxycodone 5 mg Tablet Sig: ___ Tablet PO every six (6) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Syncope Rib fracture . Secondary diagnosis: Urinary tract 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 participate in your care here at ___ ___. You were admitted after a fall. We thought your fall may have been due to low blood pressures from decreased intake of food and water. You improved after getting some intravenous fluids. On chest x-ray, you were noted to have a possible rib fracture. This will heal gradually over time. While you were here, we noted that you had some signs of infection in your urine, so you were started on antibiotics for treatment of a urinary tract infection. Please note, the following changes have been made to your medications: - START ciprofloxacin 250 mg by mouth twice daily - START oxycodone 5mg, ___ tablet by mouth every six hours as needed for pain. DO NOT DRIVE WHILE TAKING THIS MEDICATION. Please continue all of your other medications as you ad prior to your hospitalization. It is important that you follow up with your primary care doctor this week. Please call Dr. ___ at ___ to make an appointment. Wishing you all the best! Followup Instructions: ___

19987152-DS-10

DS

2147-03-26 00:00:00

2147-03-28 15:52:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Erythromycin Base / Demerol / Morphine Sulfate / Dilaudid (PF) / fentanyl / medline brand surgical film (NOT tegederm brand) / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: abdomino-pelvic pain Major Surgical or Invasive Procedure: Interventional Radiology procedure: pigtail drain removed. please see operative report for full details History of Present Illness: ___ yo ___ s/p exploratory laparotomy, removal J-pouch with end ileostomy and perineal proctectomy (___) and and bilateral ovarian cystectomy (both benign) on ___ complicated by peritoneal inclusion cyst draining through vagina via uterus requring ___ drainage and pigtail placement. First drained ___ with 190cc output (cytology negative). Replaced with sclerotherapy on ___, which had limited success and is planned to be repeated under MAC "in the next couple weeks". Reports lower abd pain started at time of ___ drain placement and has been refractory to roxicet q4 hours. Cannot take NSAIDs due to UC. Gets little reponse from pills as they "come out her ostomy" without absorption. Denies fever/chills, urinary sx, vaginal discharge or changes to ostomy output, or other systemic malaise. Past Medical History: PMH: ulcerative colitis, alcohol use, chronic abdominal pain panic attacks, depression anxiety PSH: ___ total colectomy w/ diverting ileostomy ___ - j-pouch creation ___ - ileostomy takedown ___ - admitted with closed loop obstruction and had small bowel resection (all surgeries done by Dr. ___ at ___ ___) C-Section x2 R Inguinal Hernia repair at ___ years old. Social History: Married, two small daughters, works in the home, history of alcohol abuse as documented in PCP ___. Please see social work note. Physical Exam: ED Consultation: temp 99.6 HR 85 114/78 RR 15 97% RA NAD, appears mildly uncomfortable RRR CTAB, no wheezes or increased work of breathing abd soft throughout, mildly TTP, no rebound/guarding LLQ drain without erythema/drainage, ~10cc serous fluid in bag RLQ ostomy with gas & stool in bag no peripheral edema no hives or skin changes Pertinent Results: ___ 06:33AM BLOOD WBC-9.3 RBC-4.21 Hgb-12.2 Hct-37.8 MCV-90 MCH-29.0 MCHC-32.4 RDW-12.4 Plt ___ ___ 06:33AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-140 K-3.8 Cl-105 HCO3-28 AnGap-11 ___ 06:33AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.9 Brief Hospital Course: Ms. ___ was admitted to the gynecology oncology service for pain management and further evaluation of her pelvic fluid collections. She remained stable during her hospitalization. Of note, after administration of IV contrast she experienced whole body itching and hives. This was managed with Epipen and benadryl. On hospital day #2 she was premedicated with prednisone and IV benadryl for her ___ procedure. This procedure was uncomplicated (see operative report for full details). Her pain was managed with dilaudid and toradol. She recovered well after her procedure and was stable to be dicharged home on hospital day # 3. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE-Acetaminophen Elixir 5 mL PO Q6H:PRN pain 2. Lorazepam 0.5 mg PO BID:PRN anxiety 3. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies Discharge Medications: 1. Lorazepam 0.5 mg PO BID:PRN anxiety RX *lorazepam 0.5 mg 1 tablet by mouth TID:PRN Disp #*20 Tablet Refills:*0 2. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies 3. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN pain do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg/5 mL ___ mL by mouth Q6H:PRN Disp #*500 Milliliter Refills:*1 4. Dilaudid (HYDROmorphone) 1 mg/mL Oral TID pain may take 2mL TID prn Pain. do not drive or combine with alcohol or other narcotics. obtain refills from your PCP. RX *hydromorphone [Dilaudid] 1 mg/mL 2 mL by mouth three times a day Disp ___ Milliliter Refills:*0 Discharge Disposition: Home Discharge Diagnosis: peritoneal inclusion cyst/ fluid collection Discharge Condition: stable Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology oncology service in order to better manage your pain and to address your ongoing fluid collection. You have remained stable during your stay and the team believes that you are ready to be discharged home. . Please follow these instructions: - take your medication as prescribed - keep your follow up appointments - please call if you have any concerning symptoms Followup Instructions: ___

19987152-DS-11

DS

2147-04-02 00:00:00

2147-05-02 11:15:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / Demerol / Morphine Sulfate / Dilaudid (PF) / fentanyl / medline brand surgical film (NOT tegederm brand) / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is a ___ old female with a history of ulcerative colitis s/p multiple abdominal surgeries previously admitted for removal of pigtail draining pelvic fluid collection, and presents with LLQ pain and weight loss. Her hx of UC began with a J pouch that required multiple revisions due to strictures and SBOs and was ultimately removed and converted to an and ileostomy by Dr. ___ on ___. As well, she has undergone bilateral ovarian cystectomies complicated by multiple inclusion cysts requiring drainage and sclerotherapy. She was reently admitted to the GYN service with recurrent pelvic pain ___. A CT scan was obtained and showed a new loculated fluid collection in the presacral space with rim enhancement felt to represent a peritoneal inclusion cyst, adnexal cyst or abscess. Of note, she had a drain in place at the time. She was scheduled for sclerotherapy on ___ but injection of the area showed communication of peritoneal inclusion cyst with peritoneum so sclerotherapy was not performed and the percutaneous drainage catheter was removed. She was discharged on Tylenol, Benadryl and dilaudid 2ml TID prn. Following this admission, she followed up with her gastroenterologist, Dr. ___ complained of persistent abdominal pain similar to previous SBOs. Dr. ___ going to the ED to r/o recurrent fluid collection vs new SOB or stricture. However, upon further review of the imaging, Dr. ___ writes in her note that she is skeptical that her LLQ pain is at all related to the fluid collection that was not drained from the right pre-sacral space. Her note mentions concern for drug seeking behavior, alcohol dependence and persistent request for pain meds despite nearly falling asleep during interviews. In the ED vITALS WERE: SPO2 of 100% on RA, Temp =98.8 Pulse=96 BP=121/85 RR=16. Labs were unremarkable. Exam notable for tenderness near drain site, ostomy intact, no surrounding erythema. M enterography showed decreased fluid collection. She was given a litre of normal saline,3 doses IV dilaudid with Benadryl, tramadol and Lorazepam. She was admitted for pain control. On the floor she reports of ___ abdominal and triggered by eating and swallowing, weight loss of 8lbs in 2 weeks due to not eating because of the pain. Past Medical History: PMH: ulcerative colitis, alcohol use, chronic abdominal pain panic attacks, depression anxiety PSH: ___ total colectomy w/ diverting ileostomy ___ - j-pouch creation ___ - ileostomy takedown ___ - admitted with closed loop obstruction and had small bowel resection (all surgeries done by Dr. ___ at ___ ___) C-Section x2 R Inguinal Hernia repair at ___ years old. Social History: ___ Family History: noncontributory Physical Exam: ADMISSION: Vitals: Temp = 98.9 BP=133/89 PULSE = 86 RR=18 SPO2 100%RA General: alert and oriented x3. NAD Resting comfortably in bed HEENT: Anicteric sclera. MMM . OP clear Neck: supple. No JVD. No LAD. LUNGS: CTAB HEART:RRR. No murmurs, rubs or gallops ABDOMEN: Soft, no tenderness when pressing on abdomen with stethoscope but grimaces with manual palpation of periumblical and LLQ areas without rebound or guarding. Hyperactive BS. Colostomy c/d/I. When asked to sit up for lung ausculatation, pt sits up quickly without grimacing and does not appear to be limited by pain whatsoever. GU: no foley EXT: warm, well-perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO:CNs ___ intact. motor function grossly normal DISCHARGE: Vitals: Temp = 98.0 BP=100/64 PULSE =66 RR=18 SPO2 99%RA General: alert and oriented x3. NAD Resting comfortably in bed Neck: supple LUNGS: CTAB. No wheezes, rales or rhonchi HEART:RRR. No murmurs, rubs or gallops ABDOMEN: normoactive BS. Mildly ttp, soft, no rebound or guarding GU: no foley EXT: warm, well-perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ___ 12:20PM BLOOD WBC-5.4 RBC-4.69 Hgb-13.9 Hct-41.2 MCV-88 MCH-29.6 MCHC-33.7 RDW-12.5 Plt ___ ___ 12:20PM BLOOD Neuts-59.8 ___ Monos-4.1 Eos-2.7 Baso-1.0 ___ 07:00AM BLOOD WBC-5.7 RBC-4.07* Hgb-12.4 Hct-35.5* MCV-87 MCH-30.4 MCHC-34.8 RDW-12.5 Plt ___ ___ 07:00AM BLOOD ___ PTT-32.8 ___ ___ 12:20PM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-26 AnGap-12 ___ 12:20PM BLOOD ALT-11 AST-15 AlkPhos-38 TotBili-0.4 MR ENTEROGRAPHY ___ IMPRESSION: 1. Decreased size of lesion in the deep right pelvis, compatible with a hemorrhagic ovarian cyst. 2. Small adjacent fluid in the pre-sacral space with septations, slightly larger than on prior CT when the drainage catheter was in place. 3. Normal small bowel and ileostomy post proctocolectomy. EGD ___ Impression: Normal mucosa in the whole esophagus Normal mucosa in the whole stomach (biopsy) Normal mucosa in the whole duodenum Otherwise normal EGD to third part of the duodenum Recommendations: -Patient can return to floor when recovered from sedation -Daily PPI -Follow up biopsies and if positive treat for H. pylori -Abdominal pain is not explained by the findings of this endoscopy Brief Hospital Course: This is a ___ old female with PMH of UC requiring multiple surgeries and an ___ guided drainage of pre-sacral fluid collection improved on MR enterography, who presents with persistent abdominal pain and inability to tolerate po intake. #Abdominal pain: MR enterography showed improving fluid collection. Decreasing fluid collection unlikely to be related to current abdominal pain. No new obstruction or stricture was seen on MR enterography. No evidence of infection at previous drainage site. She underwent EGD with no remarkable findings. Pain control with IV dilaudid was started in ED and continued on the floor. Prn antiemetics were given. IVF were given to rehydrate. No obvious etiology for abdominal pain was found. Physical exam was not remarkable for an acute abdomen. After bowel rest, IV pain medications and rehydration, she was more comfortable at discharge and is to continue follow up with her gastroenterologist and primary care physician for outpatient work up and management of her abdominal pain. #HX of Alcohol abuse: Consumes about 2drinks/night until the past two months when she stopped drinking because of her abdominal pain. She was placed on CIWA protocol because of outpatient provider concerns for present alcohol abuse. Folate and thiamine were supplemented. TRANSITIONAL ISSUES: Follow up biopsies from EGD and if positive treat for H. pylori Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO BID:PRN anxiety 2. DiphenhydrAMINE ___ mg PO Q6H:PRN itching 3. Dilaudid (HYDROmorphone) 2 mL Oral TID:PRN abdominal pain Discharge Medications: 1. Lorazepam 0.5 mg PO BID:PRN anxiety 2. DiphenhydrAMINE ___ mg PO Q6H:PRN itching 3. HYDROmorphone (Dilaudid) (HYDROmorphone) 2 mL ORAL TID:PRN abdominal pain Discharge Disposition: Home Discharge Diagnosis: Abdominal pain. Secondary: ulcerative colitis: alcohol use chronic abdominal pain panic attacks depression anxiety Discharge Condition: alert and oriented x 3 NAD AMBULATORY Discharge Instructions: Dear Ms. ___, you came into the hospital due to worsening of your chronic abdominal pain. An MRI showed that the fluid in your pelvis was less than before. An EGD did not show any abnormalities. You have received IV fluids for hydration and bowel rest. You have been given pain medications as needed. You are now ready to go home. Followup Instructions: ___

19987152-DS-14

DS

2147-10-27 00:00:00

2147-10-27 20:22:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / medline brand surgical film (NOT tegederm brand) / Iodinated Contrast Media - IV Dye / thimerosal / Neomycin Attending: ___. Chief Complaint: Perineal pain Major Surgical or Invasive Procedure: Sclerotherapy ___ and ___ History of Present Illness: ___ yo F with a history of UC diagnosed in ___ s/p total colectomy w/ diverting ileostomy, J-pouch s/p failure and take down ___ with recurrent pelvic seromas who presents today with ongoing perianal and perineal pain associated with JP drain placed in early ___. The patient's JP drain was placed to both drain the ceroma, and to infuse sclerotherapy for it on ___ with ___. The drain is supposed to be removed at that time. Since the drain was placed, the patient has had severe pelvic pain that prevents her from doing daily activities. She was eating and drinking until yesterday, when the pain became so severe that she was too nauseated to eat. The patient has been followed by pain clinic, most recently on ___. She expresses frustration with intolerable pain not be controlled with home narcotics (Oxycontin 20mg PO BID, oxycodone liquid ___ q4-6 hours, ativan 0.5 PRN for anxiety), which she attributes to poor absorption because of her ileostomy. No change in consistency of her stool or increased transit of her bowel. No fevers, chills, dysuria, urgency. Of note, the patient has tried fentanyl patches for pain before, but is unable to tolerate them due to hallucinations. In the ED, initial VS: 99.0 118 126/96 16 99% ra. The patient was found to be uncomfortable and tearing. Abdominal exam was benign. Labs were within normal limits. She was evaluated by surgery and ob/gyn regarding drain removal, but they recommended keeping it in place until ___ follow-up. The patient was initially placed on suicide watch because of statement that she couldn't live like this with the pain. However, she denied active plan and was not sectioned. She recieved hydromorphone 1 mg IV x 2 with 50 mg IV benadryl for pain and pruritus, in addition to home lorazepam. She ate a sandwich in the ED, but became nauseated afterwards (resolved without medication). She was admitted to medicine for pain control and consultation with ___. VS prior to transfer: 98.3 63 ___ 98% RA. On the floor, the patient complains of ongoing severe pain. She is tearful when I address trying a sublingual narcotic pain solution, as she specifically would like IV pain medication. She denies fevers, chills. Nausea resolved. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PMH: Ulcerative colitis s/p J pouch (reversed), now with end ileostomy Chronic abdominal pain Panic attacks/anxiety Alcohol use PSH: ___ total colectomy w/ diverting ileostomy ___ - j-pouch creation ___ - ileostomy takedown ___ - admitted with closed loop obstruction and had small bowel resection (all surgeries done by Dr. ___ at ___ ___) C-Section x2 R Inguinal Hernia repair at ___ years old. Social History: ___ Family History: Mother had IBS. Physical Exam: ADMISSION PHYSICAL EXAM Vitals - T: 98.3 BP: 109/70 HR: 78 RR: 18 02 sat: 99%RA GENERAL: mildly uncomfortable appearing woman, tearful HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, ileostomy in RLQ draining brown stool, JP drain without surrounding erythema with trace amount of serous fluid in bulb EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM Vitals: 98.0 89/53 80 16 100% Tmax 98.4 89-110 ___ I/O (24hr): ___ PO, 180 IV /2250 +BRP General: Awake, alert, calm but intermittently tearful or agitated. HEENT: NCAT. No scleral icterus. Face symmetric. CV: RRR, no m/g/r. Pulm: Non-labored breathing on room air. CTA bilaterally. GI: Bowel sounds present. TTP LLQ. No rigidity/guarding. Pertinent Results: ADMISSION LABS ___ 01:00PM WBC-7.1 RBC-4.96 HGB-13.8 HCT-43.7 MCV-88 MCH-27.8 MCHC-31.6 RDW-12.5 ___ 01:00PM NEUTS-61.7 ___ MONOS-4.1 EOS-3.2 BASOS-0.8 ___ 01:00PM PLT COUNT-236 ___ 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:00PM GLUCOSE-100 UREA N-11 CREAT-0.8 SODIUM-135 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-21* ANION GAP-17 ___ 02:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 02:56PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:56PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 02:56PM URINE UCG-NEGATIVE ___ 02:56PM URINE HOURS-RANDOM PERTINENT INTERIM LABS ___ 06:05PM VAGINAL FLUID Hct,Fl-39* LABS PRIOR TO DISCHARGE ___ 07:00AM BLOOD WBC-4.0 RBC-3.82* Hgb-11.6* Hct-35.0* MCV-92 MCH-30.3 MCHC-33.1 RDW-13.2 Plt ___ MICROBIOLOGY URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING/STUDIES Pelvis US ___ Small residual fluid collection in the posterior cul-de-sac measuring 3.7 x 0.4 cm, with drainage catheter in situ Pelvis US ___ Increased size of 8.4 cm fluid and debris containing collection in the cul de sac. The transgluteal drainage catheter courses within the collection, although the position of its tip is difficult to evaluate sonographically. Precise localization of the tip position would require evaluation with CT. MRI Pelvis w and wo contrast ___ Multiloculated pelvic peritoneal inclusion cyst larger since ___, now has hyperenhancing walls, likely reflecting changes of recent intervention and presence of a drainage catheter. Pelvis US ___ 1. No large intrauterine fluid collection; small amount of fluid in endometrial cavity is nonspecific. No hydrosalpinx. 2. No uterine defect is sonographically evident other than the cesarean section scar. 3. Interval decrease in size of complex collection posterior to the uterus. MRI Pelvis w and wo contrast ___ Marked decrease in size of a peritoneal inclusion cyst since the ___ MRI reflecting reponse from recent sclerotherapy. A 3.9 x 2.1 cm presacral multi-loculated collection remains, with a portion communicating with a right transgluteal drain. A small amount of gas within the collection has increased since the prior examination. Pelvis US ___ 1. Small pelvic fluid collection has decreased since ___. 2. Complex fluid in the vaginal canal. 3. Tiny amount of fluid within the endometrium. Otherwise, normal uterus and ovaries. Pelvis US ___ Posterior to the cervix is again identified complex partially solid and partially cystic fluid collection which measures approximately 4.3 x 2.1 cm, largely unchanged since most recent ultrasound dated ___. No new fluid collection is identified. The uterus is unremarkable measuring 8.9 x 4.7 x 5.5 cm. The ovaries are normal in size with a 1.5 cm anechoic physiologic cyst within the left ovary unchanged since prior examination. Complex fluid is present in the vaginal canal with an unremarkable cervix. IMPRESSION: 1. Unchanged complex fluid collection posterior to the cervix, stable in size since ___, allowing for differences in imaging modalities. No new fluid collection is detected. 2. Normal appearing uterus and ovaries with small physiologic cyst redemonstrated within the left ovary. Brief Hospital Course: ___ F h/o ulcerative colitis s/p total colectomy with ileostomy, failed J-pouch s/p take-down, recurrent pelvic peritoneal inclusion cysts s/p JP drain placement in ___ who presented with intractable buttock/perineal pain due to multiloculated peritoneal inclusion cyst and transgluteal drain, now s/p two rounds of sclerotherapy. ACTIVE ISSUES # Pain of buttock, perineum and abdomen: Patient initially presented with a chief complaint of perianal pain, described as a scraping sensation in the ___ region, which she attributed to the transgluteal drain in the left buttock. The drain had been placed in ___ to drain the pelvic peritoneal inclusion cyst. During the course of hospitalization she also developed abdominal pain, which was possibly due to the increased cyst size reflected by pelvis US on ___ and pelvis MRI ___. There was low suspicion for abscess, cellulitis, or intra-abdominal/pelvic infection based on physical exam and lack of fever, tachycardia or leukocytosis. She underwent sclerotherapy by Interventional Radiology on ___ and ___. Cyst size appeared decreased on MRI ___ and reduced further on US ___ repeat pelvis US on ___ was stable in comparison to those studies, and no new fluid collection was detected. Transgluteal drain was removed by ___ ___ once drain output had become minimal. Of note, a multidisciplinary meeting with ___, Colorectal surgery and Gynecology was held to discuss surgical management options, and no surgical options were recommended or offered (please see OMR note dated ___ for further details about that discussion). For pain control, pt initially had inadequate symptom relief with hydromorphone IV boluses, and she largely declined PO meds due to concern for poor oral absorption s/p colectomy. The Pain service was consulted to provide recommendations. She was started on a PCA. She had better pain control with the PCA with basal rate. A fentanyl patch was initially avoided due to a past history of hallucinations while on the patch (though this was possibly in the setting of sepsis). Pt is able to tolerate fentanyl IV for procedure purposes. A trial of a fentanyl patch was attempted, but the patch was poorly tolerated due to agitation. Agitation resolved as soon as patch was removed. She was returned to the PCA. On ___ pt felt comfortable with discontinuation of the basal rate, so the basal rate was DCed. For adjunctive treatment, she was on gabapentin three times a day. She initially declined standing PO acetaminophen due to concern about side effects but later agreed to standing IV acetaminophen. She declined initiation of duloxetine due to concern about side effects in general and her impression that pain would resolve after the cyst issue resolved. Initiation of an NSAID was considered, though she was reluctant about this option given her history of UC. In informal communication with GI, it was determined that an NSAID would be safe since she carries the diagnosis of UC and has had a colectomy. She received a one-time dose of ketorolac with no obvious improvement in symptoms. Pelvis ___ and acupuncture were proposed, and she declined these modalities due to having acute pain and said she would consider these in the future as preventative measures, once the problem was under control. On ___ Ms. ___ expressed a desire to wean off the PCA in efforts toward getting discharged to home. She was understandably frustrated with the lack of definitive treatment options for her problem while hospitalized. On ___ she requested transfer to a different hospital due to having pain overnight which she did not think she could tolerate at home, and so that she could seek management options elsewhere. Her hospital of choice was contacted and declined the transfer. She requested repeat imaging of the pelvis and stated that she would want to be discharged if it was stable in order to explore other options elsewhere. Pelvis US on ___ was stable in comparison to imaging on ___ and ___, and no new fluid collection was detected, as described above. She was amenable to discharge. She was discharged ___ with prescriptions for a 10-day supply of Oxycontin 20mg PO q 12 hrs and oxycodone liquid ___ PO q 4 hrs PRN breakthrough pain, as well as PRN ibuprofen, standing acetaminophen, gabapentin, ondansetron, and lansoprazole. She has follow-up appointments scheduled with her PCP ___ ___ and with Pain Clinic on ___. # Anxiety: Pt was highly anxious and was treated with lorazepam 0.5mg IV TID PRN anxiety throughout most of hospitalization, and often required additional doses. She declined using lorazepam pills under the tongue but has lorazepam elixir at home. The addition of duloxetine was strongly recommended to help with anxiety and pain, but she declined duloxetine due to concern about side effects in general and due to her impression that her symptoms would improve upon resolution of medical problem. She was offered consultation with Social Work and she declined. # Cyst communication through fallopian tube: Peritoneal inclusion cyst communicates with uterus/vagina through the left fallopian tube according to ___. Pt was concerned that alcohol from sclerotherapy was in contact with the uterus and vagina, and in multidisciplinary meeting it was stated that alcohol contacting the uterus/vagina after the procedure was not likely but could not be ruled out. Also, the communication is not a contraindication to future sclerotherapy if she does not wish to preserve fertility, and Ms. ___ stated that she does not wish to preserve fertility. She developed increased vaginal drainage on ___, with the differential diagnosis being menstrual flow versus drainage of fluid from pelvis via fallopian tube. Vaginal fluid was collected and its Hct was 39, suggestive of blood moreso than blood mixed with pelvic fluid. Serum Hct was stable, indicating that blood was menstrual rather than active extravasation. Patient was curious whether hysteroscopy would be useful to identify the source of drainage since vaginal drainage would present a major quality of life problem. Gyn consultants stated hysteroscopy was not a recommended option. One reason was that hysteroscopy requires pressurized fluid, which could further distend the peritoneal inclusion cysts that communicate with the fallopian tube. Tubal ligation was not recommended. # Bleeding from JP drain: Pt had temporary drainage of bloody fluid via transgluteal drain. It could have been due to an interval increase in cyst size, as seen on MRI. Serum Hct was stable and bleeding via transgluteal drain ceased. CHRONIC ISSUES # Ulcerative colitis: Patient is s/p total colectomy. She had complaints of rapid transit time and poor absorption of PO medications. There was no clear explanation as to why she had poor absorption of PO medications s/p colectomy. # History of chronic abdominal pain: Management of acute on chronic pain as described above. # History of panic attacks/anxiety: Management of anxiety as described above. TRANSITIONAL ISSUES []Follow up with Pain Clinic on ___. Patient was discharged with prescriptions for a 10-day supply of pain medications. []Follow up with PCP. []Obtain repeat MRI pelvis for monitoring of cyst size. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO BID:PRN anxiety 2. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis 3. OxycoDONE Liquid ___ mg PO Q6H:PRN breakthrough pain 4. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H Discharge Medications: 1. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis 2. Gabapentin 500 mg PO QAM RX *gabapentin 250 mg/5 mL (5 mL) 10 ml by mouth q AM Disp #*100 Milliliter Refills:*0 3. Gabapentin 500 mg PO NOON RX *gabapentin 250 mg/5 mL (5 mL) 10 ml by mouth q noon Disp ___ Milliliter Refills:*0 4. Gabapentin 750 mg PO HS RX *gabapentin 250 mg/5 mL (5 mL) 15 ml by mouth q HS Disp #*150 Milliliter Refills:*0 5. Lorazepam 0.5 mg PO BID:PRN anxiety 6. OxycoDONE Liquid ___ mg PO Q4H:PRN breakthrough pain RX *oxycodone 5 mg/5 mL ___ ml by mouth q 4 hrs Disp #*1200 Milliliter Refills:*0 7. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12 hr(s) by mouth q 12 hrs Disp #*20 Tablet Refills:*0 8. Acetaminophen (Liquid) 1000 mg PO Q8H RX *acetaminophen 500 mg/5 mL 10 ml by mouth q 8 hrs Disp #*300 Milliliter Refills:*0 9. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron [ZOFRAN ODT] 4 mg 1 tablet,disintegrating(s) by mouth q 8 hrs Disp #*30 Tablet Refills:*0 10. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY RX *lansoprazole [Prevacid SoluTab] 15 mg 1 tablet,disintegrat, delay rel(s) by mouth daily Disp #*10 Tablet Refills:*0 11. Ibuprofen Suspension 600 mg PO Q6H:PRN pain RX *ibuprofen 100 mg/5 mL 30 ml by mouth q 6 hrs Disp #*500 Milliliter Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Peritoneal inclusion cysts Secondary: Ulcerative colitis s/p colectomy, end-ileostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Thank you for allowing us to take part in your care at ___ ___. As you know, you came to the hospital due to severe ___ pain in the setting of a transgluteal catheter for peritoneal inclusions cysts, which was not adequately controlled on your home medications. You were evaluated by Interventional Radiology and had two rounds of sclerotherapy. The cyst size has decreased on MRI and ultrasound. You were evaluated by the Pain service, and you were treated with a PCA and oral medications. We wish you the very best in the recovery process. Followup Instructions: ___

19987482-DS-5

DS

2147-12-17 00:00:00

2147-12-18 00:10:00

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: prolonged menses, fever Major Surgical or Invasive Procedure: none Physical Exam: Discharge physical exam Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, appropriately tender, no rebound/guarding Ext: no tenderness to palpation Pertinent Results: Labs on Admission: ___ 05:45PM BLOOD WBC-13.7* RBC-3.78* Hgb-8.9* Hct-29.8* MCV-79* MCH-23.5* MCHC-29.9* RDW-15.3 RDWSD-43.8 Plt ___ ___ 05:45PM BLOOD Neuts-77.7* Lymphs-15.1* Monos-6.1 Eos-0.2* Baso-0.4 Im ___ AbsNeut-10.61* AbsLymp-2.06 AbsMono-0.83* AbsEos-0.03* AbsBaso-0.05 ___ 05:45PM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-140 K-4.1 Cl-97 HCO3-23 AnGap-20* ___ 05:45PM BLOOD ALT-6 AST-14 AlkPhos-62 TotBili-0.5 ___ 05:45PM BLOOD Lipase-16 ___ 05:45PM BLOOD Albumin-4.3 ___ 05:45PM BLOOD HCG-<5 ___ 11:04PM BLOOD Lactate-1.6 ___ 10:41PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 10:41PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-150* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 10:41PM URINE RBC-<1 WBC-3 Bacteri-FEW* Yeast-NONE Epi-3 Relevant Labs: ___ 06:48AM BLOOD WBC-15.5* RBC-3.26* Hgb-7.7* Hct-25.7* MCV-79* MCH-23.6* MCHC-30.0* RDW-15.2 RDWSD-43.7 Plt ___ ___ 12:53PM BLOOD WBC-13.4* RBC-3.25* Hgb-7.8* Hct-25.4* MCV-78* MCH-24.0* MCHC-30.7* RDW-15.3 RDWSD-42.9 Plt ___ ___ 08:06PM BLOOD WBC-11.9* RBC-3.44* Hgb-8.2* Hct-27.0* MCV-79* MCH-23.8* MCHC-30.4* RDW-15.5 RDWSD-43.8 Plt ___ ___ 04:54AM BLOOD WBC-10.4* RBC-3.36* Hgb-8.0* Hct-26.4* MCV-79* MCH-23.8* MCHC-30.3* RDW-15.3 RDWSD-43.7 Plt ___ ___ 04:54AM BLOOD Neuts-61.4 ___ Monos-8.5 Eos-1.3 Baso-0.3 Im ___ AbsNeut-6.38* AbsLymp-2.93 AbsMono-0.88* AbsEos-0.14 AbsBaso-0.03 ___ 04:49AM BLOOD WBC-8.5 RBC-2.98* Hgb-7.0* Hct-23.4* MCV-79* MCH-23.5* MCHC-29.9* RDW-15.2 RDWSD-43.3 Plt ___ ___ 04:49AM BLOOD Neuts-57.0 ___ Monos-6.2 Eos-2.2 Baso-0.4 Im ___ AbsNeut-4.85 AbsLymp-2.87 AbsMono-0.53 AbsEos-0.19 AbsBaso-0.03 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service with prolonged menses and pelvic pain. Transabdominal US showed didelphys uterus, dilated tubular structure concerning for hydrosalpinx and possibly blood within the endometrial cavity of left horn. Patient spiked a fever to a Tmax of 102.9. CXR showed no evidence of acute processes. WBC was 13.7. U/A was negative. Flu swab was negative. She was given 1 dose of IV flagyl and ciprofloxacin. Her fever resolved and further antibiotics were deferred given no clear etiology of infection. She then had an MRI pelvis that showed unicornuate uterus with left rudimentary non-communicating horn containing blood products, pelvic endometriosus with a large hematosalpinx, and non-visualized left kidney. On ___, patient underwent diagnostic laparoscopy under ultrasound guidance. Please see operative report for full details. Her post-operative course was uncomplicated. Immediately post-operatively her pain was controlled with PO acetaminophen and ibuprofen. Her diet was advanced without difficulty. By hospital day 3, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled and prescription for continuous combined oral contraceptives. Medications on Admission: none Discharge Medications: 1. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral daily RX *desogestrel-ethinyl estradiol 0.15 mg-0.03 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: unicornate uterus with left rudimentary non-communicating horn containing blood products, left hematosalpinx 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 with prolonged menses and fever. You were given IV antibiotics to treat a possible pelvic infection. You had a pelvic ultrasound that showed your previously diagnosed uterine abnormality. You then had an MRI that showed that the left side of your uterus was a separate entity that is closed off and does not connect with the right side of your uterus or your vagina. Accordingly, there was blood visualized within the left side of uterus that was found to be spilling back through your fallopian tube on that side into your pelvis. We recommended that you start continuous oral contraceptive pills to prevent further menstrual blood from collecting in the left side of your uterus. We also recommended that you have surgery to remove the left side of your uterus. The team believes you are now ready to be discharged home. Please call our Ob/Gyn office at ___ with any questions or concerns. Please follow the instructions below. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

19987702-DS-9

DS

2131-06-09 00:00:00

2131-06-09 17:44:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: ibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Abdominal wall abscess Major Surgical or Invasive Procedure: ___: Ultrasound-guided drainage of superficial right abdominal collection History of Present Illness: We have been consulted on this patient known to Dr. ___ who is status post open cholecystectomy for choledocolothiasis who presents to the ED with dehydration, leukocytosis and clinical/radiological findings concerning for abdominal wall abscess He's a ___ year old very frail male with medical history pertinent for multifocal parieto-occipital CVA, carotid stenosis s/p bilateral CEA, COPD, HTN, HLD, history of a Nissen fundoplication and a subsequent takedown, ___ esophagus that progressed to esophageal carcinoma. As above, he is status post open cholecystectomy performed for choledocholithiasis on ___ with uncomplicated postoperative course and discharged home on POD#3. Since discharge he endorses area of swelling, pain and ecchymosis at his incision. He was given Rx for Oxycodone post-op, used these, but still in pain. He presented to PCP to follow on these symptoms on ___. At that time he was found with area of ecchymosis and distention at incision site, as well as tender to palpation. A CT abdomen was performed which demonstrated postsurgical changes as well as a postoperative seroma along the right rectus musculature measuring approximately 2.2 cm. He presents to the ED today with progression of symptoms, more specifically he feels a "lump" at his incision. Denies any fever, nausea, chills, chest pain, shortness of breath, change in bowel habits, GI bleeding. Of note, he endorses lack of appetite (but this seems usual after each of the prior operations he has had) as well as intermittent dysuria. Upon arrival to the ED, VS: 98.8, 66, 108/66, 16, 97% RA. He is no in acute distress but oral mucosa is dry. Abdominal exam notable for area of swelling to subcostal incision with two ecchymotic areas at the mid portion of the incision. I could not express any purulent material of the incision. Slight tenderness to palpation. Otherwise abdomen is soft. Outside hospital labs remarkable for leukocytosis to 15 and hypokalemia. Liver function test unrevealing. Outside hospital CT abdomen performed today demonstrating a 7cm walled off collection with some fat stranding at the right upper quadrant abdominal wall. This collection seems not to communicate with the abdominal wall cavity. I could not appreciate any intraabdominal process. ROS: (+) per HPI (-) Denies pain, fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: Per HPI. Multifocal Parieto-occipital CVA (___) - (left parieto-occipital area most affected, some left MCA involvement) HTN, HLD, carotid stenosis s/p bilateral CEA AAA without rupture (2.6 cm), Aortic dissection - not otherwise specified, Esophageal adenocarcinoma, GERD, ___ Esophagus, s/p Nissen fundoplication revision, Diverticulitis, Adrenal Adenoma Asthma, COPD, Former smoker (40-pack yrs, Asbestos exposure)Pneumonia, recurrent, Chronic pain - pain agreement, potentially broken ___, Low back pain, Urinary frequency, Inguinal hernia, ventral hernias, Prior alcohol abuse Past Surgical History: Per HPI. Bilateral carotid endarterectomies Inguinal and ventral hernia repair x4 Endoscopic mucosal resection of mass at ___ junction ___ ___ and revision of ___ Fundoplication Upper EUS (___) ERCP and biliary stent placement (___) Social History: ___ Family History: Mother - CAD, PVD Father - Liver ca Other - Uncles - CVA, ___ cancer Physical Exam: Physical Exam on arrival: Vitals: 98.8, 66, 108/66, 16, 97% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Physical Exam on arrival: Vitals: Stable GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses; upper quadrant wound packed with wick (healing appropriately) Ext: No ___ edema, ___ warm and well perfused Pertinent Results: Lab Results: ___ 05:22AM BLOOD WBC-8.1 RBC-3.63* Hgb-10.7* Hct-31.7* MCV-87 MCH-29.5 MCHC-33.8 RDW-12.0 RDWSD-39.1 Plt ___ ___ 06:00AM BLOOD WBC-9.2 RBC-3.68* Hgb-11.0* Hct-32.1* MCV-87 MCH-29.9 MCHC-34.3 RDW-12.3 RDWSD-39.5 Plt ___ ___ 05:42AM BLOOD WBC-9.7 RBC-3.70* Hgb-10.6* Hct-32.9* MCV-89 MCH-28.6 MCHC-32.2 RDW-12.4 RDWSD-40.2 Plt ___ ___ 06:45AM BLOOD WBC-12.0* RBC-3.83* Hgb-10.9* Hct-33.3* MCV-87 MCH-28.5 MCHC-32.7 RDW-12.5 RDWSD-40.0 Plt ___ ___ 08:18AM BLOOD WBC-11.6* RBC-3.65* Hgb-10.8* Hct-32.5* MCV-89 MCH-29.6 MCHC-33.2 RDW-12.5 RDWSD-40.6 Plt ___ ___ 04:35AM BLOOD WBC-14.5* RBC-3.84* Hgb-11.1* Hct-33.4* MCV-87 MCH-28.9 MCHC-33.2 RDW-12.5 RDWSD-39.7 Plt ___ ___ 05:22AM BLOOD Neuts-60.2 ___ Monos-12.5 Eos-5.2 Baso-0.5 Im ___ AbsNeut-4.88 AbsLymp-1.69 AbsMono-1.01* AbsEos-0.42 AbsBaso-0.04 ___ 08:18AM BLOOD Neuts-68.6 Lymphs-17.3* Monos-12.8 Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.98* AbsLymp-2.01 AbsMono-1.49* AbsEos-0.02* AbsBaso-0.04 ___ 04:35AM BLOOD Neuts-74.2* Lymphs-11.5* Monos-13.0 Eos-0.0* Baso-0.4 Im ___ AbsNeut-10.76* AbsLymp-1.67 AbsMono-1.88* AbsEos-0.00* AbsBaso-0.06 ___ 05:22AM BLOOD Glucose-80 UreaN-6 Creat-1.2 Na-140 K-3.5 Cl-97 HCO3-31 AnGap-12 ___ 06:00AM BLOOD Glucose-100 UreaN-5* Creat-1.1 Na-141 K-3.4 Cl-99 HCO3-29 AnGap-13 ___ 05:42AM BLOOD Glucose-90 UreaN-9 Creat-1.3* Na-143 K-3.9 Cl-99 HCO3-29 AnGap-15 ___ 06:45AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-136 K-3.3 Cl-93* HCO3-29 AnGap-14 ___ 08:18AM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-142 K-3.6 Cl-106 HCO3-26 AnGap-10 ___ 04:35AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-140 K-3.9 Cl-103 HCO3-25 AnGap-12 ___ 05:22AM BLOOD Plt ___ ___ 05:22AM BLOOD ___ PTT-37.7* ___ ___ 09:50PM BLOOD PTT-36.3 ___ 01:20PM BLOOD PTT-49.3* Imaging: PERC IMAGE GUID FLUID COLLECT DRAIN W CATH (___): IMPRESSION: Successful US-guided placement of ___ pigtail catheter into the right abdominal wall collection. Sample was sent for microbiology evaluation. Microbiology results from drain: GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S). SPARSE GROWTH Brief Hospital Course: The patient presented to Emergency Department on ___. Patient was found to have an abdominal wall abscess. For this reason he was admitted to the ___ Surgery for further management. On admission the patient's INR was 4.3 and for this reason it was not possible to have the abscess drained on presentation. For this reason he was admitted for further management. His Coumadin was held and he was also given fresh frozen plasma and vitamin K. The following day the patient went to ___ and got the fluid drained and a drainage was placed. The fluid collected from the peritoneal fluid collected it grew sparse anaerobic gram negative rods (for full results please see results section of discharge summary). The patient's creatinine was elevated to 1.3 during the admission and for this reason he was started on IV normal saline. Following the ___ procedure the patient was restarted on a heparin drip. The heparin drip was then stopped and the patient was placed on warfarin with lovenox bridging. His creatinine function was downtrending. On discharge his INR was therapeutic and his lovenox was discontinued. Furthermore in summary during this hospital course review of systems had as follow: Neuro: The patient was alert and oriented throughout hospitalization pain was well controlled with acetaminophen and oxycodone. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. He had two episodes of asymptomatic high blood pressure that responded to IV hydrazine. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was on a regular diet, which was well tolerated. Patient's intake and output were closely monitored. He had two episodes of emesis during the hospital course that did not require further work up at the time. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. When the patient's admission the ___ was 14 that was within normal limits on discharge. The patient was placed on IV antibiotics (Vancomycin and zosyn) that was transitioned to oral augmentin on discharge. The patient needs to complete a two weeks course of augmentin upon discharge. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient was bridged back to Coumadin with lovenox. The INR level was appropriate at the time of discharge. Prophylaxis: ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. Social work: During this hospital course the patient expressed feelings of having difficulty coping. For this reason a social work consult was obtained and coping strategies and resources were put in place. 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 may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 2. Atorvastatin 80 mg PO QPM 3. Zolpidem Tartrate 10 mg PO QHS ___ MD to order daily dose PO DAILY16 5. TraZODone 50 mg PO QHS:PRN insomnia 6. Sertraline 100 mg PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Metoprolol Succinate XL 100 mg PO DAILY 10. LORazepam 1 mg PO Q8H:PRN anxiety 11. LevETIRAcetam 1000 mg PO BID 12. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth twice a day Disp #*17 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*9 Tablet Refills:*0 RX *oxycodone 5 mg ___ tablet(s) by mouth every 8 hours Disp #*25 Tablet Refills:*0 5. Senna 8.6 mg PO BID 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 7. Atorvastatin 80 mg PO QPM 8. Enoxaparin Sodium 70 mg SC Q12H If your INR is between ___ you can stop taking this medication. RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours Disp #*10 Syringe Refills:*0 9. LevETIRAcetam 1000 mg PO BID 10. LORazepam 1 mg PO Q8H:PRN anxiety 11. Metoprolol Succinate XL 100 mg PO DAILY 12. Ondansetron 4 mg PO Q8H:PRN nausea 13. Pantoprazole 40 mg PO Q12H 14. Sertraline 100 mg PO DAILY 15. TraZODone 50 mg PO QHS:PRN insomnia 16. ___ MD to order daily dose PO DAILY16 17. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Abdominal wall abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the ___ Surgery because you were found to have an abdominal wall abscess. You were placed on antibiotics and your anticoagulation was reversed. Then you had the abdominal wall abscess drained and have recovered well. You are now ready for discharge. 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. Coumadin: Please follow up with your PCP ___ ___ for an INR check and instructions on dosing your warfarin. Antibiotics: Please complete the full 9 day course(finish all the pills)that you were prescribed at discharge. Incision Care: Your dressing was changed on the day of discharge. Please continue to change it daily with clean dry gauze until it heals or scabs over. Then you should keep it covered only as needed. *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. It has been a pleasure looking after you and we wish you a speedy recovery. ___ Surgery Followup Instructions: ___

19988077-DS-7

DS

2140-05-22 00:00:00

2140-05-23 09:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Dysphagia and odynophagia Major Surgical or Invasive Procedure: Direct laryngoscopy with biopsy, tracheostomy, PEG placement ___ History of Present Illness: ___ yo male with laryngeal cancer s/p xrt and cirrhosis who presented with a 3 month history of dysphagia and odynophagia. He first noticed coughing with liquids, but his dysphagia progressed to complete intolerance of liquids. When drinking even small quantities, he developed severe coughing. He noted that he feels like he's "drowning". He has been able to tolerate solid foods, but experience had developed a very sore throat. He could only take liquids in very small amounts (ice and popsicles) and so he also has been producing lots of thick phlegm due to little hydration. His only other symptoms has been an associated 15 lbs weight loss over the last 3 months. He denied shortness of breath, nausea, vomiting, and abdominal pain. He had a barium study at ___ on ___ which showed deep laryngeal penetration, esophageal dysmotility, and hiatal hernia. He went to ___ ___ for an EGD and ? esophageal dilitation. OSH records noted no esophageal stricture, distal esophageal varices, and portal gastropathy. The records also indicated a pre-operative diagnosis of posterior pharyngeal tumor with dysphagia. He was then transferred to ___. Labs from OSH were WBC 7.5, Hb 10.1, Hct 28.5, Plt 87, Na 140, K 4.3, Cl 108, CO3 26, BUN 13, Cr 0.8, T Bili 2.2, AST/ALT 35/24, Alk Phos 99, Alb 3.0. He also had a normal non-contrast head CT. On arrival to ___, VSS and labs were notable for anemia, thrombocytopenia, and elevated INR to 1.5. On further interview, he revealed that he was lost to follow-up for chemotherapy after he was diagnosed with and treated for vocal cord carcinoma by ENT surgery and XRT in ___. Past Medical History: - vocal cord carcinoma, s/p ENT surgery and XRT in ___, resolved as far as patient knows - Distal esophageal stricture - Abdominal abscess ___ - diverticulitis - cirrhosis - ETOH abuse - anxiety - OSA - COPD Social History: ___ Family History: Prostate cancer in father. No hx of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals - T: 98.1 BP: 132/80 HR: 82 RR: 20 02 sat: 97% RA GENERAL: NAD, raspy voice, AAOx3, not jaundiced HEENT: AT/NC, EOMI, PERRL, anicteric sclera NECK: nontender supple neck CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, 5mm wound at LLQ draining minimal bloody discharge, no erythema, warmth or purulence. Dilated veins apparent in midepigastrium may represent mild caput madusae. No spider angiomata. EXTREMITIES: moving all extremities well, no edema SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM ======================= Vitals: 97.5 107/56 72 18 97% on 40% blow by General: NAD, sitting comfortably in bed HEENT: MMM, EOMI Neck: Trach in place, clean, no bleeding CV: RRR, no m/r/g. Lungs: CTAB, normal work of breathing. Abdomen: Soft, nondistended, tender around G tube site. No rebound tenderness, no guarding. G tube in place, dressing clean and dry, left sided ecchymosis, enterocutaneous fistula in left lower abd with colostomy bag (empty now). Ext: Warm and well perfused, 2+ distal pulses, no peripheral edema Neuro: AAOx3, able to communicate by whispering words but exam limited by trach. No asterixis. Pertinent Results: ADMISSION LABS ============== ___ 08:50PM BLOOD WBC-7.9 RBC-3.13* Hgb-10.2* Hct-31.3* MCV-100* MCH-32.4* MCHC-32.4 RDW-14.7 Plt Ct-78* ___ 08:50PM BLOOD Neuts-77.9* Lymphs-11.8* Monos-6.6 Eos-3.3 Baso-0.3 ___ 08:50PM BLOOD ___ PTT-39.7* ___ ___ 08:50PM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-140 K-4.5 Cl-110* HCO3-24 AnGap-11 ___ 08:50PM BLOOD ALT-27 AST-38 AlkPhos-105 TotBili-2.6* ___ 08:50PM BLOOD ALT-27 AST-38 AlkPhos-105 TotBili-2.6* ___ 08:50PM BLOOD Lipase-18 ___ 08:50PM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.1 Mg-1.6 ============ NOTABLE LABS ============ ___ 11:54AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:54AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG ___ 11:54AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-2 ___ 11:54AM URINE Mucous-RARE ============== DISCHARGE LABS ============== ___ 05:48AM BLOOD WBC-5.0 RBC-2.29* Hgb-7.8* Hct-23.5* MCV-103* MCH-34.2* MCHC-33.3 RDW-17.2* Plt Ct-93* ___ 05:48AM BLOOD Plt Ct-93* ___ 05:48AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-136 K-3.8 Cl-100 HCO3-31 AnGap-9 ___ 05:48AM BLOOD ALT-34 AST-30 AlkPhos-93 TotBili-1.3 ___ 05:48AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 ===== MICRO ===== BCX ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. ESCHERICHIA COLI. ___ MORPHOLOGY. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- =>64 R =>64 R CIPROFLOXACIN---------<=0.25 S =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ 8 I <=1 S TRIMETHOPRIM/SULFA---- <=1 S =>16 R BCX ___: ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ESCHERICHIA COLI. ___ MORPHOLOGY. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. CLOSTRIDIUM PERFRINGENS. Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 0040. GRAM NEGATIVE ROD(S). GRAM POSITIVE ROD(S). Peritoneal fluid ___: GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ======= IMAGING ======= CXR ___: Heart size is normal. Mediastinum is normal. There is no evidence of pneumomediastinum or pneumothorax within the limitations of the study technique. Bibasal opacities are present and unclear if represent atelectasis or aspiration. Some contribution to this appearance is done by the low lung volumes, although they cannot explain the entire extent of bibasal opacifications. There is no appreciable pleural effusion noted. CT Neck with contrast ___: Supraglottic glottic and subglottic circumferential mass consistent with known laryngeal cancer. CT Chest with contrast ___: Multifocal peribronchial, centrilobular and ___ opacities in the right middle lobe, lingula and larger consolidation in the left lower lobe are multifocal pneumonia, could be due to aspiration. Followup is recommended. Other more focal irregular soft tissue nodules described are of unclear etiology, could be infectious, but metastases cannot be excluded. Coronary calcification. Enlarged main pulmonary artery suggests pulmonary hypertension. Findings in the abdomen in keeping with patient known cirrhosis. Video oropharyngeal swallow ___: There was aspiration with liquids, nectar thick liquids, and honey thick liquids. Penetration with puree was demonstrated. Abdominal U/S ___: 1. Nodular, heterogeneous echotexture liver that is consistent with known cirrhosis. No concerning liver lesions identified. 2. Trace ascites. 3. Stable splenomegaly. 4. Gallbladder sludge and/or gravel without evidence of cholecystitis. Brief Hospital Course: ___ yo male with laryngeal cancer s/p xrt and cirrhosis who underwent attempted esophageal dilation at OSH for 3 month history of dysphagia and odynophagia, with laryngeal SCC. ============ ICU COURSE ============ The pt was admitted directly to the ICU from the general internal medicine floor. The pt presented from dysphagia and odynophagia and a CT of the neck revealed a supraglottic, glottic and subglottic circumferential mass concerning for laryngeal cancer. On the evening of the ___, the pt developed respiratory distress characterized by inspiratory stridor. He was given racemic epinephrine and 10mg IV Dexamethasone with improvement in his respiratory status and inspiratory stridor. He spent 2 night in the MICU for intensive respiratory monitoring. A surgical airway kit was placed by the bedside in the event of acute respiratory compromise requiring emergent surgical airway management. The patient was stable throughout his entire admission and did not require any additional therapies to manage his airway. He was transferred back to the ENT team for further management. ============ ACUTE ISSUES ============ # Laryngeal SCC: The patient has a history of laryngeal cancer, s/p ENT surgery (Dr. ___ in ___ and xrt in ___ with loss to follow-up for chemotherapy. As the patient presented with dysphagia/odynophagia, CT neck revealed a supraglottic, glottic, and subglottic circumferential mass consistent with laryngeal cancer. A CT chest showed multifocal peribronchial, centrilobular and ___ opacities c/w aspiration pna as well as more focal irregular soft tissue nodules that could not be ruled out as metastases. ENT was consulted, performed bedside laryngoscopy that noted a mass on the vocal cords. The patient was on Decadron ___ to reduce swelling and was placed on telemetry for continuous O2 monitoring. Speech and swallow was consulted to obtain a baseline video swallowing study, which showed aspiration with all liquids and laryngeal penetration with puree. Nutrition and general surgery were also consulted for the patient's nutritional status. The patient was started on PPN and the patient agreed to placement of a PEG by general surgery for more long-term nutritional needs. Oncology was consulted on ___ and recommended PET scan to clarify the extent of disease. Palliative care was consulted on ___ for assistance with symptom management as well as advanced care planning. On the evening of ___, the patient developed significant stridor and respiratory distress. He was given 10mg IV Dexamethasone and Racemic epinephrine with subsequent improvement in his stridor and respiratory status. He was monitored in the ICU where his course was uneventful and he did not require emergent intubation. He underwent biopsy and tracheostomy by ENT as well as PEG placement by general surgery on ___. He was monitored in the ICU for 24 hours post-op and transferred to the floor. The biopsy showed ___ and subsequent PET scan showed no evidence of metastasis. The patient was also seen by a social worker for ___, as he is the sole caretaker of his father. # LLQ Fistula: Patient describes fistula after an abdominal abscess in ___. Since that time it has been draining serosanguinous fluid, requiring ___ dressing changes per day. Surgery was consulted, but determined that there was no operative action necessary. The medical team obtained outside records from ___ in ___, which showed that the fistula is from a ruptured diverticulum and tracts to the colon. Surgery did not feel that additional imaging of the fistula was needed prior to placement of PEG tube for nutrition, as there is previous documentation of the fistula in OSH records. The fistula leaked some clotted blood throughout the hospitalization and wound care nurse saw patient and placed colostomy bag over fistula. The patient stated that he would continue to see his outpatient surgeon regarding the wound. ============== CHRONIC ISSUES ============== # Cirrhosis: The patient has a history of cirrhosis, presumably from ETOH. His MELD was 15, with normal GFR, no hyponatremia, INR 1.5, PLT 78, TBili 2.6. The patient was not encephalopathic. The patient denied a history of varices, ascites, or paracentesis, but had mild caput medusae on exam. An abdominal ultrasound ___ showed a nodular, heterogeneous echotexture liver consistent with cirrhosis and concerning liver lesions, trace ascites, and stable splenomegaly. There was concern about PEG placement in the setting of trace ascites so transplant surgery was consulted on ___, who did not believe there was any contraindication to PEG placement since the patient was not decompensated. The patient was continued on lasix, spironolactone, lactulose, and rifaximin while inpatient and these medications were continued at discharge. His lasix was increased to 40 mg PO daily. # Anemia: On admission, the patient had macrocytic anemia, likely due to alcoholic liver disease. He demonstrated no signs or symptoms of active bleeding. He was typed and screened, and cross-matched 2 units of blood for his surgery. His anemia was stable during his hospitalization. # Thrombocytopenia: On admission, the patient had thrombocytopenia with platelets of 78. However, this is likely due to alcoholic liver disease and perhaps some small serosanguinous fluid draining from the LLQ wound. His platelet count remained stable and uptrended a bit during his hospitalization. =================== TRANSITIONAL ISSUES =================== # pt should follow-up with ENT # The pt's LLQ fistula was evaluated by surgery at ___ and no operative management was necessary. Pt should continue to see his outpatient surgeon. # Patient should continue IV zosyn from ___ # Code: Full # Emergency Contact: ___ (girlfriend/HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium Bromide MDI 2 PUFF IH TID 2. Spironolactone 50 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Rifaximin 550 mg PO BID 5. Potassium Chloride 10 mEq PO DAILY 6. Aspirin 81 mg PO DAILY 7. Lactulose 30 mL PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Rifaximin 550 mg PO BID 4. Spironolactone 50 mg PO DAILY 5. Acetaminophen (Liquid) 650 mg PO Q6H pain or fever 6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 7. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation 8. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q2H:PRN pain RX *hydromorphone 0.5 mg/0.5 mL 0.25-0.5 mg IV Q2H Disp #*36 Syringe Refills:*0 9. Ipratropium Bromide Neb 1 NEB IH TID 10. Piperacillin-Tazobactam 4.5 g IV Q8H Last day of antibiotics to complete on ___ RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8) hours Disp #*21 Vial Refills:*0 11. Senna 8.6 mg PO BID:PRN Constipation 12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 13. Lactulose 30 mL PO TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ================= 1. Laryngeal cancer 2. Left lower quadrant abdominal fistula SECONDARY DIAGNOSES =================== 1. Cirrhosis 2. Anemia 3. Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. You were recently admitted for difficulty and pain when swallowing liquids and solids. A CT scan and biopsy showed that you had recurrence of laryngeal cancer. A tracheostomy was placed to ensure you would be able to breathe and a PEG tube was placed so that you can have adequate nutrition as you receive further treatment for the cancer. It is very important that you follow up with your ENT physician and oncologist, and we will help to arrange this for you. Sincerely, Your ___ care team Followup Instructions: ___

19988632-DS-4

DS

2182-05-27 00:00:00

2182-05-27 18:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: ___ to R hand Major Surgical or Invasive Procedure: I&D x2 Bone graft to thumb MC and ring MC from iliac crest History of Present Illness: CC: ___ to right hand HPI: Mr. ___ is a ___ year old RHD man with PMH of smoking and heavy EtOH use who presents with ___ to right hand. At baseline the patient smokes 1PPD and drinks 1 liter of hard EtOH per day and is currently unemployed. The patient was drinking EtOH overnight when he was shot in the hand just a few feet away at approximately 1:30am the morning of presentation. He initially presented to an OSH who transferred him to ___ for evaluation and treatment. He notes pain of his hand and swelling and decreased sensation of his third webspace. He has two wounds, one at the site of his right dorsal radial thumb, and the other between his ___ and ___ distal metacarpals on the dorsal aspect of his hand. He does not recall his last tetanus shot. He last ate around 6pm the prior evening and last drank EtOH at approximately the time of the gun shot at 1:30am. ROS: (+) per HPI (-) Denies fevers, chills, headache, dizziness, nausea, vomiting, chest pain, shortness of breath Past Medical History: ___ to left thigh Past Surgical History: L thigh surgery for ___ Medications: None Allergies: NKDA Social History: Drinks 1 bottle hard liquor daily (tequila). Smokes 1PPD ___ years). Smokes occasional marijuana. Denies other illicit drugs and IVDU. Not currently employed. Lives with sister. Physical ___: T: 98.6, HR 69, BP 103/58, RR 16, SpO2 100% RA GEN: A&O, NAD HEENT: mucus membranes moist CV: RRR PULM: Breathing comfortably on room air Ext: ___ on right hand dorsal radial base of thumb and ___ right hand dorsal between ring and little finger distal metacarpals. Doppler signal intact all digital arteries and palmar arch. Radial pulse 2+ palpable. Decreased sensation ulnar aspect middle finger and radial aspect of ring finger. Motor and tendon exam limited due to pain. Deficiency in right middle and index finger extension from MCP, but exam difficult due to limitation of pain. Some extension and flexion of right thumb IP joint however limited due to pain. Able to extend and flex wrist but limited due to pain. Right hand with volar and dorsal swelling but forearm and hand compartments currently soft. Laboratory: pending Imaging: R hand x-ray: Severely comminuted and intraarticular fracture right base of thumb metacarpal. Comminuted extraarticular fractures of distal ___ and ___ metacarpals. Assessment/Plan: Mr. ___ is a ___ year old RHD man with PMH of smoking and heavy EtOH use who presents with ___ to right hand. He is vascularly intact without current signs of compartment syndrome. He has extremely comminuted right proximal thumb metacarpal intraarticular fractures and right distal ring and little finger distal metacarpal extraarticular fractures, right ulnar middle finger and radial ring finger decreased sensation suggesting nerve injury, and inability to extend right middle and ring fingers suggestive of possible tendon injury, although exam limited due to pain. Plan for tetanus shot, IV antibiotics, and likely OR today for right hand I+D, ORIF of right thumb, ring, and little finger fractures, possible neurovascular repair, possible tendon repair, and possible ex fix. Given history of heavy EtOH use, will need to be monitored closely for withdrawal signs and symptoms. Past Medical History: Asthma Social History: ___ Family History: Noncontributory Physical Exam: No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended. ICBG site c/d/i. RUE: Incision clean/dry/intact with no erythema or discharge, minimal ecchymosis. Splint in place, clean, dry, and intact Pertinent Results: ___ 06:15AM GLUCOSE-127* UREA N-17 CREAT-1.0 SODIUM-140 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-21* ___ 06:15AM estGFR-Using this ___ 06:15AM WBC-13.7* RBC-4.50* HGB-14.8 HCT-41.5 MCV-92 MCH-32.9* MCHC-35.7 RDW-12.2 RDWSD-41.1 ___ 06:15AM NEUTS-85.9* LYMPHS-7.2* MONOS-6.2 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-11.73* AbsLymp-0.98* AbsMono-0.84* AbsEos-0.00* AbsBaso-0.03 ___ 06:15AM PLT COUNT-240 ___ 06:15AM ___ PTT-27.6 ___ 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 gunshot wound to the right hand and was admitted to the orthopedic surgery service. The patient was taken to the operating room on for I&D x2 and bone graft to thumb MC and ring MC from iliac crest, 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. He will be discharged on oral antibiotics for 7 days. 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 NWB in the RUE, and will be discharged on Keflex for antibiotics 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: N/a Discharge Medications: 1. Cephalexin 500 mg PO Q6H Duration: 7 Days RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 3. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H PRN Disp #*72 Tablet Refills:*0 5. Acetaminophen 1000 mg PO Q8H Discharge Disposition: Home Discharge Diagnosis: ___ to R hand. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. 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: - NWB RLE 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. 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. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your surgeon Dr. ___ in 2 weeks. Please call ___ to make an appointment. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Followup Instructions: ___

19988669-DS-9

DS

2156-07-29 00:00:00

2156-08-03 10:44:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / Motrin Attending: ___. Chief Complaint: bicycle accident Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old male who complains of a bicycle accident. The patient is transferred from OSH where he was an intoxicated bicyclist struck by motor vehicle. Unknown speed, whether helmeted, or whether LOC. he was reportedly riding erratically prior to the event. He had pan-CT scan at OSH which showed multiple facial fractures as well as a R PTX, chest tube placed at the OSH. Patient was combative and received a total of 6mg morphine and 3 mg ativan. Past Medical History: HIV - not on therapy. States he has been "fine" He has had HIV since age ___ HCV Social History: ___ Family History: NC Physical Exam: Admission PHYSICAL EXAMINATION: ___ Constitutional: Altered, GCS 13 HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact grossly though patient poorly compliant with exam. L sided periorbital ecchymosis. Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Psych: Normal mood Discharge PE: ___ General: NAD Lungs: LSCTAB, diminished at the bases CV: RRR, no mumurs, rubs or gallops Abd: Soft, nontender non distended Extrm: warm well perfused, L knee abrasion without edema, full ROM Neuro: Alert and oriented X3, MAE to command, PERRL Pertinent Results: ___ 08:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG ___ 08:00AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:00AM URINE RBC-0 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 06:24AM GLUCOSE-103 LACTATE-1.5 NA+-142 K+-4.2 CL--101 TCO2-26 ___ 06:15AM UREA N-9 CREAT-0.7 ___ 06:15AM ASA-NEG ETHANOL-64* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 06:15AM WBC-9.5 RBC-5.24 HGB-14.9 HCT-46.7 MCV-89 MCH-28.5 MCHC-31.9 RDW-13.9 ___ 06:15AM PLT COUNT-226 ___ 06:15AM ___ PTT-31.6 ___ ___ 07:05AM BLOOD WBC-7.8 RBC-5.39 Hgb-15.0 Hct-47.8 MCV-89 MCH-27.9 MCHC-31.4 RDW-13.8 Plt ___ ___ 07:05AM BLOOD ___ PTT-33.3 ___ ___: CXR: 1. Chest tube in appropriate position with small right-sided pneumothorax. 2. Increased opacities at the mid right lung is likely secondary to aspiration. Continued close interval follow up is recommended. ___: TIB/FIB XRAY: 1. Linear density along the posterior margin of the tibia may be secondary to an old trauma. No definite acute fracture is identified. 2. Irregularity along the lateral cortex of the distal tibia is incompletely evaluated on this exam, however also likely secondary to an old trauma ___: CXR: (CT to water seal) Stable small right pneumothorax Increased bibasilar opacities could be due to atelectasis and or aspiration Brief Hospital Course: Mr. ___ is a ___ year old man with a past medical history significant for HIV, HCV, and polysubstance abuse who was admitted to ___ from an OSH after he was hit by a car while riding his bike intoxicated. At the ___ hospital he was found to have a right pneumothorax for which a chest tube was placed, facial fractures and he was transferred to ___. His injuries include right sided tension pneumothorax, left lateral orbital wall fracture, left zygomatic fracture, nasal bone fractures, and a left maxillary sinus fracture. He was evaluated by plastic surgery and it was decided that operative management was would not be preformed on this admission. Opthalmology evaluated patient and deemed no intervention needed. Tertiary survey was negative for further injury. He was admitted to the general care floor and remained hemodynamically stable. He was placed on a CIWA scale for alcohol withdrawal. He was placed on a soft diet and sinus precautions. On ___, the right chest tube was placed to water seal; subsequent Chest X-Ray revealed increased pneumothorax. Thus, it was placed back to suction for 24 hours. Chest X-Ray on ___, showed small right pneumothorax and it placed back water seal. On ___, the Chest X-Ray was stable and his Chest tube was discontinued. A post pull film was stable small apical pneumothorax. He was discharged on ___ hemodynamically stable without an oxygen requirement. His pain was well controlled with oral Dilaudid. He was ambulating independently. He remained afebrile with a normal WBC. He was evaluated by social work and given an appointment for substance abuse follow up. Occupational Therapy saw patient for cognitive evaluation and concussive symptom education. He will see Plastic surgery and the ___ clinic as listed below. The patient was educated on discharge instructions and stated good understanding of the discharge care plan. ___ will evaluate him for medication review and home safety. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H Do not exceed 3 grams per day. 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain Do not drive or drink alcohol while on this medication. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 3. Ibuprofen 400 mg PO Q8H 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: polytrauma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ after a bike accident resulting in facial fractures and a pneumothorax requiring a chest tube. Your chest tube was removed and you are now ready to recover at home. You will follow up with the plastic surgery clinic and the general surgery clinic as listed below. Please continue a soft diet until you see plastic surgery on ___. Please maintian sinus precautions as listed below. 1. Take the prescribed medications as directed. 2. Do not forcefully spit for several days. 3. Do not smoke for several days. 4. Do not use straws for several days. 5. Do not forcefully blow your nose for at least 2 weeks, even though your sinus may feel “stuffy” or there may be some nasal drainage. 6. Try not to sneeze; it will cause undesired sinus pressure. If you must sneeze, keep your mouth open. 7. Eat only soft foods for several days, always trying to chew on the opposite side of your mouth. 8. Do not rinse vigorously for several days. GENTLE salt water swishes may be used. Slight bleeding from the nose is not uncommon for several days after the surgery. Please keep our office advised of any changes in your condition, especially if drainage or pain increases. It is important that you keep all future appointments until this condition has resolved. Please come back to the emergency room with : A fever of 101.5 or greater, chils Nausea or vomitting chest pain or shortness of breath Dizziness or changes in vision or any other concerning symptoms. You are given narcotic pain medication to treat your pain. You may also take Tylenol and Ibuprofen. Do not drive or drink alcohol while on this medication. It may cause constipation so continue to take a stool softener unless you start having loose stool. Followup Instructions: ___

19988951-DS-12

DS

2168-06-09 00:00:00

2168-06-09 22:43:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Epinephrine / Novocain Attending: ___. Major Surgical or Invasive Procedure: Percutaneous coronary intervention with drug-eluting stent placement attach Pertinent Results: ADMISSION LABS: ============== ___ 10:27AM BLOOD WBC-6.6 RBC-3.89* Hgb-12.5* Hct-37.1* MCV-95 MCH-32.1* MCHC-33.7 RDW-12.4 RDWSD-42.9 Plt ___ ___ 10:27AM BLOOD ___ PTT-29.3 ___ ___ 10:27AM BLOOD Glucose-381* UreaN-20 Creat-1.2 Na-129* K-5.2 Cl-92* HCO3-23 AnGap-14 ___ 10:27AM BLOOD cTropnT-<0.01 ___ 01:55PM BLOOD cTropnT-<0.01 ___ 07:40PM BLOOD cTropnT-<0.01 ___ 10:27AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8 ___ 10:57AM BLOOD pO2-60* pCO2-37 pH-7.43 calTCO2-25 Base XS-0 Comment-GREEN TOP ___ 11:04AM BLOOD ___ pO2-76* pCO2-40 pH-7.40 calTCO2-26 Base XS-0 DISCHARGE LABS: ============== ___ 08:56AM BLOOD WBC-6.8 RBC-4.29* Hgb-13.8 Hct-40.8 MCV-95 MCH-32.2* MCHC-33.8 RDW-12.7 RDWSD-43.8 Plt ___ ___ 08:56AM BLOOD Glucose-255* UreaN-17 Creat-1.0 Na-135 K-4.9 Cl-100 HCO3-21* AnGap-14 ___ 08:56AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0 IMAGING: ======== 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 a small to moderate area of regional left ventricular systolic dysfunction with hypo to akinesis of the basal inferior and basal inferolateral walls, mid to apical anterior wall and interventricualr septum (see schematic). The visually estimated left ventricular ejection fraction is 35-40%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with uninterpretable free wall motion assessment. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. There is a normal descending aorta diameter. 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 pulmonic valve leaflets are normal. The tricuspid valve is not well seen. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild to moderate regional dysfunction c/w multiveselCAD/infarction. Cannot assess right ventricular function due to poor image quality. No overt valvular abnormalities. Compared with the prior TTE (images not available for review) of ___, the findings are new. CARDIAC CATHETERIZATION - ___ Coronary Description LM: The left main coronary artery is with eccentric 30% distal. Circ: The circumflex coronary artery is with widely patent stent and 90% hazy stenosis distal prior to bifurcation. L-L and L-R collaterals are present. RCA: The right coronary artery is with multiple prior stents and mid occlusion. A moderate branching AM is now with origin occlusion and fills slowly via R-R collaterals. LIMA-LAD: A left internal mammary artery to the LAD is widely patent. There is retrograde filling of a diagonal branch. L-L and L-R collaterals are present. SVGs: Known occluded and not engaged. RI: The ramus intermedius is small caliber with diffuse 70-80% proximal. Complications: There were no clinically significant complications. Findings: • Three vessel coronary artery disease. • Successful PCI with drug-eluting stent of the circumflex coronary artery. Recommendations • ASA 81mg per day. • Plavix 75mg/day • Secondary prevention of CAD • Maximize medical therapy Brief Hospital Course: Mr. ___ is a ___ year old man with PMH of CAD s/p 4v CABG as well as numerous PCIs, HTN, HLD, T1DM on insulin pump, who presented with recurrent MI equivalent pain of jaw/L arm pain with EKG negative for ischemia and troponins negative x2, most concerning for unstable angina. The patient was admitted with initial plan for nuclear stress test. Following admission the patient had significant chest pain not relieved with sublingual nitro, with no troponin elevation or EKG changes. He was started on a nitro gtt and underwent PCI with coronary angiography, with placement of one DES for 90% hazy stenosis distal prior to bifurcation in the circumflex artery. The patient remained free from chest pain following PCI and was discharged home in stable condition with continuation of dual-antiplatelet therapy. #CORONARIES: CABG ___ with LIMA to LAD, SVG to OM, Diagonal, PDA (___). Multiple PCI's on SVG's, the last in ___ PTCA to ramus, PCI of mid LCX ___. #PUMP: LVEF 45-50% (echo from ___ #RHYTHM: NSR #CODE: Full Code (Presumed) #CONTACT: No healthcare proxy selected TRANSITIONAL ISSUES: ==================== [] Discharge weight: 182.98 lb (83 kg) [] Discharge creatinine: 1.0 [] Discharge Hgb/Hct: 13.8/40.8 [] Please check Chem-7 at discharge to monitor electrolytes on lisinopril [] Consider increasing dose of lisinopril from 5mg to 10mg daily [] Continue dual-antiplatelet therapy with ASA 81mg and Plavix 75mg daily indefinitely for coronary artery disease [] Consider increasing atorvastatin from 40mg to 80mg daily if patient tolerates. [] Recommend repeating TTE within 5-weeks of discharge to evaluate LVEF and regional wall motion abnormalities. Pre-cath TTE revealed suboptimal image quality, mild to moderate regional dysfunction c/w multiveselCAD/infarction and no overt valvular abnormalities, with LVEF 35-40% (reduced from prior 45-50% in ___. #ACTIVE ISSUES: =============== # Unstable Angina The patient presented with intermittent return of MI equivalent pain represented as jaw/L arm pain at rest. Symptoms started several weeks prior to admission and recurred, most recently experiencing these symptoms a few days prior to admission, while at rest. He had been using SL nitro with relief of his symptoms as well as restarted Imdur per the advice of his RN sister. He was free from chest pain upon arrival. EKG re-demonstrated LBBB. Troponins were negative x2. His presentation is concerning for UA. After discussion with patient, decision was originally to go for cardiac nuclear stress test. However due to several episodes of chest pain overnight ___ requiring nitro gtt, the patient underwent PCI for unstable angina on ___. Pre-cath TTE revealed suboptimal image quality, mild to moderate regional dysfunction c/w multivesel CAD/infarction and no overt valvular abnormalities, with LVEF 35-40%. Coronary angiography revealed 3-vessel CAD with 90% hazy stenosis distal prior to bifurcation in the circumflex artery, for which 1 DES was placed without complications. - Continued optimal medical management for CAD with aspirin, clopidogrel, atorvastatin, lisinopril and metoprolol succinate #HTN Continued home Lisinopril 5mg daily and home metoprolol succinate 100mg daily. - Consider increasing lisinopril from 5mg to 10mg daily if tolerated. #CHRONIC ISSUES: ================ #T1DM on insulin pump: ___ Diabetes was consulted for in-patient diabetes management, who determined that the patient was fully capable of operating his insulin pump. The patient managed his insulin independently throughout the admission without complications. #CAD s/p 4v CABG and numerous PCIs #Ischemic cardiomyopathy without evidence of HF, EF 45-50% (___) Continued Atorvastatin, ASA, clopidogrel and metoprolol - Consider increasing atorvastatin from 40mg to 80mg daily if patient tolerates. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Lisinopril 5 mg PO QHS 4. Atorvastatin 40 mg PO QPM 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Neck/L arm pain 8. Terazosin 5 mg PO QHS 9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 10. Vitamin D 1000 UNIT PO DAILY 11. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Target glucose: ___ Fingersticks: QAC and HS Discharge Medications: 1. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Target glucose: ___ Fingersticks: QAC and HS 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 5. Clopidogrel 75 mg PO DAILY 6. Lisinopril 5 mg PO QHS 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Neck/L arm pain 9. Terazosin 5 mg PO QHS 10. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Unstable angina Coronary artery disease SECONDARY DIAGNOSIS: Type 1 diabetes mellitus 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 having chest pain and there was concern for a blockage in one of the arteries that supplies your heart. WHAT WAS DONE IN THE HOSPITAL? - The function of your heart and lungs was monitored. You were given medications to treat your chest pain. - You had a procedure called a cardiac catheterization and a stent was placed to open a blockage in one of your coronary arteries. WHAT SHOULD I DO WHEN I GET HOME FROM THE HOSPITAL? - Continue to take all of your medications as prescribed. - Follow-up with your Cardiologist and your other doctors. - If you experience chest pain, shortness of breath or generally feel unwell, call your doctor or go to the nearest emergency room. Sincerely, Your ___ Treatment Team Followup Instructions: ___

19988997-DS-14

DS

2174-06-29 00:00:00

2174-06-29 14:05:00

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: ___ - Coronary angiogram with POBA History of Present Illness: ___ year old male with no known PMH presents as a transfer from ___ with NSTEMI and ongoing CP at rest concerning for ACS. Patient developed severe chest pressure/pain around 9PM last night. He tried to go to sleep but was unable to get comfortable. HE denied any associated shortness of breath, N/V, diaphoresis, radiation, or lightheadedness. He denied any pleuritic or positional component to the pain. Has not had recent infection. He has no cardiac history, but does get occasional chest pain lasting a few minutes relieved by drinking water. No exertional chest pain. In the ED initial vitals were: 98.4 60 144/80 20 96% RA EKG: NSR, LVH, diffuse J-point elevation, Not particularly ischemic. Labs/studies notable for: CKmb 94, troponin 1.38 Patient was given: IV heparin. full dose ASA, 500 cc IV fluids. Vitals on transfer: 50 127/69 12 95% RA On the floor He was complaining of ___ typical chest pain, refractory to SL nitro glycerine. Past Medical History: No known medical history. Denied HTN, HLD, DM. Social History: ___ Family History: Mother with cardiac disease in early ___. Divorced. Works in ___ Physical Exam: ADMISSION PHYSICAL EXAM ======================= 24 HR Data (last updated ___ @ 1701) Temp: 98.3 (Tm 98.3), BP: 109/57 (109-152/57-83), HR: 63 (51-63), RR: 18, O2 sat: 97% (97-98), O2 delivery: RA, Wt: 159.83 lb/72.5 kg (159.83-161.82) GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated CARDIAC: Regular rate and rhythm. Soft heart sounds, but nl S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: clammy, but 2+ DP's and radial pulses. SKIN: clammy PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ======================= 24 HR Data (last updated ___ @ 1205) Temp: 98.8 (Tm 98.8), BP: 104/64 (91-152/50-83), HR: 57 (47-67), RR: 16 (___), O2 sat: 95% (94-98), O2 delivery: RA, Wt: 159.83 lb/72.5 kg (159.83-161.82) Fluid Balance (last updated ___ @ 601) Last 8 hours Total cumulative -470ml IN: Total 130ml, IV Amt Infused 130ml OUT: Total 600ml, Urine Amt 600ml Last 24 hours Total cumulative -408ml IN: Total 992ml, PO Amt 50ml, IV Amt Infused 942ml OUT: Total 1400ml, Urine Amt 1400ml GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRLA. MMM. NECK: Supple. JVP not elevated CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: Normal work of breathing on RA. No crackles, wheezes or rhonchi. Pertinent Results: ADMISSION LAB RESULTS ===================== ___ 02:29PM BLOOD WBC-6.7 RBC-4.21* Hgb-13.3* Hct-39.0* MCV-93 MCH-31.6 MCHC-34.1 RDW-11.5 RDWSD-38.8 Plt ___ ___ 02:29PM BLOOD Glucose-112* UreaN-11 Creat-1.2 Na-139 K-4.4 Cl-100 HCO3-25 AnGap-14 ___ 02:29PM BLOOD cTropnT-1.38* ___ 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.2 Cholest-157 PERTINENT LAB RESULTS ===================== ___ 02:29PM BLOOD cTropnT-1.38* ___ 07:36PM BLOOD CK-MB-96* cTropnT-1.68* ___ 03:00AM BLOOD CK-MB-64* cTropnT-2.22* ___ 07:00AM BLOOD CK-MB-45* cTropnT-1.96* DISCHARGE LAB RESULTS ===================== ___ 07:00AM BLOOD WBC-7.2 RBC-3.64* Hgb-11.7* Hct-34.2* MCV-94 MCH-32.1* MCHC-34.2 RDW-11.9 RDWSD-41.0 Plt ___ ___ 07:00AM BLOOD Glucose-107* UreaN-11 Creat-1.2 Na-140 K-4.2 Cl-105 HCO3-21* AnGap-14 IMAGING ======= ___ CXR No evidence of pulmonary edema. Mildly enlarged cardiac silhouette when compared to prior. ___ Coronary angiogram A 6 ___ EBU3.5 guide provided adequate support. Crossed with a Prowater wire into the distal LAD.Dilated with a 2.0 mm balloon. Final angiography revealed normal flow, no dissection and 40% residual stenosis. Findings • Two vessel and branch coronary artery disease. • Successful POBA of the diagonal coronary artery. • Possible culprits tiny OM not amenable to PCI or diseased diagonal branch. Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] New medications on discharge: metoprolol-XL 25 mg daily, atorvastatin 80 mg daily, clopidogrel 75 mg daily for one year, imdur 30 mg, and aspirin 81 mg daily. SUMMARY STATEMENT: ================== ___ year old male with no known past medical history transferred from ___ with ongoing chest pain and troponin elevations, concerning for NSTEMI. Patient was placed on a heparin and nitro drip and noted to have troponins 1.38->1.68-2.22. Cardiac cath showed 90% stenosis of the first diagonal branch of the LAD. PCTA was performed at the site. Patient was Plavix loaded and discharged on statin, aspirin, metoprolol, and Plavix for one year. HOSPITAL COURSE: ================ # NSTEMI Patient presented with typical cardiac chest pain at rest without known cardiac risk factors except for family history of heart disease. EKG non-ischemic, with likely LVH. Patient was aspirin loaded, placed on a heparin drip, and nitro drip. Hb A1c 4.9% and lipids were within normal limits. Chest pain resolved as of ___ AM after being on nitro drip. Troponin elevations were noted 1.38->1.68-2.22 along with lactate elevations to 2.3. He was taken to cath, which showed 90% stenosis of the ___ diagonal branch of the LAD. PCTA was performed at this site. Patient was Plavix loaded and discharged on Plavix for one year, asa 81, metoprolol-xl 25, imdur 30 mg, and atorvastatin 80. TTE and ___ eval were performed prior to discharge. Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Q5MIN:PRN Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Non-ST elevation myocardial infarction 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 to the hospital because of chest pain WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were found to have a heart attack. You were started on blood thinning medication and medication to help increase blood flow in the heart. Your chest pain went away on this medication. - A procedure was done to see the vessels around the heart. It showed a significant blockage of one of the vessels. A procedure was performed to open the blockage up with a balloon through the vessel. - When your chest pain improved, you were discharged home. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Please return to the emergency room if you have severe chest pain, worsening shortness of breath, or loss of consciousness. We wish you the best! Your ___ Care Team Followup Instructions: ___

19989126-DS-15

DS

2149-08-26 00:00:00

2149-08-26 14:42:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___ Bilateral External Ventricular Drain placement ___ Diagnostic Cerebral Angiogram History of Present Illness: ___ who was ___ her usual state of health until around 3pm this afternoon when she c/o a severe headache, she than began vomiting. She was taken to ___ where a head CT showed IVH, she was intubated and medflighted to ___. Upon arrival to the ER, her head CT was reviewed and bilateral EVDs were placed given the significant IVH. Past Medical History: ___: Thalamic bleed, admitted to ___ Stroke, angio showed ___ and 2 small aneurysms near the ventricles. Patient was seen at ___ and underwent bypass surgery with Dr ___. Depression- was on medication but discontinued secondary to side effects. Social History: ___ Family History: Unknown hx of vascular anomalies Physical Exam: ADMISSION PHYSICAL EXAM: Gen: Intubated, sedated for EVD placement HEENT: Old R temporal crani scar Neuro: No ___ to stim, bringing torso off the bed, no commands, PERRL but sluggish, + cough. DISCHARGE PHYSICAL EXAM: ___: thin F ___ NAD, opens eyes to voice, speaks softly, often tearful HEENT: R and L EVD scars well-healed. Staples ___ place over R EVD scar. PERRL, mild photophobia (significantly improved). Negative Kernig/Brudzinski. Neuro: -Mental status: AAOx2 (person, place). Comprehension intact. Follows simple commands, midline and appendicular. -Cranial nerves: CN II-XII grossly intact. +mild photophobia, significantly improved. -Strength: ___ all extremities -Sensation: intact throughout Pertinent Results: ___ CT head: Bilateral IVH, left ventricle fully casted, right ventricle appears about 80% casted, blood noted ___ third and fourth ventricle. No SAH can be appreciated ___ the OSH scan. Some edema near the pons. ___ CT head: 1. No change ___ extensive intraventricular blood, status post bilateral ventricular drain placements. 2. Effacement of the basal cisterns and sulci of the occipital lobe. Low lying cerebellar tonsils is concerning for herniation, unchanged from prior study. 3. Diffuse subarachnoid hemorrhage, slightly increased from prior. ___ Portable CXR: IMPRESSION: 1. Nasogastric tube courses below the diaphragm with its tip coiled likely within the stomach. An endotracheal tube remains ___ place ___ satisfactory position. The lungs are well inflated without evidence of focal airspace consolidation, pleural effusions, or pneumothorax. Overall, cardiac and mediastinal contours are within normal limits. ___ CT head: IMPRESSION: 1. Interval improvement ___ hydrocephalus and intraventricular hemorrhage. No new hemorrhage. 2. Unchanged position of bifrontal approach EVDs. 3. Subarachnoid hemorrhage is no longer visualized, compatible with evolution of blood products. ___ head CT IMPRESSION: 1. Interval evolution of blood products with improvement ___ intraventricular hemorrhage and no significant change ___ size of ventricles. 2. Unchanged position of bifrontal approach EVDs. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 9:52 AM IMPRESSION: Interval removal of a left frontal approach EVD with post-procedural small amount of air ___ the right frontal horn and moderate amount of air ___ the right temporal horn. 1. Allowing for the new air ___ the ventricular system, the right lateral ventricle is unchanged and there is no evidence of hydrocephalus or new mass effect. 2. Right frontoparietal subarachnoid hemorrhage is stable-more conspicuous on prior exam from ___- attention on f/u. CHEST (PORTABLE AP) Study Date of ___ 12:48 AM FINDINGS: ___ comparison with the study of ___, there is no change or evidence of acute cardiopulmonary disease. Specifically, no pneumonia, vascular congestion, or pleural effusion. CHEST PORT. LINE PLACEMENT Study Date of ___ 8:56 AM Right PICC line has been inserted with the tip at the level of mid SVC. Heart size and mediastinum are unremarkable. Lungs are essentially clear. ___ PORTABLE ABDOMEN: Air is seen throughout non-distended loops of small and large bowel. There is moderate amount of dense stool throughout colon, particularly at the cecum. No evidence of pneumoperitoneum on this single supine film. Osseous structures are unremarkable. IMPRESSION: Non-obstructive bowel gas pattern. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 3:15 ___ CONCLUSION: Status post revision of EVD. Increased air ___ frontal horn of the lateral ventricle. Decreased air ___ the temporal horn of the right lateral ventricle. Small amount of blood seen ___ the bilateral occipital horns of the lateral ventricle is unchanged compared to prior study. No evidence of hydrocephalus. No evidence of new hemorrhage. ___ CT Head w/o Contrast: Decrease ___ right lateral ventricular gas and decreased intraventricular blood. Unchanged position of a right frontal approach ventriculostomy catheter ___ the parenchyma adjacent to the left side of third ventricle. Correlate clinically if this is the desired position. No new acute hemorrhage is detected PORTABLE CHEST X-RAY (___): As compared to the previous radiograph, there is no relevant change. Normal size of the cardiac silhouette. No acute changes such as pneumonia or pulmonary edema. No pleural effusions. NONCONTRAST HEAD CT (___): Status post removal of VP shunt. Normal postsurgical change. No evidence of acute hemorrhage or findings to suggest hydrocephalus. MICROBIOLOGY: ___ 11:36 am URINE Source: Catheter. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S ___ 1:09 pm URINE Source: Catheter. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S ___ 12:52 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE COCCUS(COCCI). ~8OOO/ML. ___ 9:55 am CSF;SPINAL FLUID Source: Shunt. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. Reported to and read back by ___. ___ ___, ___, 1:30PM. FLUID CULTURE (Final ___: STAPHYLOCOCCUS EPIDERMIDIS. MODERATE GROWTH. SPECIATION REQUESTED BY ___. ___ ___ ___. ENTEROCOCCUS SP.. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. Sensitivity testing performed by Sensititre. STAPH AUREUS COAG +. RARE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SECOND MORPHOLOGY. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS | ENTEROCOCCUS SP. | | CORYNEBACTERIUM SPECIES (DI | | | STAPH AUREUS COA | | | | STAPH | | | | | AMPICILLIN------------ <=2 S GENTAMICIN------------ <=0.5 S <=2 S <=0.5 S <=0.5 S OXACILLIN-------------<=0.25 S 0.5 S =>4 R PENICILLIN G---------- 8 S 0.25 S RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S 1 S <=1 S 1 S ___ 1:50 pm CSF;SPINAL FLUID Source: Shunt. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. Reported to and read back by ___ @ 1645, ___. FLUID CULTURE (Final ___: STAPHYLOCOCCUS EPIDERMIDIS. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 350-3181N ___. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 350-3181N ___. ENTEROCOCCUS SP.. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 350-3181N ___. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 2:08 pm FOREIGN BODY Site: CATHETER EXTERNAL VENTRICULAR DRAIN CATHETER. **FINAL REPORT ___ WOUND CULTURE (Final ___: NO GROWTH. ___ 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-PICC. BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 4:42 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-PICC. BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 5:00 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Pending): ___ 11:17 am CSF;SPINAL FLUID Source: Shunt. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 5:30 am BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: On ___, Ms. ___ required urgent placement of bilateral EVDs for obstructive hydrocephalus ___ the setting of bilateral intraventricular hemorrhage. The EVDS were placed emergently ___ the ED and she was subsequently transferred to the Neuro-ICU intubated. The patient was extubated on ___, HD #2, without event. Her total drain output was maintained at > 20 mL/hr. On ___, it was noted that right EVD drained well with left EVD having minimal output. Protocol drain trouble shooting efforts, improved the left EVD output. On HD #4, ___, bleeding from EVD site was observed on rounds. PTT was elevated at 64.8. Patient's subcutaneous heparin was temporarility discontinued. The head CT remained stable. On HD #5, ___, patient's subcutaneous heparin was re-initiated with a bid dosing schedule rather than tid. On examination, patiet appeared delerious, which was attributed to sleep deprivation. On HD #6, ___, patient remained agiated on examination. We continued to monitor her closely ___ the neuro-ICU. On ___, PTT was elevated to 57.1, SQH was decreased to 2500 units. She was febrile to 101.1 overnight, urine culture was sent. Patient reported significant headache and toradol was added. Her L EVD was clamped ___ attempt to remove and R drain remained open. On ___, there were no issues with elevated ICPs while L EVD clamped. A head CT was done which showed stable ventricle size and L EVD was removed. R EVD was clamped ___ attempt to removed as well. She was afebrile overnight. Patient reported pain and aggitation, she was placed on standing toradol and prednisone. On ___ patient was found to have an enterococcus UTI and was started Vancomycin. The patients Intercranial pressures were ___ and the EVD was opened. On ___, The External Ventricular Drain was open and the ICP was 10. The patient had complaints of severe headache and a Head Ct was performed which was consistent with interval removal of a left frontal approach EVD with post-procedural small amount of air ___ the right frontal horn and moderate amount of air ___ the right temporal horn. Allowing for the new air ___ the ventricular system, the right lateral ventricle is unchanged and there is no evidence of hydrocephalus or new mass effect. Right frontoparietal subarachnoid hemorrhage is stable. Ampicillin was added by ICU for the UTI. On exam, the patient opened eyes to command, exhibited signs of photophobia. The patient was not answering questions secondary to pain, but did follow commands ___ all 4 extremities. On ___, The patient had a temperature of 101 overnight and urine/blood/Cerebral SpinalFluid cultures were sent. The CSF culture prelim findings were consistent with +3Gram Postive Cocci and 2+Gram Negative Rods. There was a question that this may have been a contaminant and a second CSF culture was sent. The patient was more lethargic ___ am and this was thought to be due to fever and lack of sleep. The neurological assessment was changed to every four hours to allow for sleep. The patient became more alert as the ___ progresses and followed command more readily. The serum sodium was 129. Urine lytes were send dueto urine output of 200cc /hr for repeated hours and were consistent with Creatinine of 15, serum sodium 10, potassium 9, chloride of 16, and Osmolality of 92. Due to poor nutritional intake the patient was initiated on IVF at 75cc/hr. The External ventricular drain was open and draining well. The EVD was level at 10 above the tragus. A Infectious Disease consult was called to recommend planning for laproscopic Ventricular Peritoneal shunt and steroid therapy for headache given fevers 101-103 and infection. The White Blood Count was slightly elevated at 11.1. The patient continued to complain of servere headache and neck pain. Topiramate (Topamax) 25 mg PO/NG BID for headache was initiated perthe ICU team. A KUB was performed given temperature of 103 for abdominal tenderness. On exam, the patient opened eyes to voice and followed intermitent commands. The pupils were equal reactive. The patient briskly localized. The patient moved the bilateral lower extremities to command intermitently. On ___, pt continued spiking fevers (Tmax 102.8). Her antibiotics were switched to Vanc/Meropenam per ID recs for empiric treatment of meningitis (Vanc also covering her pan-sensitive UTI). Her EVD was replaced ___ the OR out of concern that EVD contamination had caused the meningitis. On ___, pt remained confused with persistent photophobia and meningismus. Head CT assessing EVD position showed Status post revision of EVD. Increased air ___ frontal horn of the lateral ventricle. Decreased air ___ the temporal horn of the right lateral ventricle. Small amount of blood seen ___ the bilateral occipital horns of the lateral ventricle is unchanged compared to prior study. No evidence of hydrocephalus. No evidence of new hemorrhage. The Cerebral Spinal Fluid preliminary culture grew gram negative staph, cornyebacterium (diptheroids), enterococcus (rare growth). Per infectious disease recommendations antibiotics were narrowed to Vancomycin 1g every 8 hrs for External Ventricular Drain-associated meningitis. Severe headaches persist and patient pain managed with fioricet/dilaudid/topomax. On ___, The patient exam was slightly improved exam improved and the patient was noted to have multiple loose stools. A urine culture was sent which was negative. On ___, The patient experienced fever to 101.8 overnight, The external ventricular drain was clamped as a trial to see if the patient would tolerate it. The Intercranial Pressures were low ___ ___ the morning. Intercranial pressures rose, prompting the right EVD to be re-opened wtih 5 mL of drainage. Pysical Therapy and Occupational Therapy orders were placed. The foley catheter was discontinue. The patient has had poor po intake due to pain and delerium and was initiated on intravenous fluid at a rate of 75cc/hr. On ___, the patient remained agitated during examination. As her ICPs were ___, her EVD was reclamped. ICPs remained near 3. Ms. ___ Foley was replaced per nursing request to optimize care. On ___, patient's examination was dramatically improved. Agitation was substantially decreased and patient was able to move all four extremities to command. The EVD remained clamped with tolerable ICP. Repeat head CT revealed decrease ___ right lateral ventricular air and decreased intraventricular blood. ___ the afternoon, the patient was febrile to 100.3, a fever workup was institued and CSF cultures were obtained. ___, patient spiked to Tm 102.8. As per ID's recommendations we change her antibiotics from Vancomycin to Linezolid to rule out Vancomycin as the source of her fevers. Her EVD was removed and a CSF sample was sent again. Patient no longer requires ICU level care and is ready for transfer to a SD unit. On ___, patient remained afebrile on the floor; photophobia mildly improved but still confused and oriented only to self. Her right EVD staples were removed. CSF cultures have shown no growth to date since the positive cultures on ___. On ___, Patient self-DC'd her PICC twice, so her Linezolid was switched to PO (confirmed OK with ID). On ___, patient spiked fever to 102.3. Blood cultures were sent (no growth to date). Chest x-ray showed no infiltrate. Unable to obtain urine culture as patient incontinent and refusing straight cath. On ___, patient was discharged to rehab. ===================================== TRANSITION OF CARE: -Studies pending on discharge: blood cx (___) -If spikes fever, consider UTI (unable to obtain UCx after pt spiked fever on ___ -Needs right-sided head staples removed on ___ -Needs follow-up appointment with Dr. ___ ___ 4 weeks (phone # ___. Will need head CT prior to appointment. Medications on Admission: none Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN pain max apap ___ 2. Heparin 2500 UNIT SC BID 3. Linezolid ___ mg PO Q12H Use while patient has no IV access instead of IV dosing 4. Topiramate (Topamax) 25 mg PO BID 5. DiphenhydrAMINE 25 mg PO Q6H:PRN Itch 6. Docusate Sodium 100 mg PO BID 7. Senna 1 TAB PO BID Constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Intraventricular hemorrhage Cerebral AVM UTI EVD-associated meningitis Chronic pain Hypertention Acute confusion/delerium Altered mental status Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___, It was a pleasure participating ___ your care at ___ ___. You were admitted to the hospital with headache, nausea and vomiting. You were found to have intraventricular hemorrhage (bleeding into the ventricles of your brain), caused by your ___ disease. Extraventricular drains (EVDs) were placed for monitoring and drainage, and you were admitted to the ICU. ___ the ICU you developed meningitis - infection of the fluid surrounding the brain. You were treated with antibiotics and your meningitis resolved. Your EVDs were then removed and you were transferred to the medical floor where your symptoms continued improving. Because you are still too weak to go home alone, you are being discharged to rehab. We made the following changes to your medications: 1. STARTED Linezolid ___ by mouth every 12 hours for your meningitis. (Last ___ = ___ 2. STARTED Fioricet (acetaminophen-caffeine-butalbital) ___ tabs every 4 hours as needed for headache 3. STARTED Topomax (topiramate) 25mg by mouth twice daily for headache 4. STARTED Benadryl 25mg by mouth every 6 hours as needed for itching 5. STARTED Heparin subcutaneous 2500mg twice daily to prevent blood clots ___ the legs until you are able to walk independently 6. STARTED Colace (docusate) and Senna for constipation •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion, lethargy or change ___ mental status. •Any numbness, tingling, weakness ___ your extremities. •Pain or headache that is continually increasing, or not relieved by pain medication. •New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ___

19989126-DS-16

DS

2155-02-03 00:00:00

2155-02-03 14:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: ___: Diagnostic angiogram History of Present Illness: ___ yo female with known ___ s/p right EDAS. She had previous admission her since then in ___ with ___ that required bilateral EVDs and TPA. She returns with 1 week of HA and nausea. Head CT at the OSH shows left occipital IPH with ___. She c/o continued HA and Nausea. Past Medical History: ___: Thalamic bleed, admitted to ___ Stroke, angio showed ___ and 2 small aneurysms near the ventricles. Patient was seen at ___ and underwent bypass surgery with Dr ___. Depression- was on medication but discontinued secondary to side effects. Social History: ___ Family History: Unknown hx of vascular anomalies Physical Exam: ON ADMISSION ============ Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 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, propioception, pinprick and vibration bilaterally. Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin ON DISCHARGE ============ Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: 2.5-2mm b/l PERRL EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip ___ IPQuadHamATEHLGast ___ Left5 5 5 5 5 5 [x]Sensation intact to light touch throughout Pertinent Results: Please see OMR for pertinent imaging & labs Brief Hospital Course: ___ On ___, Ms. ___ was admitted to the Neuro ICU. Arterial line was placed for BP control with SBP goal <160. Diagnostic angio on ___ re-demonstrated bilateral ___. U/S of right groin was obtained on ___ for palpable nodule and was negative for pseudoaneurysm. Medications were adjusted for headache management. On ___ she was called out of the ICU to ___ where she remained neurologically stable. She was mobilized and encouraged POs. She was transferred to the neuro floor. NCHCT on ___ was stable to improved. #Moyamoya Neurology was consulted to assist with management of her Moyamoya. It was recommended to avoid significant hypotension. Patient was cleared to start ASA 81mg on ___. She should follow-up with Dr. ___ discharge. #Depression/anxiety Psych was consulted for the patient stating "I want to die." It was felt the patient did not require a 1:1 sitter. The valium was discontinued and the patient was started on Seroquel per Psych recommendation. The Seroquel was discontinued and low dose Ativan was ordered BID PRN. Patient was started on mirtazepime 7.5mg qHS to help with sleep, mood, appetite, and nausea. Social work was consulted to assist with setting up outpatient psych for follow-up after discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. Docusate Sodium 100 mg PO BID 4. LORazepam 0.25 mg PO BID PRN anxiety RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth BID PRN Disp #*7 Tablet Refills:*0 5. Mirtazapine 7.5 mg PO QHS RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 6. Multivitamins W/minerals 1 TAB PO DAILY 7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H PRN Disp #*24 Tablet Refills:*0 8. Senna 17.2 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Brain Hemorrhage without Surgery 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 (Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • Your neurosurgeon is recommending starting aspirin 81mg daily starting on ___. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • 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 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. • 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: ___

19989783-DS-21

DS

2128-06-21 00:00:00

2128-06-21 22:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / niacin Attending: ___ Chief Complaint: Weakness Major Surgical or Invasive Procedure: ___: EGD and Colonoscopy History of Present Illness: Mr. ___ is a ___ gentleman with PMH significant for atrial fibrillation on warfarin, prostate cancer s/p radiation, HFrEF (EF 40-45%), and history of lower GI bleed in ___ due to rectal angioectasia in the setting of radiation proctitis who presents with weakness found to have BRBPR and Hgb 4.4. Per patient, he was at work earlier today when he developed feelings of weakness, lightheadedness, and dizziness while standing. He reports he sat down to take a break and, on attempting to stand back up, became extremely dizzy again. He reports a co-worker told him he looked really pale and ill, and so called EMS. On EMS arrival, patient was noted to have 1 mm STE in I and aVL. He received aspirin x4 and was transferred to ___. Of note, patient reports x3 days of BRBPR; he reports seeing bright red blood in the toilet bowl and mixed with his stool. He also notes some maroon colored stools; he denies tarry or black stools, diarrhea, increased frequency of BM. He denies N/V/abd pain, f/c, CP/palp, SOB, dysuria, MSK/joint pain. In the ED, initial vitals: HR 71, BP 90/64, RR 18, SAT 98% on RA. - Exam notable for gross blood in the rectum. - Labs were notable for H/H 4.4/16.1, PLT 52, INR 3.1, Cr 2.2, Trop-T 0.02. - CXR showed "Cardiomegaly without evidence of pulmonary edema. No evidence of pneumonia." - Patient was given: 1L NS, 1 unit of uncrossmatched blood, pantoprazole 40 mg IV x1, Kcentra 2490 units, vitamin K 10 mg IV, 1u crossmatched blood. - GI was consulted in the ED. On arrival to the MICU, patient reports feeling "much better" than this AM. He denies current dizziness, lightheadedness. Past Medical History: Atrial fibrillation Systolic heart failure (LVEF of 40-45% in ___ Hypertension Hyperlipidemia Gout Prostate cancer status post radiation therapy Sarcoidosis Sickle cell trait Right total knee replacement in ___ Solitary pulmonary nodule followed since ___ Osteoarthritis Peripheral neuropathy Asthma Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vitals: afebrile, 70 126/71 15 97% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, pale conjunctiva, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: clear without ecchymoses/rash NEURO: AAOx3, moves all extremities spontaneously ACCESS: PIVs DISCHARGE PHYSICAL EXAM: =========================== VS: 97.8, 74, 110/72, 18, 100%RA GENERAL: NAD, pleasant HEENT: PERRL, EOMI, poor dentition NECK: no JVD CARDIAC: Irregularly irregular, S1/S2, no MRG LUNG: LCTA-bl, no w/r/r ABDOMEN: Soft, NTND, no HSM EXTREMITIES: FROM, no c/e/e PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact; strength and sensation symmetric and intact bl Pertinent Results: ADMISSION LABS: =================== ___ 09:30AM BLOOD WBC-4.7 RBC-2.50*# Hgb-4.4*# Hct-16.1*# MCV-64*# MCH-17.6*# MCHC-27.3*# RDW-23.7* RDWSD-53.5* Plt Ct-52* ___ 09:30AM BLOOD Neuts-70.5 Lymphs-13.8* Monos-11.0 Eos-3.9 Baso-0.2 NRBC-1.1* Im ___ AbsNeut-3.28 AbsLymp-0.64* AbsMono-0.51 AbsEos-0.18 AbsBaso-0.01 ___ 09:30AM BLOOD ___ PTT-59.0* ___ ___ 09:30AM BLOOD Glucose-137* UreaN-58* Creat-2.2* Na-138 K-4.9 Cl-104 HCO3-22 AnGap-17 ___ 09:30AM BLOOD ALT-12 AST-21 AlkPhos-82 TotBili-0.4 ___ 02:03PM BLOOD Ret Man-4.1* Abs Ret-0.12* ___ 09:30AM BLOOD proBNP-1654* ___ 09:30AM BLOOD cTropnT-0.02* ___ 09:30AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.6 Mg-2.2 Iron-46 ___ 09:30AM BLOOD calTIBC-455 ___ Ferritn-5.8* TRF-350 ___ 09:36AM BLOOD Glucose-131* Lactate-1.9 Na-138 K-4.9 Cl-105 calHCO3-23 ___ 09:36AM BLOOD Hgb-4.9* calcHCT-15 MICRO DATA: =================== ___ MRSA Screen: Negative IMAGING/STUDIES: =================== - CXR (___): IMPRESSION: Cardiomegaly without evidence of pulmonary edema. No evidence of pneumonia EKG ___: Sinus rhythm. Left axis deviation with left anterior fascicular block. Right bundle-branch block. Occasional premature ventricular contraction. Compared to the previous tracing of ___ atrial flutter has now converted to sinus rhythm. Abd US ___: FINDINGS: LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is nodular. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 7 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: 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. SPLEEN: Normal echogenicity, measuring 12.1 cm. KIDNEYS: The right kidney measures 11.3 cm. The left kidney measures 10.9 cm. 2 parapelvic cysts are noted in the upper pole of the right kidney. Several cysts are that are identified in the left kidney. The largest measures 3.6 cm. A 2.0 cm cyst is seen in the interpolar region on the left. A 4 cm cyst is seen in the lower pole a 2.8 cm cyst is seen in the upper pole. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Coarsened liver echotexture and nodular contour of the liver are concerning for cirrhosis. 2. Multiple bilateral renal cysts 3. Normal size of spleen EGD ___: Findings: Esophagus:Normal esophagus. Stomach: Mucosa:Diffuse angioectasias of the antrum consistent with GAVE. There were also more scattered angioectasias spreading up into the body. Some of those in the body displayed mild ooze and were treated with APC. Small areas in the antrum were also treated with APC. An Argon-Plasma Coagulator was applied for hemostasis and tissue destruction successfully. Duodenum:Normal duodenum. Impression:Diffuse angioectasias of the antrum, with scattered in the stomach (thermal therapy) Otherwise normal EGD to third part of the duodenum Recommendations:GAVE likely a source of chronic blood loss, but likely does not explain acute bleeding BID PPI Sucralfate QID for a week Consider repeat EGD in 8 weeks Proceed to colonoscopy Colonoscopy ___: Findings: Contents:Dark red and clotted blood was seen only in the rectum and the recto-sigmoid junction. Despite extensive washing, no source of underlying mucosal abnormality was identified. Careful exam in retroflexion also did not reveal any abnormalities. Excavated LesionsMultiple non-bleeding diverticula were seen. Diverticulosis appeared to be of mild severity. Impression:Diverticulosis of the colon Blood in the colon Otherwise normal colonoscopy to cecum Recommendations:Return to hospital ward Source of bleeding likely from rectum or rectosigmoid given the distribution of blood, however no specific source identified. A rectal Dieulafoy is possible. DISCHARGE LABS: =================== ___ 06:55AM BLOOD WBC-7.4 RBC-3.29* Hgb-7.3* Hct-24.0* MCV-73* MCH-22.2* MCHC-30.4* RDW-28.2* RDWSD-72.5* Plt Ct-36* ___ 06:55AM BLOOD ___ PTT-31.9 ___ ___ 06:55AM BLOOD Glucose-89 UreaN-30* Creat-2.0* Na-138 K-4.1 Cl-108 HCO3-24 AnGap-10 ___ 06:55AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-0.5 ___ 06:55AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-0.5 ___ 06:55AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8 Other Relevant Labs: ___ 07:43PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+ Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Spheroc-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Pencil-OCCASIONAL Tear ___ ___ 02:03PM BLOOD Ret Man-4.1* Abs Ret-0.12* ___ 09:30AM BLOOD proBNP-1654* ___ 09:30AM BLOOD cTropnT-0.02* ___ 07:43PM BLOOD cTropnT-0.01 ___ 07:43PM BLOOD TotProt-6.7 ___ 09:30AM BLOOD D-Dimer-167 ___ 09:30AM BLOOD calTIBC-455 ___ Ferritn-5.8* TRF-350 ___ 07:43PM BLOOD PEP-TRACE ABNO IgG-1031 IgA-398 IgM-147 IFE-TRACE MONO ___ 09:36AM BLOOD Glucose-131* Lactate-1.9 Na-138 K-4.9 Cl-105 calHCO3-23 ___ 09:36AM BLOOD Hgb-4.9* calcHCT-15 ___ 07:42PM URINE Hours-RANDOM TotProt-7 ___ 07:42PM URINE U-PEP-NO PROTEIN Brief Hospital Course: BRIEF SUMMARY STATEMENT: ========================== Mr. ___ is a ___ man with atrial fibrillation on warfarin, prostate cancer s/p radiation, HFrEF (EF 40-45%), and history of lower GI bleed in ___ due to rectal angioectasia likely secondary to radiation proctitis who presented with weakness, found to have new profound anemia with gross rectal bleeding, concerning for lower GI bleed. Pt was admitted to the ICU but transferred to general medicine floor on ___. # LOWER GI BLEED: On admission, Hgb 4.4 with GI bleed was thought to be lower given gross blood. He had a history of angioectasia in the rectum secondary to radiation proctitis and had APC in ___. He also had a coagulopathy with thrombocytopenia, and received reversal with Kcentra, vitamin K, and platelets. On admission, he was not tachycardic or hypotensive, but he was taking a beta blocker at home. He received 4 units of pRBCs on ___ with improvement in H/H. He also received 1U platelts. GI was consulted, and patient received EGD/colonoscopy on ___, which showed GAVE and mild diverticulosis. Colonoscopy showed likely rectal bleeding but no clear lesion. Bleeding was thought to be ___ diverticulosis vs. rectal dieulafoy lesion. On discovery of pt's cirrhosis, rectal varices vs. other ectopic varices were in ddx but given pt's creatinine, further eval was limited. During Colonoscopy, these were not noted. Pt GIB resolved during hospitalization and HCT remained stable. Per GI, pt was felt to be safe for discharge. # ___ on CKD: Baseline Cr ~1.5-1.7 c/w grade 3 CKD, based on previous labs here in ___ and at ___ in ___. Here on admission 2.2, likely pre-renal in the setting of poor renal perfusion from blood loss. At time of discharge, creatinine was 2, which was considered close to baseline. ___ was held at time of discharge. # THROMBOCYTOPENIA: Baseline low PLT ~100s. S/p 1u platelets in ED with inappropriate response. LFTs were normal, haptoglobin and fibrinogen were normal, SPEP showed non-specific abnormality and UPEP wnl. Abd US showed cirrhosis. # CHRONIC COMPENSATED SYSTOLIC HEART FAILURE: last TTE (___) showed LVEF 45%. Euvolemic on exam. CV meds were held on initial presentation given concern for instability. As he stabilized, his Nifedipine was re-started. Metoprolol was re-started at below home dose (Metoprolol 50mg/day as compared to 100mg per day in outpatient setting). ___ was held prior to discharge given Cr 2 and normotension. Lasix was also held in setting of euvolemia. # Atrial Fibrillation: CHADS2-VASc score of 3 for (C-H-A). Given active bleeding, patient received kaycentra and vitamin K in ED. In anticipation of GI intervention, patient's anticoagulation was held. given cirrhosis/thrombocytopenia and recent GIB and per conversation with pt's Cardiologist, decision was made to hold anticoagulation pending outpatient re-assessment. Notably pt was in sinus rhythm during admission. # Anemia: concern for acute on chronic etiology given low MCV, patient reported "weeks" of fatigue. Has known Sickle Cell trait. Iron studies were notable for low ferritin. # Cirrhosis: Given thrombocytopenia, pt underwent abd US which showed evidence of cirrhosis. Dx discussed with pt and he endorsed drinking a considerable amount of etoh use (several beers/shots of liquor per day). He denied prior hx of withdrawal sx. Folate and thiamine were prescribed after discharge and sent to pt's pharmacy. DDx for cirrhosis included sarcoid. Per GI, pt was felt to be safe for discharge with outpatient Hepatology follow-up. TRANSITIONAL ISSUES: =========================== - Please start on iron supplementation given low ferritin - Consider hematology CS - Please ensure Sucralfate is continued for 1 week - Per GI, f/u for repeat EGD in 8 weeks - Please ensure follow-up with Hepatology for evaluation of new dx of cirrhosis - Please ensure follow-up with Cardiology for decision re risk/benefit of resuming anticoagulation - Please note, Lasix and Valsartan held; metoprolol re-started at below home dose; consider switching to Carvedilol given lower selectivity and possible advantage from Hepatology perspective if pt were to develop varices. - Please repeat CBC at follow-up - Please note evidence of ?MGUS on SPEP, please consider repeat SPEP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. NIFEdipine CR 60 mg PO DAILY 4. Tamsulosin 0.4 mg PO BID 5. Allopurinol ___ mg PO DAILY 6. Furosemide 40-80 mg PO ASDIR 7. Warfarin 2.5-5 mg PO DAILY16 8. Valsartan 160 mg PO DAILY 9. Aspirin EC 81 mg PO 3X/WEEK (___) 10. Vitamin D 1000 UNIT PO DAILY 11. Osteo Bi-Flex Triple Strength (___) 750 mg-644 mg- 30 mg-1 mg oral DAILY 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO 3X/WEEK (___) 2. NIFEdipine CR 60 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Allopurinol ___ mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Tamsulosin 0.4 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Osteo Bi-Flex Triple Strength (___) 750 mg-644 mg- 30 mg-1 mg oral DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Sucralfate 1 gm PO QID RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: # Lower GI bleeding # Cirrhosis # GAVE 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 participate in your care at ___. You were admitted for gastric bleeding. You underwent blood transfusion, platelet transfusion, EGD and Colonoscopy and your symptoms resolved. You were found to have scarring of the liver. Your blood-thinning medications were held because of your recent bleeding though there is a slight increase in stroke risk as a result. Please follow up with your Cardiologist to discuss if it is safe to re-start Coumadin. Please follow up with a liver specialist to discuss treatment plan for cirrhosis. Please note that a repeat endoscopy was recommended in approximately 8 weeks. If you experience any recurrence in bleeding, please seek medical attention. Best Regards, You ___ Medicine Team Followup Instructions: ___

19989783-DS-24

DS

2130-08-07 00:00:00

2130-08-07 12:43:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: lisinopril / niacin Attending: ___. Chief Complaint: Leukocytosis, fever Major Surgical or Invasive Procedure: Diagnostic Paracentesis ___ History of Present Illness: ___ with history of NICM (EF 25% ___, CKD Stage IV (baseline Cr 4.4 from ___ presumed due to cardiorenal origin, alcoholic cirrhosis who was discharge from ___ ___ to rehab who re-presents to the ED from rehab after being found to have WBC of 17 and temp of 100.9 at rehab. Per report, he was also extremely agitated and tried to remove his dialysis line, and is now restrained. He was also found to have a hematocrit of 22, which is in the range of his norm, and the ED transfused 1 unit of pRBC. The patients labs reflect CHF exacerbation as he has a BNP of >70000. No immediate source of infection was found on initial ED workup. Of note, the patient received a ketamine bolus and was started on a ketamine drip prior to surgical consult, so no history or reliable physical exam can be obtained. Past Medical History: Atrial fibrillation Systolic heart failure (LVEF of 40-45% in ___ Hypertension Hyperlipidemia Gout Prostate cancer status post radiation therapy Sarcoidosis Sickle cell trait Right total knee replacement in ___ Solitary pulmonary nodule followed since ___ Osteoarthritis Peripheral neuropathy Asthma Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Vitals: 98.5, 82, 109/74, 17, 94% on 40% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mildly distended, nontender (on ketamine), no rebound or guarding, no palpable masses Ext: No ___ edema, ___ warm and well perfused Brief Hospital Course: Mr. ___ was admitted to the Trauma ICU where he was known given his recent hospital admission. He was off pressors and off ketamine drip. His mental status improved. His WBC was 17.3. He continued to produce copious amounts of respiratory secretions and receive chest physical therapy as before. He was on trach mask with intermittent vent requirement for agitation. CT abd/pelvis showed ascites, post-surgical changes in the splenic fossa and no drainable collections. He had no abdominal pain. He was started on CTX. Diagnostic paracentesis suggested spontaneous bacterial peritonitis. A 10 day Ceftriaxone course was planned followed by prophylactic Ciprofloxacin per Hepatology recommendation. He received HD as scheduled. The patient remained stable with normal vital signs. He was discharged to ___ to continue his recovery. Medications on Admission: 1. Acetaminophen (Liquid) 650 mg PO Q8H:PRN Pain - Moderate RX *acetaminophen 325 mg/10.15 mL 20 cc by mouth Every 8 hours Disp #*2 Bottle Refills:*0 2. Albuterol Inhaler ___ PUFF IH Q6H RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff Trach Every 6 hours Disp #*2 Inhaler Refills:*0 3. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % Mouth rinse with 15 cc three times a day Refills:*0 5. Docusate Sodium (Liquid) 100 mg PO BID RX *docusate sodium [Diocto] 50 mg/5 mL 100 mg by mouth twice a day Disp ___ Milliliter Refills:*0 6. Heparin 5000 UNIT SC TID RX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units Subcutaneous three times a day Disp #*90 Cartridge Refills:*0 7. Ipratropium Bromide MDI 2 PUFF IH Q6H RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFF Trach every six (6) hours Disp #*2 Inhaler Refills:*0 8. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 9. OLANZapine 2.5-5 mg PO QHS RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 10. OxycoDONE Liquid 2.5-5 mg PO Q8H:PRN Pain - Severe RX *oxycodone 5 mg/5 mL 5 mg NG tube three times a day Refills:*0 11. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth Daily Refills:*0 12. Ramelteon 8 mg PO QHS:PRN insomnia RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHR Disp #*30 Tablet Refills:*0 13. Senna 8.6 mg PO BID RX *sennosides [senna] 8.8 mg/5 mL 8.8 mg by mouth twice a day Disp ___ Milliliter Refills:*0 14. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN resp secretions RX *sodium chloride 3 % 15 cc Trach Q6H PRN Disp #*100 Vial Refills:*0 15. Vancomycin Oral Liquid ___ mg PO/NG Q6H RX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth every six (6) hours Refills:*0 Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 160 mg/5 mL 650 mg by mouth Every 6 hours Disp #*2 Bottle Refills:*0 2. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth every 12 hours Disp #*60 Tablet Refills:*0 3. CefTRIAXone 2 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV Daily Disp #*7 Intravenous Bag Refills:*0 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % 15 ml for mouth rinse twice a day Refills:*0 5. Heparin 5000 UNIT SC TID RX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units Subcutaneous twice a day Disp #*30 Cartridge Refills:*0 6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID RX *lansoprazole 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. OLANZapine 2.5-5 mg PO QHS RX *olanzapine 5 mg ___ tablet(s) by mouth Every night Disp #*30 Tablet Refills:*0 8. Ramelteon 8 mg PO QHS RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Every night Disp #*30 Tablet Refills:*0 9. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin [Firvanq] 25 mg/mL 125 mg by mouth Every 6 hours Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Spontaneous Bacterial Peritonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were re-admitted to ___ for fevers and a high white blood cell count suggestive of infection. You were found to have Spontaneous Bacterial Peritonitis which was treated with antibiotics. You are ready for discharge. Follow these instructions - You should continue to take your oral Vancomycin 125 mg Q6H until ___. - You should continue your antibiotic (Ceftriaxone 2gr/day) until ___. - On ___, you should start taking Ciprofloxacin 500 mg/day to prevent recurrent infections. Keep taking this medication until you see your Hepatologist in clinic. Followup Instructions: ___

19989918-DS-25

DS

2179-09-16 00:00:00

2179-10-05 20:40:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ___ / Depakote / Tegretol / Codeine / Phenobarbital / Penicillins Attending: ___ Chief Complaint: Brought from epilepsy clinic for complex partial status Major Surgical or Invasive Procedure: none History of Present Illness: from Dr. ___ note: Mr. ___ is a ___ year old man who carries a diagnosis of intractable complex partial epilepsy (affecting right arm & leg) on 5 AEDs and s/p VNS, cortical sectioning who was brought to the ED from epilepsy clinic for question complex partial status. Mr. ___ is followed by ___. According to his wife, who provided the history, he has only one spell type which involves right sided twitching of the arm and leg (not the face). During these spells, his eyes are closed and he is not responsive, but reportedly can recall everything that happened afterwards. She has been with him since ___ and is confident that this is his only semiology. These are often protracted spells (lasting > 30 minutes) and he often comes out of them with the help of his wife saying soothing things about their children, etc. He had a recent admission in ___ (about 3 weeks ago) to the epilepsy service when he had a similar spell. He was actually on ___ 11 visiting his son, who was admitted to the neurology service, when he had his incident. The semiology was as above and lasted about 30 minutes. He got 9mg of lorazepam (and has received similarly high doses without respiratory compromise in the past). It was noted that the right arm would drift slowly down if dropped and that passive movement of the RUE would cause the shaking to abate. It was not obviously clonic. EEG was deferred since it had been negative with similar spells in the past. He had about 2 episodes per day of the above semiology. Ativan did not curtail these spells, but he did get 2mg q5-10 minutes during spells. He was sent home on ___ (6 day admission) with epilepsy clinic follow up. In the interim, he had a similar spell for which he was seen at a hospital in ___. He received about 10mg lorazepam and was sent back home. In epilepsy clinic today, he had a few staring spells (unusual for him) and then towards the end of the appointment (3:40) began to have right sided motor activity similar to prior. He was brought to the ED where he received 10mg lorazepam without change in spell. When I arrived, his spell had stopped and I was able to conduct most of the MS examination before his spells resumed. He got another 2mg but the spell continued. My examination was similar to prior (frequency arm > leg, arm drops slowly, mvmts stop with passive ROM). He was 3 minutes into a gram of Keppra when I asked his wife to speak to him and over the next ___ seconds, he stopped entirely and was somnolent. ROS: Unable to obtain, but earlier today reported to ___ ___: "Triggers: many life changes/stresses in recent months (wife lost job, son with poor health, insurance changes/worries, death of close friend in past few weeks, off modified ketogenic diet when hospitalized here Other symptoms/problems: - excessive fatigue, poor energy, malaise - memory/concentration problems, can't keep track of time, poor historian lately - h/o depression, on antidepressant but not managed by pyschiatrist recently - sleep apnea, uses cpap -c/o right sided headaches - constipation major problem r/t diet - blurry vision - c/o breathing problems when magnet used- coughing witnessed once today" Past Medical History: Per OMR as patient unable to provide in current state. Per Dr. ___ note in ___ and subsequent notes since: "- Fell of slide at grade school, loss of consciousness, withconcussion. - Viral meningitis when ___ years old, but without seizures. - Epilepsy: first seizure ___, mentions ___ and referral to Dr. ___ initial ___ seems to have been in ___ in ___ - had been evaluated given funny spells with headache, right temporal discharge on EEG (see ___ summary, ___, started on phenobarb. Essentially the same semiology as now with aura: Aura consists of a one or more of a 'drunk' feeling, double vision, and numbness on his right side, before right hand twitching - what he calls the seizure proper - begins. Few true generalized seizures, but patient recalls "Grand mal" initiated during intraoperative recording and then shortly after that same craniotomy/intracranial recording. At the end of this three week intracranial monitoring in ___, he underwent subpial transection with Dr. ___ and Dr. ___, in the now-eponymously named ___ procedure, which seemed to reduce seizure frequency for some time (see ___ Summary ___, and per Dr. ___. Of note he had some pathological evidence of infection afterward and was treated with gentamycin. Left VNS was placed in ___, then replaced ___. This was interrogated and adjusted today, by ___ (see her note of today). - Depression - he has been doing better from this point of view, and he only has the occasional day with low mood presently - two days this week without getting out of bed, but for pills. No suicidal ideation. He has seen his psychiatrist in ___. - Sleep apnea, on CPAP - Prior myocarditis (details unclear), since on Toprol - Hypercholesterolemia - Gastroesophageal reflux - Chronic headaches and prior sinusitis - Low back surgery, L4-5 disc herniation s/p left L4-5 hemilaminectomy, median facetectomy and L4-5 diskectomy ___ (___) - Tonsillectomy - Vasectomy - Benign hematuria, kidney stones (thought to be ___ topamax) - Pulmonary Embolus in ___, ~6 months of Coumadin" Social History: ___ Family History: Mother living, age ___ with a history of MI and uterine cancer. Father died at age ___ of a stroke and MI Physical Exam: ADMISSION EXAM: ___ 90 132/72 59 20 98 2L NC General: Lying in bed HEENT: NC/AT, no scleral icterus, MMM Neck: Supple, no nuchal rigidity Pulmonary: Moving air well bilaterally, upper airway sounds Cardiac: RRR difficult to hear over upper airway sounds Abdomen: soft, NT/ND, scant bowel sounds, no masses or organomegaly. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions Neurologic: -Mental Status: Prior to resumption of spells, was oriented to self, place, and year (not month or date). Speech was quiet but fluent with naming to high and low. Repetition and comprehension were normal. There was no left/right confusion and he could follow 2 step commands. He could not get through days of the week ___ -> ___ -> ___ -> ___ -> ___. He then had a spell, during which he was not responsive to commands (voice or motor). -Cranial Nerves (examined during spell): Pupils 4-3mm bilaterally without hippis. On testing oculocephalics, eyes remained midline then corrected to primary position or had disorganized saccades without nystagmus. Corneals were strong bilaterally. Face was symmetric. There was actually some mild resistance to eye opening bilaterally. Strong gag. -Motor/Sensory: Prior to spell, could lift all extremities at least anti-gravity (during MS testing asking pt to follow commands). No response to pain during spell. No Babinskis. During the spell, the right arm twiched in flexion/extension without convincing clonic activity at a rate of approximately 3 Hz. The leg extended at the knee at a rate of approximately 1.5 Hz. There was no facial activity. When the arm was raised and dropped, it fell slowly. The movements could be distracted with movement of the arm about the elbow. -DTRs: ___ throughout. DISCHARGE EXAM: Unchanged. Pertinent Results: ADMISSION LABS (___) 8.1 > 11.9/37.2 < 267 Neuts-70.0 ___ Monos-6.4 Eos-0.4 Baso-0.3 141 | 106 | 17 --------------< 87 4.3 | 28 | 0.7 Lactate-1.6 IMAGING: Chest XRay: FINDINGS: AP portable supine view of the chest. Vagal nerve stimulator projects over the left chest wall with catheter extending to the left neck soft tissues, unchanged. Heart size is mildly enlarged. Lung volumes are low. No overt signs of pneumonia or edema. No large effusion or pneumothorax. The mediastinal contour is stable. No acute osseous injuries. IMPRESSION: No acute intrathoracic process Brief Hospital Course: ___ was admitted to the epilepsy service in stable condition. He had several more spells similar to his episodes on admission: prolonged, associated with arm and leg twitching at different frequencies, disctractable and responsive to his wife's voice. A conservative workup was negative for any infectious, toxic or metabolic trigger. His anti-epileptic medication levels were sent on admission. His vagal nerve stimulator was activated for spells and he received lorazepam 2 mg IV for spells lasting longer than thirty minutes. Since his spells were similar in semiology and frequency to his home events (multiple episodes a day), no further adjustments to his antiepileptic medications were made. His modified ketogenic diet was continued. An ictal SPECT study was discussed with the patient and his wife but as this could not be obtained over the weekend, they preferred to go home and follow up outpatient. He was discharged in stable condition with close neurology follow-up. Medications on Admission: 1. Atorvastatin 40 mg PO DAILY 2. Clobazam 20 mg PO BID 3. Clobazam 10 mg PO DAILY 4. Ezetimibe 10 mg PO DAILY 5. felbamate 800 mg oral qAM 6. felbamate 1200 mg ORAL TWICE DAILY 7. LACOSamide 200 mg PO TID 8. LaMOTrigine 100 mg PO BID 9. LaMOTrigine 300 mg PO HS 10. LeVETiracetam 1000 mg PO TID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Ranitidine 300 mg PO DAILY 14. Venlafaxine XR 150 mg PO QHS 15. Aspirin 81 mg PO DAILY 16. Docusate Sodium 100 mg PO BID 17. Multivitamins 1 TAB PO DAILY 18. Senna 8.6 mg PO BID:PRN constipation 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Clobazam 20 mg PO BID 3. Clobazam 10 mg PO DAILY 4. Ezetimibe 10 mg PO DAILY 5. felbamate 800 mg oral qAM 6. felbamate 1200 mg ORAL TWICE DAILY 7. LACOSamide 200 mg PO TID 8. LaMOTrigine 100 mg PO BID 9. LaMOTrigine 300 mg PO HS 10. LeVETiracetam 1000 mg PO TID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Ranitidine 300 mg PO DAILY 14. Venlafaxine XR 150 mg PO QHS 15. Aspirin 81 mg PO DAILY 16. Docusate Sodium 100 mg PO BID 17. Multivitamins 1 TAB PO DAILY 18. Senna 8.6 mg PO BID:PRN constipation 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Home Discharge Diagnosis: intractable complex partial epilepsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you have been having your typical spells frequently at home and in the clinic. Here we saw that you were continuing to have these spells. We continued your anti-epileptic medications without any changes. We discussed performing a SPECT study, but since this could not be completed this week, you do not need to stay in the hospital just for this test. You will continue to work with Dr. ___ to discuss further testing for these spells. It was a pleasure taking care of you. - The ___ Neurology Team Followup Instructions: ___

19990072-DS-16

DS

2180-07-27 00:00:00

2180-07-27 12:38:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: LP History of Present Illness: ___ year old F who comes in with headache, neck stiffness, photophobia. Pt developed headache 8 days prior to admission. Symptoms present and persistent so she saw an MD on ___ who prescribed exedrin and zofran. ___ and ___ she developed fevers to 102-103 which persisted despite tylenol. ___ afternoon, she started vomiting and had a syncopal event. Says she felt like she was going to pass out beforehand and had no confusion following event. Unwitnessed. Pt decided to come to the ED for evaluation the following morning. Traveled 1.5 months ago to ___, no travel since. No significant time outdoors. No tick or insect bites. No outdoor pets. In the ED pt had CT head which was negative. LP done which showed elevated WBC with lymphocytic predominance. Urinalysis showed pyuria. Pt given CTX and Vanc at meningitis dosing and admitted for further management. ROS: negative except as above Past Medical History: None Social History: ___ Family History: Parents generally healthy. Grandparents with diabetes. Physical Exam: Vitals: T 101 114/67 83 16 98%RA Gen: NAD HEENT: mild nuchal rigidity CV: rrr, no r/m/g Pulm: clear bl Abd: soft, nt/nd, +bs Ext: no edema Neuro: alert and oriented x 3, CN ___ intact, strength ___ in all extremities Skin: no rash Pertinent Results: ___ 01:30PM BLOOD WBC-6.7 RBC-3.91* Hgb-12.7 Hct-35.6* MCV-91 MCH-32.5* MCHC-35.7* RDW-12.7 Plt ___ ___ 07:20AM BLOOD WBC-5.7 RBC-3.77* Hgb-11.9* Hct-33.6* MCV-89 MCH-31.6 MCHC-35.4* RDW-12.4 Plt ___ ___ 12:55PM BLOOD WBC-5.9 RBC-3.78* Hgb-12.2 Hct-34.0* MCV-90 MCH-32.2* MCHC-35.8* RDW-12.4 Plt ___ ___ 01:00PM BLOOD WBC-10.7 RBC-4.57 Hgb-14.4 Hct-40.7 MCV-89 MCH-31.5 MCHC-35.3* RDW-12.7 Plt ___ ___ 01:32PM BLOOD ___ PTT-24.5* ___ ___ 01:30PM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-138 K-3.5 Cl-97 HCO3-32 AnGap-13 ___ 12:55PM BLOOD Glucose-134* UreaN-7 Creat-0.6 Na-136 K-3.6 Cl-103 HCO3-23 AnGap-14 ___ 01:00PM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-132* K-3.8 Cl-93* HCO3-24 AnGap-19 ___ 07:00AM BLOOD ALT-14 AST-12 AlkPhos-27* TotBili-0.1 ___ 01:00PM BLOOD ALT-21 AST-23 AlkPhos-39 TotBili-0.3 ___ 07:00AM BLOOD HIV Ab-NEGATIVE ___ 07:00AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ (Malaria)Malaria Antigen Test-FINALINPATIENT ___ Viral Load/Ultrasensitive-FINALINPATIENT ___ CULTUREVIRAL CULTURE-PRELIMINARYINPATIENT ___ CULTURE NOT PROCESSED INPATIENT ___ PLASMA REAGIN TEST-FINALINPATIENT ___ SEROLOGY-FINALINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ FLUIDGRAM STAIN-FINAL; FLUID CULTURE-FINAL; Enterovirus Culture-PENDINGEMERGENCY WARD ___ CULTURE-FINALEMERGENCY WARD ___ CULTUREBlood Culture, Routine-PENDING . CT head: IMPRESSION: No acute intracranial process. Please note that MRI would be more sensitive for subtle intracranial lesions. Brief Hospital Course: Assessment/Plan: ___ y.o woman with no PMH who presents with headache and fever found to have aseptic meningitis. . #aseptic meningitis #headache (likely combination of post LP and meningitis) ?NSAID related #fever Pt was treated for a presumed viral meningitis. CSF gram stain and cx negative. She was given CTx and vancomycin in the ED which were discontinued on the floor given negative CSF. She was treated with acyclovir until HSV and VZV were negative. GIven that she continued to spike fevers despite supportive care, consulted ID who recommended a more intensive work up that was unrevealing by the time of discharge. She did develop some abdominal pain mostly in the ruq. LFTs were slightly elevated, and multiple additional serologies were sent and were unrevealing at the time of discharge. Transvaginal, abdominal, and ruq ultrasounds were negative for pathology. Pt's continued headache could have also been due to post LP headache and/or NSAId induced. Symptoms improved. On the day of discharge pt. had been afebrile for over 24 hours, and was strongly desirous of going home. Her pain was controlled, she was tolerating po intake, ambulatory, and voiding on her own. Her LFTs were stable, with ALT of approx 100, without any elevation in bilirubin. This was felt to be part of a likely viral syndrome. Doxycycline was started emperically at ID's recommendation over concern for possible anaplasmosis (test pending at discharge), and this was well tolerated. The plan is for her to return home and we will follow up on the results of multiple pending serologies. She should see Dr. ___ this week for repeat evaluation including a repeat test of LFTs, CBC, and Chemistry 7 (see below, and this was explained to patient). . #hyponatremia-likely hypovolemic in etiology. Improved with IVF. . #elevated lactate-improved with IVF Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN headache do not drink any alcohol while using this 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. TraMADOL (Ultram) 50 mg PO Q4H:PRN severe pain RX *tramadol 50 mg 1 tablet(s) by mouth every four hours as needed for pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: asceptic meningitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fever, headache, and neck pain and found to have a condition known as asceptic meningitis, which is usually caused by a virus. The cause of your condition remains unknown at this time, however, as we discussed. You underwent an extensive work up and were evaluated by the infectious disease team. Your symptoms improved, and as of the time of discharge, we have multiple test results still pending, and will alert you to the final results if they are positive. You should NOT: take any ibuprofen or other NSAID as this may worsen your headache (as can cause rebound headaches and also asceptic meningitis), NOT take more than ___ mg of tylenol (acetaminophen) in any one 24 hour period, NOT drink any alcohol. You SHOULD: Call Dr. ___ to arrange to be seen by her later this week to be re-evaluated and to have your liver function tests repeated, and to follow up on the results of the tests that are pending. When you see Dr. ___ following should be checked (blood tests): Complete blood count, ALT, AST, Alk Phos, Total Bilirubin, and a 'Chemistry-7' Followup Instructions: ___

19990106-DS-15

DS

2161-06-05 00:00:00

2161-06-05 20:56:00

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 cath with ___ 3.0x14 mm placed to LAD on ___ History of Present Illness: ___ yo M with CAD, s/p LAD and D1 ___ in ___ and ___ respectively, and restenosis of LAD stenit in ___ s/p angioplasty, who presented to ED with chest pain. Started after breakfast. Patient was sitting in kitchen drinking juice. Came on suddenly, felt like heaviness in mid chest. Non-radiating, no relation to inspiration. Associated with SOB. No diaphoresis, palpitations, n/v. He took 1 nitro with minimal relief so took another one, still w/o complete relief and called ___. By the time he came to the ED his chest pain had mostly resolved but he received nitro spray x 2. He had stable EKG abnormalities with ST abnormalities in the inferolat leads. Enzymes were negative. He was placed in obs and had an exercise nuclear test. He ex ___, no CP, but sig EKG changes with 1-2 mm of STD which persisted through 15:00 of recovery. These changes are worse compared to prior ETTs. Perfusion with TID. In the ED intial vitals were: 97.8 80 127/83 20 97% 2L Patient was given: Nitro x 2 and home meds Vitals on transfer: 79 147/64 17 99% RA On the floor, pt reports no current complaints. He relays the above history. ROS: On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for positive chest pain now resolved, dyspnea on exertion (without chest pain), positive paroxysmal nocturnal dyspnea, orthopnea ___ post-nasal drip, negative for ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: S/P prior D1 Cypher stenting on ___ at ___ and an Endeavor ___ to the LAD in ___. Had a50% D1 lesion at last cath. Had ___ cath at ___ with finding of 80% instent resten of the LAD, treated with angioplasty. A 3-4 mm pseudoaneurysm was seen at the distal tip of the patent ___ in the diag. Dr. ___ a 6 mos CT scan of the chest for that. That was done in ___, and no FA was noted. - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: HIV not on therapy PUD w/ h/o GIB CAD DM with DIABETIC RETINOPATHY- am sugar 100-135 SLEEP APNEA HTN HLD GERD ED BPH RHINITIS CLBP OBESITY DEPRESSION ASTHMA Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam: VS: T=97.9 BP=156/80 HR=69 RR= 18 O2 sat= 98 RA GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple witwithout JVD CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. ___ early peaking systolic murmur best heard over RUSB. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, 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: 2+ radial and DP bilaterally Discharge Physical Exam: VS: T=98.4 SBP=126-162 (126/86) HR= ___ RR= ___ O2 sat= ___ RA GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple without JVD CARDIAC: RRR, normal S1, S2. ___ early peaking systolic murmur best heard over RUSB. LUNGS: CTAB, no crackles, wheezes or rhonchi. Normal WOB ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ radial and DP bilaterally Pertinent Results: Admission Labs: ___ 12:15PM BLOOD WBC-5.6 RBC-4.93 Hgb-13.0* Hct-41.8 MCV-85 MCH-26.4* MCHC-31.2 RDW-14.6 Plt ___ ___ 12:15PM BLOOD Neuts-58.1 ___ Monos-7.1 Eos-2.4 Baso-1.0 ___ 12:15PM BLOOD Glucose-169* UreaN-13 Creat-1.3* Na-140 K-3.9 Cl-102 HCO3-29 AnGap-13 Pertinent Labs: ___ 12:15PM BLOOD cTropnT-<0.01 ___ 06:34PM BLOOD cTropnT-<0.01 ___ 11:30AM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD cTropnT-<0.01 ___ 08:22AM BLOOD HCV Ab-NEGATIVE ___ 08:22AM BLOOD HBsAg-NEGATIVE ___ 07:00PM BLOOD Calcium-10.1 Mg-1.7 Discharge Labs: ___ 07:30AM BLOOD WBC-6.3 RBC-5.04 Hgb-13.6* Hct-42.5 MCV-84 MCH-27.0 MCHC-32.1 RDW-14.7 Plt ___ ___ 07:30AM BLOOD Glucose-184* UreaN-18 Creat-1.5* Na-138 K-4.3 Cl-100 HCO3-30 AnGap-12 ___ 07:30AM BLOOD Calcium-9.8 Mg-2.2 Imaging: EKG ___: Sinus rhythm. Left atrial abnormality. Delayed anterior R wave progression. Prior inferior wall myocardial infarction. Lateral ST segment depression consistent with possible ischemia. Compared to the previous tracing of ___ no diagnostic interval change EKG ___: Sinus rhythm. Delayed R wave progression. Lateral ST segment abnormalities consistent with ischemia. Possible left ventricular hypertrophy, although voltage criteria are not present. Compared to the previous tracing there is now only isolated Q wave in lead III, since diagnostic criteria for inferior wall myocardial infarction are not met on this tracing. TRACING #2 Stress ___: Average exercise tolerance. Ischemic ECG changes persisting late post-exercise in the absence of anginal symptoms to achieved workload. Appropriate hemodynamic response to exercise. Nuclear report sent separately. Nuclear ___: Pending Cardiac Cath ___: Technical Anesthesia: Local Specimens: None Catheter placement via , 5 ___ Coronary angiography using 5 ___ Hemodynamic Measurements (mmHg) Baseline Site ___ ___ End Mean A Wave V Wave HR ___ Contrast Summary Contrast Total (ml): Optiray (ioversol 320 mg/ml)173 Radiation Dosage Effective Equivalent Dose Index (mGy) ___.52 Radiology Summary Total Fluoro Time (minutes) 26.9 Medication Log Start-StopMedicationAmountComment 10:00 AM Heparin in NS 2 units/ml (IA) IA0 ml 10:08 AM Versed IV1 mg 10:08 AM Fentanyl IV25 mcg 10:25 AM Lidocaine 1% Subcut3 ml 10:30 AM Lidocaine 1% Subcut2 ml 10:33 AM Nitroglycerine bolus (IA) IA200 mcg 10:34 AM Diltiazem bolus (IA) IA500 mcg 10:34 AM Heparin bolus (IV) IV5,000 units 11:23 AM Ticagrelor PO180 mg 11:27 AM Heparin bolus (IV) IV3,000 units 11:33 AM Versed IV0.5 mg 11:33 AM Fentanyl IV25 mcg 11:45 AM Nitroglycerine bolus (IC) IC200 mcg Materials ManufacturerItem Name ___ 320100ml ___ SCIENTIFICFL 3.5 DIAGNOSTIC5fr ___ SCIENTIFICFR 5 DIAGNOSTIC5fr COOKJ WIRE 260cm.035in ___ SCIENTIFICMAGIC TORQUE .035 180cm.035in NAVILYSTPRESSURE MONITORING LINE 12" ___ MEDICALLEFT HEART KIT ___ MEDICAL PROD & sCUSTOM STERILE KIT(STERILE PACK) TERUMOGLIDESHEATH SLENDER5Fr TERUMOTR BAND (LARG) ___ 320100ml ___ SCIENTIFICAL 1 DIAGNOSTIC5fr CORDISXBLAD 3.56fr MALLINCKRODTCONRAY 60 50 ml ABBOTTPROWATER WIRE180CM ABBOTTP-PACKS ___ (INDEFLATORS) ___ SCIENTIFICAPEX RX 12mm2.5mm1st ___ SCIENTIFICAPEX RX 12mm2.5mm2nd MEDTRONICRESOLUTE RX 15mm3.0mm MEDTRONICNC SPRINTER RX 09mm3.0mm Findings ESTIMATED blood loss: Minimal Hemodynamics (see above): Access: Right radial Coronary angiography: right dominant LMCA: mild LAD: Shelf-like ostial 50%, Ostial diag extending into the stented segment 80-90% diffuse. There is a pseudo aneurysm in the mid diagonal beyond the stented segment that appears to be 4-5mm in size.Hazy, eccentric 80% lesion in the proximal to mid LAD treated with a 3.0 drug-eluting ___ post dilated with a 3.0 NC balloon LCX: mild ectasia, (no progression when compared to films from ___ RCA: mild disease (no significant progression when compared to films from ___ Interventional details A ___ XB LAD 3.5 guide provided adequate support (It was decided to proceed with a PCI of the lesion in the proximal to mid LAD, and not to intervene on the diagonal branch at this time due to the ostial nature of the disease and the potential of jeopardizing the proximal LAD) ASA, Ticaegrelor and Heparin were used for thromboprophylaxis The lesion in the proximal to mid LAD was crossed with a Prowater wire into the distal vessel with relative ease ___ dilation was performed with a 2.5 balloon A 3.0 x 15 drug eluting ___ was deployed across the lesion and post dilated with a 3.0 NC balloon at 16 ATM Final angiography revealed no evidence of dissection, embolization or thrombus. There was TIMI III flow in the distal vessel. Assessment & Recommendations 1. Severe single vessel and branch vessel disease of the LAD in this right dominant coronary system 2. Successful PCI of the mid LAD with a 3.0 drug-eluting ___ 3. Residual ostial Diagonal disease (with ___ restenosis component and pseudo-anuerysm immediately distal to the stented segment) 4. Re-load with Clopidogrel 300mg in 12 hours 5. Follow for angina symptoms 6. Aggressive secondary risk factor modification 7. * Post PCI the patient developed amnesia without any focal motor or sensory deficits, stroke team assessed STAT and the patient was transferred to the CT scanner for immediate imaging CTA Neck ___: No evidence of infarct. No vascular abnormality. Final read pending reformats. CTA Head ___: No evidence of infarct. No vascular abnormality. Final read pending reformats. Brief Hospital Course: ___ yo M with h/o CAD, HIV, s/p stents to D1 and LAD, CKD, admitted with chest pain and abnormal nuclear stress with prolonged ST changes and transient ischemic dilation. S/p cath ___ with LAD ___ 3.0x14 mm. Pt with transient amnesia post-op. CT head negative. Stroke team consulted and followed and believed to be due to dye, no stroke. Pt returned to baseline orientationx3, no neurological findings. Creatinine with slight increase above baseline 1 day after cath. Deemed safe for discharge with outpatient f/u. Home medications changed to include high dose statin and plavix in addition to BB, ___, aspirin. Transitional Issues: -Patient should have creatinine re-checked on ___ given slight elevation during hospital stay; if it remains elevated, should consider holding ___ -Medication changes: increased atorvastatin to 80 mg daily, added plavix 75 mg daily (plavix to be taken for ___ year) -Outpatient f/u with cardiologist, appt to be made -Outpatient f/u with PCP -___ orientation and changes in MS- may require MRI per neurology Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Oxybutynin 5 mg PO DAILY 2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain, SOB 3. Terazosin 10 mg PO HS 4. TraZODone 200 mg PO HS 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Gabapentin 300 mg PO TID 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Losartan Potassium 50 mg PO BID 9. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 10. Amlodipine 5 mg PO DAILY 11. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL) subcutaneous QAM 12. Pantoprazole 40 mg PO Q12H 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 14. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous before meals 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q4-6h: prn sob 16. Hydrochlorothiazide 37.5 mg PO DAILY 17. Atorvastatin 40 mg PO DAILY 18. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Gabapentin 300 mg PO TID 6. Hydrochlorothiazide 37.5 mg PO DAILY 7. Losartan Potassium 50 mg PO BID 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain, SOB 10. Oxybutynin 5 mg PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Terazosin 10 mg PO HS 13. TraZODone 200 mg PO HS 14. Clopidogrel 75 mg PO DAILY Duration: 12 Months RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 16. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL) subcutaneous QAM 17. MetFORMIN (Glucophage) 1000 mg PO BID 18. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous before meals 19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q4-6h: prn sob Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Narrowing of left anterior descending coronary artery Secondary Diagnoses: Coronary Artery Disease Chronic Kidney Disease Diabetes HIV 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 taking care of you during your stay at ___. You were admitted for chest pain that started after breakfast and responded to nitroglycerin. Work-up of your chest pain in the ED showed an abnormality during stress testing that warranted cardiac catheterization. This was performed ___ and one ___ was placed. After the procedure, you were confused and concern over a stroke prompted imaging of your head. The stroke neurology team was called to see you as well. The scan of your head was negative, and your memory returned, and the neurology team did not think you had a stroke. On the day of discharge, your kidney function slightly worsened. This should be re-checked at ___ in 2 days (an order has placed all you have to do is go to the lab to have blood drawn) on ___. You should follow up with your cardiologist Dr. ___ as an outpatient. Her office will call you to make an appointment. You have been started on a medication called Plavix (clopidogrel). This is important to take everyday to prevent clots in your new heart ___. Do NOT stop taking unless directed by a physician. Wishing you well, Your ___ Cardiology Team Followup Instructions: ___

19990141-DS-18

DS

2133-03-05 00:00:00

2133-03-05 21:55:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Hayfever / Keflex / filbert nuts Attending: ___. Chief Complaint: pleuritic chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a history of varicose veins who presented to his PCP earlier today with ___ weeks of R leg pain. The pain developed while he was on vacation in ___ but he did not mention the pain to his family until 3 days ago, at which time he was brought to ___ in ___ and extensive superficial venous thrombosis was noted and it was recommended that he undergo f/u ultrasound in ___ days, which he underwent this morning and was found to have worsening SVT and also DVT. When he presented to his PCP this AM he denied dyspnea but did endorse some pleuritic L sided chest pain and worsening ___ edema. He was referred from PCP to ___ for PE scan, which L subsegmental pulmonary emboli involving the LLL with possible early infarct. Of note the patient reports ~50 lbs weight loss over approximately ___ years. He reports mostly this has been gradual, although potentially more rapid recently. He reports that to some degree he feels he is less hungry but his wife also reports that sometimes he "forgets to eat." He also notes that he is in the process of evaluation for memory loss. He is still able to do complex legal work (he is a retired ___) and manage finances but has been somewhat slower at these jobs and repeats things more often than he used to. He is awaiting brain MRI. He has been taken off Lipitor for this reason. He has also been taken off some of his antihypertensives recently (atenolol and amlodipine). He reports that he is up to date on colonoscopy screening. He also reports that he has an elevated PSA that has been attributed to BPH and that he is followed closely by urology who does not feel he has prostate cancer. No recent prolonged immobility. Patient's daughter believes he had superficial vein thrombosis remotely. His daughter also had a DVT in her ___ with negative work-up for hypercoagulability. She was on OCP and had been on long plane flight. ___ Course: Afebrile, HRs ___, BPs 120s-150s/50s-80s, 99-100% on RA Received 500 cc NS and 70 mg lovenox Review of systems: Const: no fevers, chills, dizziness, +weight change as above HEENT: no HA, changes in vision or hearing CV: +pleuritic chest pain Pulm: no dyspnea, cough, or wheezing GI: no abd pain, n/v, c/d, + increased eructation today GU: no changes in urine or dysuria MSK: no new myalgias/arthralgias Neuro: no new focal weakness or numbness Derm: no new rashes Hem: no new bleeding/bruising Endo: no hot/cold intolerance Psych: no recent mood changes per patient, although his wife feels he has been down at times Past Medical History: HL HTN BPH Nasal plyps Elevated PSA Spinal stenosis Varicose veins History of remote spine surgery History of hernia repair Social History: ___ Family History: History of provoked DVT in daughter in her ___ w/ neg coag w/u. Physical Exam: Admission Physical Exam: Vital signs: 97.9 188/78 87 16 100% on RA gen: pt in NAD HEENT: nc/at, sclera anicteric, conjunctiva noninjected, PER, EOMI, MMMs CV: RRR no m/r/g Pulm: CTAB No c/r/w (notes L sided lateral chest wall pain w/ deep inspiration) Abd/GI: S NT ND BS+, no masses/HSM palpated Extr: wwp, distal pulses intact, bilateral legs w/ varicose veins, R medial thigh with hardened cords and tenderness, mild edema R>L GU: no CVA tenderness, no Foley Neuro: alert and interactive, strength intact, sensation to light touch slightly reduced over distal RLE Skin: no rashes on limited skin exam Psych/MS: normal range of affect' DISCHARGE VS: 97.8 124/64 62 16 100%RA Gen: sitting up in bed, comfortable Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft nontender, normoactive bowel sounds Ext - no edema Skin - chronic venous stasis changes bilaterally Vasc - venous varicosities over R leg; 2+ ___ pulses bilaterally Neuro - AOx3, moving all extremities Psych - appropriate Pertinent Results: ADMISSION ___ 02:40PM BLOOD WBC-7.6 RBC-4.38* Hgb-12.5* Hct-39.0* MCV-89 MCH-28.5 MCHC-32.1 RDW-12.9 RDWSD-42.2 Plt ___ ___ 02:40PM BLOOD ___ PTT-29.2 ___ ___ 02:40PM BLOOD Glucose-125* UreaN-27* Creat-0.9 Na-142 K-3.8 Cl-107 HCO3-27 AnGap-12 DISCHARGE ___ 08:00AM BLOOD WBC-6.3 RBC-4.45* Hgb-12.6* Hct-38.9* MCV-87 MCH-28.3 MCHC-32.4 RDW-12.5 RDWSD-40.2 Plt ___ ___ 08:00AM BLOOD ___ PTT-38.1* ___ ___ 08:00AM BLOOD Glucose-99 UreaN-19 Creat-0.7 Na-141 K-3.8 Cl-107 HCO3-27 AnGap-11 RLE Doppler There is thrombosis of the majority of the greater saphenous vein from its origin to the level of the distal calf with extension into the common femoral vein at the greater saphenous vein origin, compatible with superficial and deep venous thrombosis. CTA Chest 1. Subsegmental pulmonary emboli involving the left lower lobe with probable left lower lobe infarct. 2. Filling defects within subsegmental pulmonary veins in the right and left lower lobes. 3. Intermediate density small left pleural effusion. Brief Hospital Course: This is a ___ year old male with past medical history of hypertension, BPH, varicose veins, who was referred for admission from PCP's office after diagnosis of new DVT in the setting of pleuritic chest pain, subsequently found to have acute pulmonary embolism, with reassuring telemetry and EKG, started on rivaroxaban and able to be discharged home # Acute pulmonary embolism / Acute right Common Femoral DVT - Patient with several days worsening leg swelling in setting of recent diagnosis of superficial thromboembolism, found to have acute R common femoral DVT--given ongoing pleuritic chest pain, he was referred to ___ ___, where he was found to have acute DVT. He was started on lovenox and admitted to medicine. Per PESI score he was intermediate risk (based on age and gender, no additional risk factors). EKG without signs of right heart strain and patient was without any vital sign abnormalities or symptoms (other than mild pleuritic L chest pain). Telemetry was unremarkable. After discussion with patient and his PCP ___. ___ was prescribed rivaroxaban, delivered to bedside, and instructed to begin taking 12 hours after last dose of lovenox. At time of discharge patient was ambulating comfortably. He and wife were educated on warning signs that should prompt additional care, and verbalized their understanding. # Hypertension - continued lisinopril # Mild Cognitive Impairment - continued donezpezil TRANSITIONAL - Discharged home with 21-day supply of rivaroxaban twice daily--at follow-up visit he will need prescription for maintenance daily dosing of rivaroxaban - Defer to outpatient providers regarding utility of additional workup for unprovoked venous thromboembolism > 30 minutes spent on this discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Donepezil 5 mg PO QHS 3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Rivaroxaban 15 mg PO BID with food; continue for 21 days RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. Donepezil 5 mg PO QHS 3. Lisinopril 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Acute pulmonary embolism / Acute right Common Femoral DVT # Hypertension # Mild Cognitive Impairment Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___: It was a pleasure caring for you at ___. You were admitted with a new diagnosis of a deep vein thrombosis (blood clot) in your leg, and a pulmonary embolism (blood clot) in your lung. You were treated with a blood thinning medication. You underwent cardiac testing that was reassuring. We discussed the situation with your primary care doctor who recommended the medication Xarelto (rivaroxaban). Please take it twice a day for 21 days. After this you will be able to take it once a day--please see your primary doctor who will provide you with this once-a-day prescription. Followup Instructions: ___

19990366-DS-18

DS

2133-08-13 00:00:00

2133-08-14 17:26:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of COPD, CHF, hypertension, TIA, osteoarthritis and remote colon cancer, who presented with atraumatic back pain that started when she was getting out of bed and found to have a T-spine fracture. She developed atraumatic back pain 3 days prior to admission while walking to the bathroom. She states the pain was ___ in severity and non-radiating. She states it is worse with movement and pain medication helps with the pain. She also reported some subjective left leg weakness. She presented to the eye ___ where she was found to have urinary retention and a Foley was placed. She states that she has been having urinary retention for about a year but never sought medical attention. She also states that she has not had a bowel movement in 3 days and has good appetite. She denied any fever, night sweats, chest pain, shortness of breath, lightheadedness, abdominal pain, nausea, vomiting. - In the ED, initial vitals were: T 97.7 HR 94 BP 138/51 RR 16 O2 96% RA - Exam was notable for: "Midline low T-spine and ___ tenderness. Strength and sensation intact in distal extremities although the right lower extremity flexion is limited by pain. Normal rectal tone." - Labs were notable for: CBC unremarkable BMP unremarkable LFTs unremarkable UA unremarkable INR 1.0 - Studies were notable for: MR ___ spine with and without contrast Cord or cauda equina compression: No. Please note that imaging can make the anatomic diagnosis of cauda equina COMPRESSION, but that cauda equina SYNDROME is a clinical diagnosis based on the patient examination. Imaging can never make a diagnosis of cauda equina SYNDROME. Cord signal abnormality: no Epidural collection: no Other: Increased fluid signal within the T12 and L1 vertebral bodies at the site of known compression fractures. Multilevel disc bulges, most prominent at L2-L3 causing moderate spinal canal stenosis and bilateral neural foraminal stenosis. - The patient was given: IV morphine sulfate 2 mg x3 - Spine were consulted and recommended: "TLSO ___ at edge of bed, no ___ restrictions, follow up with Dr. ___ in 1 month with lumbar spine AP/lateral x-ray, pain management." On arrival to the floor, She states her pain is ___ and her pain is adequately controlled. She also complains of constipation. Past Medical History: HTN COPD TIA Osteoarthritis Hypothyroidism CHF (EF 60% in ___ Colon cancer Sigmoid diverticulitis Hysterectomy Colectomy in ___ COPD Squamous cell carcinoma Social History: ___ Family History: Not relevant to current presentation Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 742) Temp: 98.4 (Tm 98.4), BP: 172/70, HR: 86, RR: 20, O2 sat: 97%, O2 delivery: 2L Fluid Balance (last updated ___ @ 756) Last 8 hours Total cumulative 360ml IN: Total 360ml, PO Amt 360ml OUT: Total 0ml Last 24 hours Total cumulative 360ml IN: Total 360ml, PO Amt 360ml OUT: Total 0ml GENERAL: Alert and interactive. In no acute distress. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. crescendo-decrescendo murmur RUSB LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. Non-tender to palpation. Deferred Sciatic exam given fracture. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. multiple healed scars. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM ======================= PHYSICAL EXAM: VS: ___ 1115 Temp: 98.0 PO BP: 123/61 HR: 70 RR: 18 O2 sat: 94% O2 delivery: Ra Fluid Balance (last updated ___ @ 1200) Last 8 hours Total cumulative 185mL IN: Total 360 ml PO OUT: Total 175ml, Urine Amt 175ml + inctx1 Last 24 hours Total cumulative 700ml IN: Total 940ml, PO Amt 940ml OUT: Total 285ml +inctx3 GENERAL: Alert and interactive. In no acute distress. Not wearing TLSO brace while in bed. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ crescendo-decrescendo murmur appreciated throughout precordium LUNGS: Decrease breath sound in all lung fields anteriorly BACK: Deferred Sciatic exam given fracture. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: 1+ pitting edema in bilateral lower extremities. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. multiple healed scars. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs. Pertinent Results: ADMISSION LABS: ============== ___ 01:10PM WBC-9.4 RBC-3.79* HGB-11.7 HCT-35.6 MCV-94 MCH-30.9 MCHC-32.9 RDW-14.5 RDWSD-49.6* ___ 01:10PM NEUTS-78.7* LYMPHS-11.1* MONOS-7.2 EOS-2.1 BASOS-0.4 IM ___ AbsNeut-7.39* AbsLymp-1.04* AbsMono-0.68 AbsEos-0.20 AbsBaso-0.04 ___ 01:10PM PLT COUNT-242 ___ 01:10PM GLUCOSE-63* UREA N-25* CREAT-0.7 SODIUM-138 POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-18 ___ 01:10PM estGFR-Using this IMAGING ======= MR ___ & W/O CONTRAST ___. No evidence of cauda equina compression. 2. Compression fractures of L1 vertebral body (severe and with mild retropulsion) and L3 vertebral body (moderate). Superior endplate fracture of T12 vertebral body. The L1 and T12 fractures appear recent. 3. Moderate lumbar spondylosis, most marked at L2-L3, with moderate spinal canal narrowing, secondary to diffuse disc bulge and ligamentum flavum thickening. There is moderate bilateral neural foraminal narrowing at L3-L4. Chest radiograph ___. Mild pulmonary vascular congestion without frank pulmonary edema. 2. Consolidation in the left lower lung field, consistent with moderate left pleural effusion alongside associated atelectasis. Remaining left lung is clear. Right lung is free of consolidation 3. Density projecting above the aortic arch is of unknown etiology. Recommend clinical correlation. DISCHARGE LABS: =============== ___ 07:59AM BLOOD WBC-7.1 RBC-3.56* Hgb-11.1* Hct-34.6 MCV-97 MCH-31.2 MCHC-32.1 RDW-14.6 RDWSD-52.4* Plt ___ ___ 07:59AM BLOOD Glucose-88 UreaN-27* Creat-0.8 Na-138 K-5.1 Cl-99 HCO3-31 AnGap-8* ___ 07:59AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.8* Brief Hospital Course: ___ with history of COPD, DMII, hypertension, and remote colon cancer who presented with atraumatic back pain and found to have T-spine fracture, urinary retention (for about a year) and hypoxia which has improved. Currently has a TSLO brace for support and HD and vitally stable. Discharged to rehab. ACUTE/ACTIVE ISSUES: ==================== # Atraumatic T-spine fracture Concerning for underlying osteoporosis. No cord compression by imaging and urinary symptoms of unclear duration potentially. No surgical intervention per spine surgery. Being treated with TLSO brace when ambulating and pain medications. She also has an appointment with Dr. ___ in 2 weeks. She should continue to wear TLSO for duration when out of bed until f/u appointment. She should continue to take calcium and vitamin D and f/u with pcp for osteoporosis management. Pain control with Tylenol and PRN oxycodone, pt at times not taking oxycodone. Encourage pt to consider small dose in AM to help with mobilization/getting out of bed to chair. #Constipation - resolved Patient complained of 5 days with no BM and recent indigestion. She was started on multiple bowel regiments and had 2 bowel movements on ___ and multiple BM on ___. Outpatient bowel regimen can be PRN. # Urinary retention - resolved Concerning for cord compression, but no evidence on imaging and rectal tone is normal, which is reassuring. Patient states that she has been having an issue with urinary retention for about a year. Perhaps secondary to severe pain. Foley in place and removed on ___. She has been voiding without complaint. # New Left pleural effusion- Resolved # Hypoxemia She was noted to be hypoxic to the low ___ on RA after receiving multiple doses of IV morphine. CXR revealed left-sided pleural effusion which was resolved after continuation of home lasix. Subsequent CXR shows resolved effusion. CHRONIC/STABLE ISSUES: ====================== # Hypertension - Continue home amlodipine and losartan # Hypothyroidism - Continue home levothyroxine TRANSITIONAL ISSUES: =================== [] f/u appointment with Dr. ___ in 2 weeks ___ at 10:45 am at ___. She should continue to wear TLSO brace when out of bed until this appointment. -- She will repeat Xray on same day as appt with Dr. ___ ___: no HCP on file Emergency ___: ___ (___ (DAUGHTER ___ ___) New medications - oxycodone - vitamin d Changed medications none Stopped medications none CORE MEASURES: ============== # CODE: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN wheezing Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*14 Tablet Refills:*0 3. Vitamin D 1000 UNIT PO DAILY 4. amLODIPine 10 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Losartan Potassium 100 mg PO DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN wheezing Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: # Atraumatic T-spine fracture # Constipation # Urinary retention # pleural effusion- Resolved # Hypoxemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because severe back pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - At the hospital we did imaging of your back that showed a fracture in your lower back. - We got a brace for you to stabilize your back. - We also noted that you were having a hard time with passing stool which we gave you some medication to help you have a bowel movement. - You were also having a hard time voiding so we place a foley that we removed on ___. You were voiding with no issues afterward. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. -You should wear your brace when out of bed until your follow up appointment with Dr. ___. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

19990545-DS-20

DS

2139-10-29 00:00:00

2139-10-29 17:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / Unasyn Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: ERCP . ___: CT-guided drainage of a retroperitoneal and pelvic collections. . ___: ___ . ___: CT-guided drainage of right perinephric collection. History of Present Illness: Mrs. ___ is a ___ w/ h/o chest/epigastric pain who presents with 3 days of symptoms and U/S concerning for acute cholecystitis. Patient reports that she has had a few of these "attacks" over the past ___ years, occurring about every 6 months, and described mostly as "twisting" chest pain, but usually spontaneously resolves. For her current episode, she had symptoms again mostly described as chest pain, and was worsened with food intake. Her pain had not improved over the past few days, thus she went to her PCP. There, she was noted to have RUQ tenderness, and an U/S was obtained which was concerning for acute cholecystitis. Patient underwent ERCP with sphincterotomy on ___. Post ERCP patient developed abdominal pain, distention, lipase was 1886 concerning for post ERCP pancreatitis. Patient was admitted to the ___ surgery service for evaluation, management of pancreatitis and possible cholecystectomy. Past Medical History: None Social History: ___ Family History: Diabetes, h/o CAD Physical Exam: Prior to Discharge: VS: 98.3, 61, 118/78, 18, 97% RA GEN: Somewhat anxious without acute distress HEENT: NC/AT, EIOM, PERRL, neck supple, no scleral icterus SKIN: Trunk and thighs with multiple dark circular spots CV: RRR, no m/r/g PULM: CTAB ABD: Soft non tender, non distended. Right flank with ___ drain to bulb suction with minimal cloudy yellow output. Site with drain sponge over and c/d/I. EXTR: Warm, no c/c/e Pertinent Results: RECENT LABS: ___ 11:40AM BLOOD WBC-11.1* RBC-2.81* Hgb-7.8* Hct-24.1* MCV-86 MCH-27.8 MCHC-32.4 RDW-13.8 RDWSD-43.8 Plt ___ ___ 11:40AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-132* K-4.0 Cl-98 HCO3-24 AnGap-14 ___ 06:01AM BLOOD ALT-156* AST-90* AlkPhos-289* TotBili-0.9 ___ 11:40AM BLOOD Lipase-62* ___ 11:40AM BLOOD Calcium-7.7* Phos-3.5 Mg-2.3 MICROBIOLOGY: ___ 12:30 pm PERITONEAL FLUID PERITONEAL FLUID ( FROM RETROPERITONEAL ABSCESS DRAIN ). **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 4:40 pm FLUID,OTHER PERIPHERAL COLLECTION. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: ___ ALBICANS. SPARSE GROWTH. Yeast Susceptibility:. Fluconazole MIC = 0.5 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. Sensitivity testing performed by Sensititre. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. RADIOLOGY: ___ LIVER US: IMPRESSION: 1. Mobile gallstones and sludge within a moderately distended gallbladder. No gallbladder wall edema or pericholecystic fluid is seen at the present time, although findings may represent early acute cholecystitis. In addition there is note of choledocholithiasis, with at least 1 shadowing stone seen in the common bile duct. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Relative areas of hypo echogenicity within the liver parenchyma are consistent with geographic sparing from steatosis. 3. Trace right pleural effusion. ___ ERCP: The scout film was normal. •Normal major papilla. •Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. •Contrast medium was injected resulting in complete opacification. •The common bile duct, common hepatic duct, right and left hepatic ducts, biliary radicles and cystic duct were filled with contrast and well visualized. •The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, one small stone was noted at the distal CBD •A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. •No evidence of post sphincterotomy bleeding was noted. •Balloon sweeps reveled small amount of sludge and one small stone. •Occlusion cholangiogram showed no evidence of filling defects. •Post balloon sweeps good drainage of contrast and bile was noted both endoscopically and fluoroscopically •Otherwise normal ercp to third part of the duodenum ___ KUB: IMPRESSION: No evidence of free intraperitoneal air. ___ CT ABD: IMPRESSION: 1. Extraluminal retroperitoneal air is identified posterior to the second portion of duodenum. There is fluid extending from the duodenum and to right perinephric space. Duodenal wall is thickened. Findings are suspicious for duodenal perforation although no oral contrast extravasation or discrete duodenal wall defect is identified. 2. Cholelithiasis with gallbladder wall thickening. Hyperenhancement of gallbladder mucosa and extrahepatic bile ducts may be inflammatory. 3. Peritoneal enhancement is consistent with peritonitis. Omental nodularity may reflect edema. 4. Right colonic wall thickening may reflect secondary inflammation. 5. Small to moderate ascites. 6. Bilateral pleural effusions are small. ___ CT ABD: IMPRESSION: 1. Unchanged extraluminal retroperitoneal air and fluid posterior to the second portion of the duodenum and extending throughout the right perirenal space, remaining suggestive of duodenum perforation. 2. Moderate free fluid throughout the abdomen pelvis is slightly increased from prior with new rim enhancement suggestive of organizing fluid collections/ early abscess formation. New peritoneal enhancement, particularly in the pelvis, suggestive of peritonitis. 3. Mildly prominent small bowel loops with air-fluid levels are suggestive of reactive ileus. 4. Probable reactive colonic mucosal thickening. 5. No definite CT evidence of acute cholecystitis. ___ ___ PROCEDURE: 1. Repositioning of wire placed under CT guidance from the retroperitoneal abscess into the retro duodenum region 2. Placement of 8 ___ biliary drain over wire with pigtail formed in the retro duodenum region 3. Upper GI series through NG tube to evaluate for persistent duodenum perforation ___ CT ABD: IMPRESSION: 1. Interval placement of a pigtail catheter, with resulting decrease in size of the retroperitoneal fluid collection along its course. 2. However, remainder of the small multiloculated perirenal fluid collections on the right are unchanged in size. 3. Within the pelvis, a new 3.7 x 1.9 cm organized collection in the region of the left adnexa could represent walled-off ascites. Fluid collection along the posterior uterine wall has decreased. 4. Fatty infiltration of the liver. 5. Trace pericardial effusion, grossly unchanged. ___ ___ PROCEDURE: IMPRESSION: Successful CT-guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. Brief Hospital Course: The patient is a ___ female with acute cholecystitis s/p ERCP. She was admitted to the HPB Surgical Service for possible cholecystectomy. Overnight patient developed abdominal pain and her lipase was 1886 with WBC 12. Surgery was postponed and patient was started treatment for acute pancreatitis. She was started on Unasyn, aggressive fluid resuscitation and made NPO, pain was controlled with Dilaudid PCA. On HD 3, patient was patient was noticed to have SOB, she was required supplemental O2. Fluid rate was turned down, she was diuresed with Lasix x 2 and her respiratory status improved. On HD 6, patient's diet was advanced to clear liquids. After taking clears, patient's abdominal pain increased and she developed fever, she was made NPO. On HD 7 (___) patient's WBC increased to 14K and CT scan was obtained. Abdominal CT demonstrated extraluminal retroperitoneal air, thickened duodenal wall, no active contrast extravasation, peritoneal enhancement concerning for peritonitis, ascites and acute cholecystitis. Patient's antibiotics were changed to Cipro/Flagyl in the setting of possible perforation. On HD 8 (___), patient's diet was advanced to clears per GI recommendations. Patient spiked fever to 103, vomited, and WBC increased to 16K, she was pan cultured and ID was consulted. Cipro/Flagy was changed to meropenem per ID recommendations. On HD 9 (___), patient remained febrile, her blood, urine and stool cultures were negative. Patient developed itchy rash, which start on her abdomen and spread. Dermatology was consulted. Patient's WBC continued to climb and was 18K. Patient was started on Allegra for itching and Diprolene cream per Dermatology. On HD 10 (___) patient's WBC continued to increase to 18.8, patient was afraid to have CT scan secondary to her resent allergic reaction. On HD 11 (___), WBC up to 19.6 and CT scan was obtained. CT demonstrated unchanged extraluminal retroperitoneal air and fluid posterior to the second portion of the duodenum and extending throughout the right perirenal space, remaining suggestive of duodenum perforation; moderate free fluid throughout the abdomen pelvis is slightly increased from prior with new rim enhancement suggestive of organizing fluid collections/ early abscess formation; new peritoneal enhancement, particularly in the pelvis, suggestive of peritonitis (please see Radiology report for details). ___ was consulted for possible CT-guided drainage of the fluid collections. On HD 12 (___) patient underwent placement of two drains, one in retroperitoneal, and second into pelvic fluid collections. Sample was sent for microbiology and cell count. On HD 13 (___), patient underwent PICC line placement and TPN was started for nutritional support. Abdominal fluid cultures were positive for yeast and Mucafungin was added per ID recommendations. On HD 14 (___) patient's diet was advanced to clears and was well tolerated. On HD 15 (___) micofungin was changed to Fluconazole as cultures growing ___. Patient's pelvic drain was discontinued. On HD 16 (___) patient's diet advanced to fulls. Patient's spiked a fever to 101.7, WBC started to downward. Patient remained febrile next four days with Tmax 102.1, WBC continued to downtrend. On HD 19 (___) patient underwent CT scan, which revealed decreased retroperitoneal fluid collection, small multiloculated perirenal fluid collections and small walled off ascites (please see Radiology report for details). On HD 20 (___) patient underwent CT-guided drainage of right perinephric collection. After drainage diet was advanced to regular. HD 21 (___), pain was well controlled, both retroperitoneal and perinephric drain with minimal output, WBC down tranding and patient remained afebrile. HD 22 (___), TPN was discontinued. On HD 23 (___), perinephric drain fluid positive for Candina, retroperitoneal drain was discontinued as output was scant. HD 23 (___) patient discharged home in stable condition with one drain remained in place and on Fluconazole for 7 days total. Prior to discharge, patient remained afebrile, pain was well controlled, PICC line was removed, patient tolerated regular diet and ambulate without assistance. Patient was discharged home with ___ services to continue drain care. Follow up appointment with abdominal CT was scheduled prior to discharge, patient instructed to call back if fever or increased output from ___ drain. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild do not exceed more then 3000 mg/day 2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID RX *betamethasone, augmented 0.05 % aplly twice a day on affected areas twice a day Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Fexofenadine 180 mg PO DAILY 5. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Acute cholecystitis 2. Post ERCP pancreatitis and small bowel perforation 3. Severe allergic reaction to antibiotics (Unasyn/Ciprofloxacin) with skin rash 4. ___ peritonitis with intra abdominal abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at ___ for management acute pancreatitis and small bowel perforation after ERCP, which was performed for acute cholecystitis. Your recovery was complicated by severe allergic reaction to antibiotics and ___ peritonitis with intraabdominal abscesses, which required ___ drainage. You required bowel rest and were placed on TPN for nutritional support. Your diet is now advanced and TPN was discontinued. You are now safe to return home to complete your recovery with the following instructions: . Please call Dr. ___ office at ___ or ___ ___, RN at ___. During off hours: Call pager operator at ___ and ask to page ___ ___ ___ team. . Please call back right away if you have fever > 100.5 or increased abdominal pain. Call the numbers above if you drain output significantly increase. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . ___ drain care: *Keep to bulb suction. *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). *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 or ___ strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *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: ___

19990545-DS-22

DS

2140-03-04 00:00:00

2140-03-04 14:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ciprofloxacin / Unasyn Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ year old woman with history of choledocholithiasis, cholecystitis in ___ s/p ERCP decompression complicated by post-ERCP pancreatitis, duodenal microperforation with RP and pelvic abscesses (s/p ___ drain placement) briefly requiring TPN, s/p cholecystectomy ___ now with episodic epigastric pain who presents with worsening of her known abdominal pain. Patient has had episodic epigastric pain for the past ___ year. Prior to her cholecystitis episode in ___, she used to experience the epigastric pain during ___ episodes per day, characterized by sudden onset burning/throbbing pain that "feels like spasms." The pain lasted 30 seconds to 1 minute and then would go away. She was admitted for abdominal pain and was diagnosed to have cholecystitis. She underwent ERCP with stone extraction. However subsequently had a complicated course with worsening sxs/fever/leukocytosis, and eventually diagnosed with duodenal perforation with RP/pelvic abscesses. SHe was treated with a prolonged course of antibiotics (unasyn-->cipro/flagyl-->meropenem) and ___ drainage of the fluid collections. Abdominal fluid cultures were positive for yeast and Mucafungin was also added per ID recommendations. SHe also briefly required TPN. Her LFTs, WBC were trending down on day of discharge. Her drains were removed at outpatient follow up and she completed her course of abx. Her fluid collections improved on post-dc CT scans. SHe was then admitted in ___ for n/v, presumed to viral gastroenteritis, improved with symptomatic therapy. SHe then underwent CCY on ___. For the past week she has been having ___ episodes of the epigastric pain per day and also has a baseline ___ aching in epigastrium for most of the day. Severe, cramping, non radiating, worse when she does not eat for a long time, worst in the morning. Also associated with several episodes of bilious emesis over the past 2 days. Denies fevers, chills, recent weight loss In ED, VSS On exam, tender in epigastrium to light palpation, voluntary guarding in epigastrium. Labs unremarkable KUB did not show any free air under diaphragm, or any other abnormality Declined any pain medications On arrival to floor, ROS negative except for as noted above. During interview, noted to have one of the episodes of pain, lasted 30 seconds, patient curled up clutching stomch, visibly in significant distress, associated with retching. Past Medical History: - Choledocholithiasis and cholecystitis ___ s/p ERCP decompression complicated by post-ERCP pancreatitis, duodenal microperforation with RP and pelvic abscesses (s/p ___ drain placement) briefly requiring TPN - S/p cholecystectomy ___ - Chronic abdominal pain Social History: ___ Family History: - No liver/gallbladder FH - Dyslipidemia, HTN, diabetes, CAD Physical Exam: Gen: NAD, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear GI: soft, epigastric tenderness, guarding, ND MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Pertinent Results: ___ 01:14PM ___ PTT-31.0 ___ ___ 12:37PM ___ COMMENTS-GREEN TOP ___ 12:37PM LACTATE-0.9 ___ 12:34PM GLUCOSE-95 UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16 ___ 12:34PM estGFR-Using this ___ 12:34PM ALT(SGPT)-20 AST(SGOT)-21 ALK PHOS-63 TOT BILI-0.2 ___ 12:34PM LIPASE-57 ___ 12:34PM ALBUMIN-4.5 CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.0 ___ 12:34PM WBC-9.9 RBC-4.87 HGB-13.2 HCT-40.0 MCV-82 MCH-27.1 MCHC-33.0 RDW-14.7 RDWSD-44.4 ___ 12:34PM NEUTS-58.5 ___ MONOS-4.4* EOS-1.9 BASOS-0.6 IM ___ AbsNeut-5.78 AbsLymp-3.40 AbsMono-0.44 AbsEos-0.19 AbsBaso-0.06 ___ 12:34PM PLT COUNT-292 ___ 11:45AM URINE HOURS-RANDOM ___ 11:45AM URINE UCG-NEGATIVE ___ 11:45AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 11:45AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 11:45AM URINE MUCOUS-RARE KUB: There is a nonobstructive bowel gas pattern. No large air-fluid levels are seen. There is no evidence of free air. Right upper quadrant surgical clips are from presumed cholecystectomy. The lung bases are grossly clear. MRCP: official read pending at time of discharge Brief Hospital Course: ___ year old woman with history of choledocholithiasis, cholecystitis in ___ s/p ERCP decompression complicated by post-ERCP pancreatitis, duodenal microperforation with RP and pelvic abscesses (s/p ___ drain placement) briefly requiring TPN, s/p cholecystectomy ___ now with episodic epigastric pain who presented with worsening of her chronic abdominal pain. The cause of the acute increase of her chronic abdominal pain remained unclear. She had no signs of perforation or obstruction on KUB. MRCP was performed. GI team contacted radiology who stated the wet read had no concerning findings. Labs including lipase are unremarkable. She remained hemodynamically stable with no systemic signs of toxicity. GI and ERCP teams recommended discharge to home on PPI BID and hyoscyamine prn abdominal cramping. They plan on performing an outpatient EGD in the next ___ days. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY 3. Ranitidine 150 mg PO BID 4. Senna 8.6 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate Discharge Medications: 1. Hyoscyamine 0.125 mg SL Q4H:PRN abdominal cramping RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) sublingually every four (4) hours Disp #*30 Tablet Refills:*0 2. Omeprazole 40 mg PO BID RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: abdominal pain Discharge Condition: condition: good mental status: intact at baseline ambulatory status: independent Discharge Instructions: You were admitted to the hospital for abdominal pain and expedited work-up. You had an MRCP that was unrevealing. You were seen by GI who recommend an outpatient EGD be done early this week. They will contact you with the specific date and time. They have also recommended you start 2 new medications. Omeprazole is to decrease gastric acid production and Levsin (hyoscyamine) to treat abdominal cramping/muscle spasms. Followup Instructions: ___

19990786-DS-23

DS

2154-11-04 00:00:00

2154-11-04 16:50:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Lovastatin Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history if CAD s/p ___ and POBA of the R-PDA in ___, hx TIAs in ___, HTN, HLD, DM, presenting as OSH transfer ___ for management of NSTEMI. The patient noted that since ___ he had been experiencing "stoimach upset" which was partially relieved by ___. He continued to experience symptoms which he thought were dyspepsia. The early ___ morning he was awoken from his sleep by the onset of left sided chest pain/pressure approximately 2am with some radiation to the upper back. Associated with diaphoresis, nausea and vomiting. He called his daughter who took him to the ED at ___. Found to have elevated troponin and STDs V4-6. Given ASA. Started on heparin PTA. Patient continuing to endorse chest pain on arrival to the ___ ED, though much improved. +d-dimer at ___. In the ED, initial vitals were 97.8 66 184/103 18 96%, he was started on a nitro gtt for ongoing chest pain. He continued on Heparin gtt and received 1L NS. Labs remarkable for Troponin 0.02, CK 209, MB 5. Cr 1.3 (baseline ___. Had CTA Chest given positive D dimer, which was negative for PE. He was admitted to ___ for further management. Vitals on transfer: 63 186/92 13 98% RA. On arrival to the floor, patient reports that his chest pain has resolved. Past Medical History: Past medical/surgical history: - Hypercholesterolemia - Hypertension - CAD: * ___, with circumflex cypher stent and right PDA POBA. * ___: repeat cath: patent stent, diffuse disease in other vessels - Left hemiparesis after subdural hematoma - Diabetes - Gout - Hernia repair - Right below-knee amputation ___ years ago after a motor vehicle accident and recent revision ___ has prosthesis; walks with a cane - Subdural hematoma s/p evacuation ___ - GERD - h/o BPPV - h/o TIA Social History: ___ Family History: father had hx of MIs and stroke, mother died of stomach cancer, brother who needed CABG and died during CABG procedure. Physical Exam: On Admission: -------------- Vitals:Temp 98, BP 122/74, HR 66, RR 16, O2 100% RA General: well-appearing man in NAD Neck: JVP flat, no carotid bruits CV: RRR, S1, S2, S4, no murmurs or rubs Lungs: clear to auscultation bilaterally Abdomen: soft, nontender, nondistended, no evidence of masses or organomegaly GU: no foley Extr: Right BKA, left with diminished ___ and DP pulses, feet cool to touch At Discharge: -------------- Pertinent Results: Labs on Admission: ------------------- ___ 07:41AM NEUTS-78.7* LYMPHS-16.3* MONOS-4.5 EOS-0.4 BASOS-0.2 ___ 07:41AM PLT COUNT-217 ___ 07:41AM NEUTS-78.7* LYMPHS-16.3* MONOS-4.5 EOS-0.4 BASOS-0.2 ___ 07:41AM ___ PTT-96.7* ___ ___ 07:41AM ALBUMIN-4.0 CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.4* ___ 07:41AM GLUCOSE-316* UREA N-33* CREAT-1.3* SODIUM-136 POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-22 ANION GAP-20 ___ 07:41AM ALT(SGPT)-22 AST(SGOT)-41* CK(CPK)-209 ALK PHOS-99 TOT BILI-0.4 ___ 07:41AM LIPASE-29 ___ 07:41AM cTropnT-0.02* ___ 01:45PM cTropnT-0.02* ___ 07:48PM CK-MB-3 cTropnT-0.01 REPORTS THIS ADMISSION: Cardiac Perfusion Test ___: There is mild fixed defect in the inferolateral wall in setting of soft tissue attenuation. LV size and wall motion is normal. EF is 60%. Cardiac Stress Test ___: INTERPRETATION: This ___ year old IDDM with a PMH of old MI, PCIs, 3VD and traumatic LLL ambutation was referred to the lab for evaluation of chest discomfort. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segment changes during the infusion or in recovery. The rhythm was sinus with 1 apb. Appropriate hemodynamic response to the infusion and recovery. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or ST segment changes. Nuclear report sent separately. Brief Hospital Course: ___ PMH CAD, HTN, T2DM and HLD presenting with chest pain, HTN and elevated troponin c/w NSTEMI. # Unstable Angina with Troponin leak: patint with unstable angina, and troponin leak, however troponin elevation <0.1, so not true NSTEMI. Nitro gtt discontinued and patient remained free of chest pain. Heparin gtt was discontinued, and he had no recurrence of chest pain. He was medically optimized with Atorvastatin 80, Beta-blocker, and ASA. He went for stress-mibi to rule out reversible defects, and this study showed no new reversible defects as well as no new irreversible defects and a preserved ejection fraction. Please see "reports" section for full details. He was discharged on his home medication regimen, with the exception that his atorvastatin was increased to 80mg PO daily from a dose of 40mg for CAD optimization. # CAD: continued home atorvastatin at an increased dose of 80mg as above; switched home atenolol to labetalol while in house but transitioned back to home atenolol at discharge; continued home ASA. # DMT2: held home oral metformin and glipizide; ISS and QACHS ___ while in house # HTN:continued home lisinopril and atenolol at discharge. # Gout: continued home allopurinol. # GERD: continued home omeprazole. *****TRANSITIONAL ISSUES***** - Atorvastatin was increased to 80mg qDaily. - CPET without reversible defects. - may consider switching atenolol to carvedilol as outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Lisinopril 10 mg PO DAILY 3. Chlorthalidone 12.5 mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. GlipiZIDE XL 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Omeprazole 20 mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. Chlorthalidone 12.5 mg PO DAILY 6. GlipiZIDE XL 10 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Tamsulosin 0.4 mg PO QHS 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually every 5 minutes as needed for Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: -------- Unstable Angina with Troponin Leak Hypertensive Emergency Secondary: ---------- Coronary Artery Disease Diabetes Mellitus Type 2 HTN HLD Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospital stay at ___. You came in because you were having chest pain. At the hospital we found that you had a heart attack and your blood pressure was very high. We treated you for the heart attack. You went for a stress test which showed no evidence of worsening in your heart's function. It is now safe for you to be discharged. Please be sure to take all of your medications as prescribed and keep your follow-up appointments. We wish you the very best ! Sincerely, Your ___ Cadiology Team Followup Instructions: ___

19991085-DS-19

DS

2125-01-10 00:00:00

2125-01-10 18:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abnormal PET scan Major Surgical or Invasive Procedure: Mediastinoscopy with lymph node biopsy History of Present Illness: ___ year old female with history of spinal stenosis, cervical radiculopathy, AV block s/p PPM (___), and morbid obesity who was referred to the ED for abdnormal CT findings. The patient is being followed by Neurology for spinal stenosis and cervical radiculopathy. CT C-spine in ___ revealed enlarged cervical and mediastinal lymph nodes. CT Chest on ___ showed enlarged mediastinal and peripancreatic lymph nodes, up to 1.5x 2.3cm with mild splenomegaly. She was referred to Oncology, Dr. ___, and underwent a PET scan on ___, which returned suspicious for lymphoma. There was also concern for cervical cord/canal involvement by enlarged lymph nodes. The patient was referred to the ED for further management. In the ED, initial vitals were: 98.2 89 116/81 16 98% RA. Labs were notable for WBC 7.1 (17.7L) and Cr 0.8. An MRI could not be performed due to PPM. Radiology and neuoradiology felt there would be no benefit to assess possible lymphoma involvement with CT. Neurosurgery was consulted and there was low concern for acute cord impingement or surgical lesion. Upon arrival to the floor, the patient described stable numbness in her arms, legs, and bottom of her feet. She describes numbness at the lateral aspects as well as hands (Lt > Rt). The numbness in her legs is prominent in her thighs above the knees bilaterally. She describes intermittent weakness in her arms and legs as well, that has been ongoing for years. She describes having to sit after walking for long perioids. She also describes difficulty with picking up objectss. The patient also describes intentional 16 lb weight loss over 2 months. She has night sweats at baseline, which has worsened as she is ___. Lastly, she describes feeling overwhelmed with the new diagnosis of potential lymphoma. She denies any fevers, chills, cough, shortness of breath, and abdominal pain. She has stress incontinence at baseline, which has not changed. Past Medical History: - Morbid obesity - Hypothyroidism - 2nd degree AV block s/p PPM ___, Adapta L, implated ___ - Spinal stenosis - Cerivical radiculopathy - GERD - Colon polyps, adenomatous - Tinnitus - Polycistic ovaries - Stress urinary incontinence - Genital herpes - H/o wide complex tachycardia: VT versus SVT with aberrancy - Depression Social History: ___ Family History: Brother: DM Father: Died of lung cancer MGF: Heart disease MGM: Lung cancer PGM: Aneurysm PGF: Stomach cancer Physical Exam: Exam on Admission: Vitals: 98.4 143/89 91 16 99RA General: Alert, oriented, tearful, pleasant, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated. No lymphadenopathy. CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur at ___. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: +BS, soft, nondistended, nontender to palpation. LYMPH NODES: No asxillary or inguinal lymph nodes palpated. GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. Exam on Transfer: Vitals: Weight-92.3kg, Tc-98.4, Tm-98.4, BP-141/68 (141-143/68-89), HR-70 (70-91), RR-16 (16), O2-97% RA (97-99), I/O since ___ admission: 120/not measured General: AAOx3, comfortable appearing, in NAD, tearful when discussing diagnosis and child care HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink. MMM. OP clear. Neck: supple, no LAD, no JVP elevation Lungs: CTAB, no w/r/r CV: RRR, normal S1 and S2, no m/g/r Abdomen: NABS, soft, nondistended, nontender. No HSM. GU: no foley Ext: WWP. 2+ peripheral pulses. No edema. Neuro: CNs II-XII intact. Equal strenght in upper extremities bilaterally. Decreased hamstring strength on L leg. Equal proprioception, sensation to light touch and pin prick, and vibratory sensation in upper and lower extremities bilaterally Exam on Discharge: VS: 97.6 134/64 52 18 98%RA Wt: 196.6lbs (90kg) GEN: Pleasant, NAD HEENT: NCAT Cards: Bradycardic, S1/S2 normal. Pacer site on left anterior chest without induration, warmth or erythema. Pulm: CTAB no crackles or wheezes Abd: soft, NT, no rebound/guarding, no HSM. Nontender in RUQ Extremities: wwp, no edema. Skin: no rashes or bruising Neuro: AOx3, CNs II-XII intact. ___ strength in U/L extremities. sensation intact to LT, cerebellar fxn intact (RAM). Gait grossly normal Pertinent Results: Imaging: Pelvic US ___: No abnormality identified in the cervix. Vaginal canal not well evaluated. RECOMMENDATION(S): Pelvic MRI can be considered to better evaluate the vaginal canal. Hand Xray ___: Pending ECHO ___: IMPRESSION: Normal global and regional biventricular systolic function. CXR ___: FINDINGS: There is subsegmental atelectasis in both lower lungs. There is no pneumothorax. The appearance of the dual lead pacemaker is unchanged. The upper lungs are clear Groin US ___: IMPRESSION: 1. No abnormal right groin lymph node identified for marking. 2. Few normal-appearing right groin lymph nodes. CXR ___: Compared to the prior study there is no significant interval change. There is a dual lead pacemaker with the leads projecting over the expected location. No other radiopaque foreign bodies are visualized.The cardiac and mediastinal silhouettes are normal and are unchanged compared to prior. MRI Head w/ and w/o contrast ___: 1. Study is limited by motion artifact, as described, limiting the spatial resolution. 2. Diffuse nodular enhancing disease involving the leptomeningeal and pachymeningeal extra-axial spaces, as described, predominantly within the basal cisterns consistent with intracranial lymphoma. 3. Mass like enhancing disease within the visualized upper cervical canal from C1 through C3 levels, which may be compressing or infiltrating the adjacent cervical cord. 4. Low signal within the cranial marrow which is nonspecific and may be seen with hematopoetic marrow or infiltration. MRI Cervical/Thoracic spine ___: 1. Motion artifact which limits space resolution of this study. 2. Diffuse total spine leptomeningeal carcinomatosis consistent with lymphoma. 3. More focal areas of nodular masslike enhancing disease, as described, with large 2 cm lesion at the C3 level severely compressing the traversing cervical cord causing intrinsic cord edema. 4. Enhancing lesion within the S2 vertebral body which may represent metastatic osseous disease. 5. Prominent bilateral iliac chain lymph nodes, as described. ___ FDG PET IMPRESSION: 1. Widespread multifocal FDG adenopathy involving the cervical, mediastinal, retroperitoneal, retrocrural, pelvic side wall, and inguinal nodes consistent with neoplasm. 2. Focal uptake within the spinal canal within the cervical, thoracic, and sacral levels consistent with intrathecal involvement for which emergent MRI is advised. 3. Scattered foci of FDG avidity within the spleen consistent with splenic involvement. 4. Foci of uptake involving the vagina and anterior cervix are suspicious for neoplasm for which pelvic ultrasound or MRI is additionally warranted. ___ CXR Compared to the prior study there is no significant interval change. There is a dual lead pacemaker with the leads projecting over the expected location. No other radiopaque foreign bodies are visualized.The cardiac and mediastinal silhouettes are normal and are unchanged compared to prior. Admission Labs: ___ 06:25PM GLUCOSE-108* UREA N-13 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 ___ 06:25PM TOT PROT-7.2 CALCIUM-9.3 URIC ACID-5.5 ___ 06:25PM LD(LDH)-218 ___ 06:25PM WBC-7.1 RBC-3.99 HGB-12.3 HCT-37.5 MCV-94 MCH-30.8 MCHC-32.8 RDW-13.2 RDWSD-45.5 ___ 06:25PM NEUTS-70.1 LYMPHS-17.7* MONOS-8.0 EOS-3.5 BASOS-0.4 IM ___ AbsNeut-4.99 AbsLymp-1.26 AbsMono-0.57 AbsEos-0.25 AbsBaso-0.03 ___ 06:25PM PLT COUNT-191 Discharge Labs: ___ 07:50AM BLOOD WBC-13.2* RBC-4.30 Hgb-13.5 Hct-39.2 MCV-91 MCH-31.4 MCHC-34.4 RDW-13.5 RDWSD-45.1 Plt ___ ___ 08:35AM BLOOD ___ PTT-28.7 ___ ___ 07:50AM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-137 K-4.2 Cl-102 HCO3-25 AnGap-14 ___ 07:50AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.3 ___ 07:45AM BLOOD 25VitD-39 ___ 09:53PM BLOOD b2micro-1.9 ___ 06:25PM BLOOD PEP-NO SPECIFI ___ 08:35AM BLOOD HIV Ab-Negative ACE level: 31 (normal Brief Hospital Course: Ms. ___ is a ___ y.o. woman with a history of spinal stenosis, cervical radiculopathy, and obesity who presents for workup after multiple CTs revealed cervical and mediastinal lymphadenopathy and a PET scan on ___ was concerning for lymphoma with possible cord involvment/compression. MRI ___ revealed significant brain and cord involvement with concern for cord compression at C3 and T8 despite absence of clinical findings. Lymph node biopsy consistent with sarcoidosis. #Sarcoidosis: Patient found to have significant lymphadenopathy on CT C spine done for progressive neuropathy and weakness now with PET scan showing widspread lymphadenopathy concerning for neoplasm with possible intrathecal involvement. MRI ___ showed brain and cord involvement with possible compression of cord at C3 and T8, for which patient was given steroids. In the mean time, she underwent mediastinoscopy for biopsy and tissue diagnosis on ___, with final pathology still pending but so far consistent with sarcoidosis. HIV was negative. There was a low suspicion for CNS lymphoma but it could not be ruled out because LP was contraindicated given risk of cervical spine cord compression. Rheumatology was consulted. She was treated with methylprednisolone 1g qday x 3 days and will be discharged on 1mg/kg (IBW) prednisone (currently 50mg PO daily). She was placed on PCP prophylaxis and ___ PPI that she will continue as an outpatient. She will need a TB test as an outpatient. Lymph node final pathology, ACE level, and hand xray reads are still pending. She may need a cardiac-protocol PET to evaluate for cardiac sarcoidosis. #Gait abnormalities: The patient has had gait abnormalities progressive over years, possibly related to stenosis but concerning for worsening impingement on spinal cord. She was managed with steroids and her gait problems have improved. She should use a cane to ambulate per ___. #Spinal stenosis: Patient has history of spinal stenosis for which she takes gabapentin. She has no focal deficits on exam. She should continue home gabapentin 300mg QD #Cervical/vaginal lesion: PET showed uptake in cervix, which would be atypical for sarcoid.Pelvic US revealed no lesions of the cervix but MRI would better evaluate the vaginal canal. #History of wide complex tachycardia: She has a pacer which doesn't seem to be ICD. She was continued on metoprolol XL 100mg. #Hypothryroidism: She was continued on levothyroxine 150mcg daily TRANSITIONAL ISSUES: [] Started on 90mg PO prednisone daily, will need to continue PPI and bactrim for PPX [] Please obtain TB test as an outpatient [] Follow-up ACE & 1,25 vitD levels [] Consider cardiac-protocol PET to evaluate for cardiac involvement of sarcoid [] Follow-up final pathology of lymph node biopsy [] Follow-up appointment with ___ Rhematology [] Follow-up read of hand xray [] Consider pelvic MRI for evaluation of vaginal canal CODE STATUS: Full CONTACT: ___ (Husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO PRN prior to PET scan 2. Gabapentin 300 mg PO DAILY 3. Levothyroxine Sodium 150 mcg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Vitamin D 1000 UNIT PO DAILY 7. urea 40 % topical BID Discharge Medications: 1. Gabapentin 300 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Vitamin D 1000 UNIT PO DAILY 6. urea 40 % topical BID 7. PredniSONE 50 mg PO DAILY RX *prednisone 50 mg 1 tablet by mouth Daily Disp #*30 Tablet Refills:*0 8. Senna 17.2 mg PO BID constipation RX *sennosides [senna] 8.6 mg ___ Tablets by mouth BID prn Disp #*30 Tablet Refills:*0 9. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet by mouth Daily Disp #*30 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills:*0 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Lymphadenopathy Sarcoidosis Spinal cord compression 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 ___ after a PET scan revealed lymphadenopathy concerning for malignancy and concerning for spinal cord involvement. You underwent brain and spine MRI to evaluate your spinal cord, and multiple brain and spine lesions were detected. To better assess the nature of the lesions, you subsequently underwent mediastinoscopy to obtain a lymph node for histological analysis. The results of the biopsy showed that you had sarcoidosis, not lymphoma. You were seen by rheumatology and treated with high-dose steroids. You will need to continue to take the prednisone steroid as well as your prophylactic antibiotic. Please report to an ED or your PCP with any worsening weakness, numbness, cough, fevers, or chills. It was our pleasure taking care of you, Your ___ Team Followup Instructions: ___

19991135-DS-18

DS

2133-07-11 00:00:00

2133-07-12 16:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: tofu / moxifloxacin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo F with medical history notable for atrial fibrillation (not on Coumadin due to recurrent fall history, s/p watchman ___, COPD on O2 (5L at rest), and frequent falls who presented with shortness of breath and dizziness. Per PCP notes patient was discharged from ___ ___ after being admitted 1 week previously with a severe flare of her advanced COPD. Unfortunately, no records available on BID community link in OMR. She was recommended to go to rehab but apparently did not want to do this. Per note PCP started her on ___ mg Lasix PO on ___ due to cocern for volume overload. In the last few days since discharge from the hospital she has had significant worsening of her baseline shortness of breath. Normally when she gets up from lying down to sitting her saturations will drop to mid ___ and then recover to low ___. This week she has been dropping to the ___ with significant shortness of breath. Today she became extremely dyspneic when going to the bathroom, got dizzy, and fell down. Denies striking her head. She crawled to her bedroom and was able to call for an ambulance. In the ED: Initial vitals: -98.6 90 115/82 26 92% 5L NC - Labs notable for: WBC 15.8, Hb 9.7, Cr 1.3, pBNP 3155, trop <0.1, INR 1.0, pH 7.51 - Imaging notable for: CTA with extensive segmental and subsegmental PE, right ventricular prominence and pHTN noted - Pt given: ___ 02:37 IH Albuterol 0.083% Neb Soln 1 NEB ___ 02:37 IH Ipratropium Bromide Neb 1 NEB ___ 02:51 IH Albuterol 0.083% Neb Soln 1 NEB ___ 02:51 IH Ipratropium Bromide Neb 1 Neb ___ 03:40 IH Albuterol 0.083% Neb Soln 1 Neb ___ 03:40 IH Ipratropium Bromide Neb 1 Neb ___ 06:52 IV Azithromycin ___ 06:52 IV CefTRIAXone ___ 06:52 IV Heparin 7000 UNIT ___ 06:52 IV Heparin ___ 07:03 IV CefTRIAXone 1 gm ___ 07:37 IV Azithromycin 500 mg - Vitals prior to transfer: HR 90 BP 105/65 RR 20 SPO2 87% 5L NC Of note, patient was also admitted to ___ in ___ for Watchman occlusion device, however the procedure was aborted due to recurrent device dislodgements. During the procedure she had an episode of severe hypotension and bradycardia requiring two minutes of CPR until her condition stabilized. After This was thought to be secondary to an air embolism. Dr. ___ was consulted for left atrial appendage ligation, went to operating Room on ___ where she underwent exclusion of left atrial appendage via left mini thoracotomy with Dr. ___. She was on warfarin but due to multiple falls and appendage surgery, this was stopped at some point in ___. Upon arrival to the floor, the patient denies chest pain or dizziness. She reports mild shortness of breath. Past Medical History: 1. HTN 2. Hypercholesterolemia 3. chronic back pain 4. COPD/emphysema 5. C spine disc disease 6. Depression 7. pneumonia ___. Right brachial plexus neuropathy 9. Right eye with decreased vision, ? macular degeneration 10. SLE (severe ophthalmopathy, diffuse arthropathy) 11. OSA/cpap 12. MVP 13. Fibromyalgia PSH 1. S/P B/L cataracts 2. S/P C4-5 fusion 3. S/P multiple skin Ca exc both squamous and basal cell Social History: ___ Family History: No family history of premature coronary artery disease, cardiomyopathy, congestive heart failure, or sudden death. Physical Exam: ADMISSION PHYSICAL EXAM: ___ 1506 Temp: 97.8 PO BP: 117/67 R Lying HR: 87 RR: 20 O2 sat: 90% O2 delivery: 5 L General: Lying in bed, on 5L NC HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, Right pupil fixed 6mm, Left pupil 5-4mm CV: Irregular, no murmurs, rubs, gallops Lungs: Globally decreased breath sounds, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses; 1+ edema to the ankles b/l Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact (pupil exam as above), ___ strength upper/lower extremities, grossly normal sensation, DISCHARGE PHYSICAL EXAM: VITALS: Afebrile, HR ___, BP 127/79, RR ___, satting 96% on hi flow NC, 40L with 50% FiO2 GENERAL: Resting in bed, overall appears comfortable HEENT: Sclera anicteric CARDIAC: Tachycardic, distant heart sounds, no murmurs PULMONARY: Significant diffuse wheezing w/ reduced breath sounds ABDOMEN: Soft, nt, nd EXTREMITIES: Warm with lower extremity ecchymoses, no ___ edema SKIN: Warm and dry NEURO: A&O x3 Pertinent Results: ___ 11:09PM BLOOD WBC-15.8* RBC-3.64* Hgb-9.7* Hct-32.4* MCV-89 MCH-26.6 MCHC-29.9* RDW-14.7 RDWSD-48.0* Plt ___ ___ 07:09AM BLOOD WBC-16.3* RBC-3.08* Hgb-8.3* Hct-28.3* MCV-92 MCH-26.9 MCHC-29.3* RDW-15.7* RDWSD-51.7* Plt ___ ___ 05:03AM BLOOD WBC-15.3* RBC-2.82* Hgb-7.7* Hct-25.9* MCV-92 MCH-27.3 MCHC-29.7* RDW-15.6* RDWSD-51.1* Plt ___ ___ 04:40AM BLOOD WBC-11.5* RBC-2.58* Hgb-7.0* Hct-23.3* MCV-90 MCH-27.1 MCHC-30.0* RDW-15.4 RDWSD-49.4* Plt ___ ___ 11:09PM BLOOD Glucose-277* UreaN-17 Creat-1.3* Na-143 K-4.4 Cl-95* HCO3-29 AnGap-19* ___ 05:10PM BLOOD Glucose-285* UreaN-18 Creat-1.0 Na-136 K-4.2 Cl-96 HCO3-25 AnGap-15 ___ 04:40AM BLOOD Glucose-253* UreaN-30* Creat-1.0 Na-139 K-3.7 Cl-102 HCO3-27 AnGap-10 ___ 07:09AM BLOOD cTropnT-<0.01 proBNP-2778* ___ 06:30PM BLOOD Digoxin-0.9 ___ 06:09PM BLOOD ___ pO2-22* pCO2-43 pH-7.43 calTCO2-29 Base XS-2 CTA CHESTStudy Date of ___ 5:15 AM 1. Extensive filling defects in the pulmonary vascular tree compatible with pulmonary emboli. These are seen as proximal as the right intralobar artery. Emboli are seen at both the segmental and subsegmental level involving nearly every lobe, but predominantly in the lower lobes. 2. There is mild prominence of the right ventricle. Clinical correlation for right heart strain is recommended. 3. Dilation of the main pulmonary and right and left pulmonary arteries compatible with pulmonary hypertension. 4. Severe emphysematous changes. Ground-glass opacification is seen bilaterally which suggests interstitial pneumonitis. However, in the superior left upper lobe there is a more consolidative appearance favored to represent infection with atelectasis and infarction also considerations. 5. Trace left pleural effusion. Transthoracic Echocardiogram Report Name: ___ ___ MRN: ___ Date: ___ 09:45 The left atrium is mildly elongated. The estimated right atrial pressure is ___ mmHg. The left ventricle has a normal cavity size. Overall left ventricular systolic function is normal. Mildly dilated right ventricular cavity with moderate global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The mitral valve leaflets appear structurally normal. There is trivial mitral regurgitation. There is moderate to severe [3+] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. IMPRESSION: Right ventricular cavity dilation with free wall hypokinesis. Severe pulmonary artery systolic hypertension. Moderate to severe tricuspid regurgitation. Brief Hospital Course: ___ is a ___ year old woman a history of atrial fibrillation s/p Watchman procedure in ___ (with prior Watchman issues with device dislodgments and a cardiac arrest ___ possible air embolism in ___, not on home anticoagulation due to frequent falls, COPD (5L O2 at home), who was admitted to ___ on ___ for a submassive pulmonary embolism. She was treated in the medical ICU until ___ for this, along with pneumonia, copd exacerbation, and pulmonary edema before being discharged directly to ___ ___. ACUTE ISSUES: =================== #ACUTE RESPIRATORY FAILURE: #SUBMASSIVE PULMONARY EMBOLISM: #PULMONARY EDEMA: #COPD WITH EXACERBATION #HOSPITAL ACQUIRED PNEUMONIA: Admitted to medicine initially, treated on the floor initially with a heparin gtt, stable O2, transitioned to apixaban. She was transferred to the MICU when she developed worsening hypoxemia as well as tachcyardia and hemoptysis. She maintained that she was DNR/DNI and was managed with non-invasive oxygenation methods. Failure of anticoagulation was considered unlikely, but she was transitioned to enoxaparin BID. Her acute respiratory failure was felt to be from pulmonary edema, copd exacerbation, and possible pneumonia. She improved with treatment of all three and was weaned to <10 L/hr oxymizer, sats ok on NRB mask for transfer to rehab. - Discharged with azithromycin as well as a slow prednisone taper, finishing vancomycin and cefepime (D7/last day = ___ - Restarted home furosemide at discharge #GOALS OF CARE: Spoke at length with the team and palliative care. She very clearly wants to be in the hospital as little as possible. Remains DNR/DNI. She was OK with a short stay at rehab to maximize her chances of doing well at home, very important for her to return there to be with her cats. Her mother does not know that wants to be DNR/DNI and is even considering hospice care, but her friend/sister-in-law/HCP ___ ___ is in the loop. #STEROID INDUCED ANXIETY: Prednisone taper significantly affecting the patient's anxiety, well known issue for the patient. She was given large doses of clonazepam here without respiratory drive depression, and it is OK and actually preferable to continue controlling her anxiety at rehab with this medication. Please call PCP if any concerns. CHRONIC ISSUES: ===================== #ATRIAL FIBRILLATION: Now on anticoagulation, but for PEs. Continued metoprolol and digoxin. #DIABETES MELLITUS: Continued insulin #DEPRESSION/ANXIETY: Continued home antidepressants and anxiety medications #GERD: Continued home PPI, sucralfate #CHRONIC PAIN: Continued home gabapentin, oxycodone TRANSITIONAL ISSUES: ===================== - Last day of vanc/cefepime is ___. OK to continue vancomycin at 750 mg BID without checking levels. - Last day of azithromycin is ___ - OK for patient to get significant doses of clonazepam, especially while on prednisone taper. Please call PCP if any concerns. - Please consult palliative care and social work if available - Prednisone taper, written out in discharge orders - OK to use IV pain medication if needed, please avoid sending patient back to hospital for pain management if possible CODE STATUS: DNR/DNI HCP: ___ (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Cetirizine 10 mg PO DAILY 4. ClonazePAM 1.5 mg PO QHS:PRN insomnia and agitation 5. Digoxin 0.125 mg PO DAILY 6. DULoxetine 120 mg PO DAILY 7. Gabapentin 2400 mg PO QHS 8. Omeprazole 40 mg PO DAILY 9. PredniSONE 10 mg PO DAILY Tapered dose - DOWN 10. Sucralfate 1 gm PO QID:PRN GI upset 11. Diazepam 5 mg PO Q12H:PRN m spasm 12. melatonin 10 mg oral QHS:PRN 13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 14. nicotine (polacrilex) 4 mg buccal DAILY:PRN 15. Aspirin EC 81 mg PO DAILY 16. Furosemide 20 mg PO DAILY 17. ClonazePAM 0.5 mg PO DAILY:PRN anxiety 18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath/wheezing 19. Metoprolol Succinate XL 100 mg PO DAILY 20. GlipiZIDE XL 5 mg PO DAILY 21. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 22. ipratropium bromide 0.03 % nasal DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Azithromycin 250 mg PO DAILY Duration: 4 Doses Last day ___. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 4. CefePIME 2 g IV Q8H Last day ___. Enoxaparin Sodium 80 mg SC Q12H 6. Glargine 8 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. Metoprolol Tartrate 25 mg PO Q6H 9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*12 Tablet Refills:*0 10. PredniSONE 10 mg PO DAILY Duration: 3 Days Start after the patient finishes 3 days of pred 20 mg Qd, and then stop prednisone completely. Tapered dose - DOWN 11. Ramelteon 8 mg PO QHS:PRN insomnia Should be given 30 minutes before bedtime 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. Vancomycin 750 mg IV Q 12H Last day ___. ClonazePAM 0.5 mg PO BID:PRN anxiety RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 15. PredniSONE 60 mg PO DAILY Duration: 2 Days 16. PredniSONE 50 mg PO DAILY Duration: 3 Doses This is dose # 1 of 5 tapered doses 17. PredniSONE 40 mg PO DAILY Duration: 3 Doses This is dose # 2 of 5 tapered doses 18. PredniSONE 30 mg PO DAILY Duration: 3 Doses This is dose # 3 of 5 tapered doses Tapered dose - DOWN 19. PredniSONE 20 mg PO DAILY Duration: 3 Doses This is dose # 4 of 5 tapered doses Tapered dose - DOWN 20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 21. Aspirin EC 81 mg PO DAILY 22. ClonazePAM 1.5 mg PO QHS:PRN insomnia and agitation RX *clonazepam 1 mg 1.5 tablet(s) by mouth at bedtime Disp #*5 Tablet Refills:*0 23. Digoxin 0.125 mg PO DAILY 24. DULoxetine 120 mg PO DAILY 25. Furosemide 20 mg PO DAILY 26. Gabapentin 2400 mg PO QHS 27. nicotine (polacrilex) 4 mg buccal DAILY:PRN 28. Omeprazole 40 mg PO DAILY 29. Sucralfate 1 gm PO QID:PRN GI upset 30. HELD- Albuterol Inhaler 2 PUFF IH Q4H:PRN sob This medication was held. Do not restart Albuterol Inhaler until you go home 31. HELD- Cetirizine 10 mg PO DAILY This medication was held. Do not restart Cetirizine until you need it 32. HELD- Diazepam 5 mg PO Q12H:PRN m spasm This medication was held. Do not restart Diazepam until you need it 33. HELD- GlipiZIDE XL 5 mg PO DAILY This medication was held. Do not restart GlipiZIDE XL until you go home 34. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate This medication was held. Do not restart HYDROcodone-Acetaminophen (5mg-325mg) until you go home 35. HELD- Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath/wheezing This medication was held. Do not restart Ipratropium Bromide Neb until you go home 36. HELD- ipratropium bromide 0.03 % nasal DAILY This medication was held. Do not restart ipratropium bromide until you go home 37. HELD- melatonin 10 mg oral QHS:PRN This medication was held. Do not restart melatonin until you go home 38. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This medication was held. Do not restart MetFORMIN XR (Glucophage XR) until you go home. 39. HELD- Metoprolol Succinate XL 100 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until you go home. Right now you are getting a short acting version of this while in the hospital/rehab. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Submassive pulmonary embolism COPD exacerbation Pneumonia Pulmonary edema 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 ___ because you were having trouble breathing. You were diagnosed with a blood clot in your lungs and given blood thinners to treat this, while being closely monitored in the intensive care unit. You were also treated for pneumonia, a COPD exacerbation, and diuresed to get extra fluid out of your lungs. Now that you are breathing with much less oxygen support, we are able to discharge you to a rehabilitation center so that you can get stronger before going home. It was a pleasure caring for you, Your ___ team Followup Instructions: ___

19991805-DS-15

DS

2143-02-02 00:00:00

2143-02-02 18:55:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: theophylline / clarithromycin / quinidine Attending: ___. Chief Complaint: hypoxia, shortness of breath, confusion Major Surgical or Invasive Procedure: NONE History of Present Illness: Ms. ___ is an ___ with history of coronary artery disease s/p CABG (___) and PCI (___), chronic diastolic heart failure (EF 55%), asthma/COPD, and CKD with baseline creatinine 2.1-2.5 who presents for hypoxia. Per EPOCH of ___ records: Was treated for bilateral lobe pneumonia with 7 days of vantin (cefpodoxime) from ___. She looked better and was back to baseline on ___. Today she desatted to ___ on 2L O2 with increase ___ O2 to 4L NC with sats at 92-93%. They ordered CBC, BMP, and CXR which revealed ?old consolidation of both lower lobes compatible with pneuonia small right pleural effusion. Labs revealed worsening hgb to 6, BUN 59, Na to 150. She received levoquin 500 mg x1, IV ___ NS 250 cc. Lasix 60 mg was held. Weights the past week have been around 131, Tm 99, HRs ___, SBPs 130s. Per daughter, states she thought she was getting better. Denied fatigue, worsening cough. Has known aspiration risk and has been on a diet of pureed food. States her mother normally does not need oxygen at baseline. Has been at EPOCH since her last discharge from ___ ___ ___. She says the doctors there say she ___ lived alone due to early signs of dementia and a weakened state. ___ the ED, initial vitals were: 97.9 67 137/68 22 99% 4L Nasal Cannula which improved to 100% RA. UA positive for 180 WBC, large lueks, 30 protein, few bact3eria, and <1 epis. Lactate 1.4, Na 149, BUN/Cr 59/2.4 and glucose 68, CBC with WBC 3.8, hgb 7.6. She was given ___ amp of D50 as well as 1L D5H20 for hypernatremia. She desatted to ___ on RA, put back on 4L. Upon arrival to the floor, patient was alert and oriented x 3. She states her cough is slightly worse than before but overall feels ok. She denies fevers, chills, nausea, vomiting abdominal pain REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change ___ bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - CABG: s/p CABG ___ - PERCUTANEOUS CORONARY INTERVENTIONS: ___ - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: CKD stage IV (Creatinine baseline ??, previously Diastolic heart failure s/p multiple prior admits for CHF exacerbation Hx of DVT s/p IVD filter Peripheral neuropathy Anemia of iron deficiency Asthma/COPD Abdominal aortic aneurysm Peripheral arterial disease Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAM ON ADMISSION ========================================= Vitals: 97.8 110/48 68 22 100% 2L Weight 59.4 kg General: Alert, oriented, no acute distress HEENT: Sclera anicteric, oropharynx dry, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Slight poor air movement, crackles sparingly throughout both feels, small expiratory wheezes noted bilaterally Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding 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. PHYSICAL EXAM ON DISCHARGE ========================================= PHYSICAL EXAM: Vitals: T 98.1 BP 118/57 HR 91 RR 18 O2 93 on RA Weight 56kg General: Alert, oriented, no acute distress HEENT: Sclera anicteric, oropharynx dry, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Slight poor air movement, crackles throughout both fields at bases Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding 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. Pertinent Results: ADMISSION LABS ===================== ___ 08:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 08:15PM URINE RBC-3* WBC-180* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 08:15PM URINE MUCOUS-RARE ___ 04:38PM LACTATE-1.4 ___ 04:26PM GLUCOSE-68* UREA N-59* CREAT-2.4* SODIUM-146* POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-28 ANION GAP-13 ___ 04:26PM estGFR-Using this ___ 04:26PM proBNP-GREATER TH ___ 04:26PM WBC-3.8* RBC-2.39* HGB-7.6* HCT-23.5* MCV-98 MCH-31.8 MCHC-32.3 RDW-17.2* ___ 04:26PM NEUTS-54.4 ___ MONOS-6.2 EOS-5.2* BASOS-0.4 ___ 04:26PM PLT COUNT-181 MICROBIOLOGY ====================== ___ 11:20 am SPUTUM Source: Expectorated. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . GRAM NEGATIVE ROD(S). RARE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 PND GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ___ 8:15 pm URINE Site: NOT SPECIFIED **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R STUDIES ================================ ___ ___ F ___ ___ Cardiovascular Report ECG Study Date of ___ 5:18:58 ___ Sinus rhythm and frequent atrial ectopy. Non-specific ST-T wave changes. Delayed R wave transition, similar to that recorded on ___. The rate has slowed. There is variation ___ precordial lead placement. No diagnostic interim change. Read by: ___ ___ Axes Rate PR QRS QT QTc (___) P QRS T 69 ___ 433 0 -27 -168 ___ CXR (PORTABLE) IMPRESSION: Substantial opacities at both lung bases, raising concern for pneumonia. Findings also suggest mild coinciding vascular congestion and possibly small pleural effusions. DISCHARGE LABS ============================ ___ 07:20AM BLOOD WBC-3.0* RBC-2.83* Hgb-9.2* Hct-29.6*# MCV-105*# MCH-32.5* MCHC-31.1 RDW-17.9* Plt ___ ___ 07:20AM BLOOD Plt ___ ___ 07:20AM BLOOD Glucose-56* UreaN-40* Creat-2.0* Na-146* K-3.9 Cl-109* HCO3-24 AnGap-17 ___ 07:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9 ___ 08:02PM BLOOD Type-ART pO2-74* pCO2-42 pH-7.40 calTCO2-27 Base XS-0 Brief Hospital Course: Ms. ___ is an ___ with history of coronary artery disease s/p CABG and PCI, congestive heart failure, and COPD/asthma who presents with new hypoxia, encephalopathy and hypernatremia. Patient had recently received prior treatment for pneumonia at her rehab facility with good affect. The patient was started on Vanc/Cefepime empirically for treatment of HCAP. The patien had UA/culture showing VRE ___ > 100,000 colonies that was sensitive to doxycycline. The patient was transitioned from IV antibiotics to oral doxycycline on day of discharge. The patient will completed a 5 day course of antibiotics for treatment of her pneumonia and a 3 day course for treatment of her UTI. The patient's encephalopathy improved dramatically with antibiotics and she was breathing comfortably and satting well on room air on day of discharge (patient satting ___ 92-93 at rest). The patient will be discharged on oxygen with ambulation. Her hypernatremia resolved with increased free water intake. Her lasix was held due to concern for dehydration on admission and restarted during her hospitalization. The patient will return to her rehabilitation facility for ongoing care. ACUTE ISSUES #Hypoxia: On arrival to the hospital the leading differential was pneumonia s/p treatment failure vs. recurrent aspiration with aspiration pneumonitis. Patient does have a history of MRSA pneumonia during last admission. CHF less likely given she is under her dry weight of 62.6 kgs and is dry on exam (and labs). Other diagnoses such as PE were less likely. The patient was started on Vanc/Cefepime empirically for treatment of HCAP. Sputum culture grew coag + staph sensitive to doxycyline. It is unclear whether true sputum sample versus contamination from oral/nasal flora. The patient was rapidly weaned from 4LNC to room air within one day on antibiotics making her presentation of hypoxia more concerning for aspiration pneumonitis. Vanc/Cefepime were discontinued after 48 hours of treatment. She was continued on pureed diet/thickened liquids with aspiration precautions ___ the hospital without further evidence of aspiration and did not undergo speech/swallow evaluation. It is possible that her aspiration occurred ___ the setting of transient delerium from UTI/hypernatremia. Lasix was held during admission and restarted at discharge. Her weight at time of discharge was 56kg. #VRE UTI was identified and treated with Vanc and then transitioned to doxycycline once sensitivities returned. The patient completed a 3 day course for doxycylcine per geriatric team recommendations. It is possible that patient's confusion was ___ to UTI after being treated for pneumonia as an outpatient. # Hypernatremia: 150 at Rehabilitation facility. Likely from dehydration ___ setting of infection. Patient received 1L D5 H20 ___ ED and encouraged free water intake with resolution of her hypernatremia. Discharge sodium was 146 and followup sodiums should be monitored. # Metabolic Encephalopathy Likely ___ the setting of infection, dehydration and hypernatremia. The patient's mental status returned to baseline within 24 hours after initiation of antibiotics. There is likely an underlying dementia. We recommend evaluation with MOCA/MMSE as outpatient for cognitive evaluation and trending. Chronic Problems # CKD: at baseline Cr. Patient had all meds renally dosed. Lasix held on admission and restarted during hospitalization. . # Anemia: Patient's reported hgb was ___ the 6s at her rehab but is slightly more stable here at 7.6. She does not have any signs of bleeding currently. No scopes ___ our system. CBC stable throughout hospitalization. Guiac negative. Patient will need close follow up ___ rehabilitation facility. Consider EPO given chronic kidney disease. Patient should have follow up labs ___ the week after discharge. # Systolic CHF: No signs of volume overload on admission and she was below dry weight. Lasix was held on admission and restarted during hospitalization. #Neuropathy Continue gabapentin at adjusted renal dose of 300 mg daily from TID. #Coronary artery disease s/p CABG, PCI: -Continued aspirin, metoprolol, statin #GERD: Continued omeprazole. TRANSITIONAL ISSUES ================================= -patient completed 3 day course of doxycyline for VRE UTI. If patient febrile post discharge we recommend restarting doxycycline with UA/culture; If patient remains febrile consider oral linezolid based on sensitivities from culture -patient should have repeat chest xray to evaluate for resolution of disease ___ approximately 6 weeks -patient should continue to be weighed and evaluated daily for monitoring of fluid status for management of her heart failure -patinet had stable low hgb ~ 7.5 during admission; patient should have blood drawn on ___ to evaluate for stablity of anemia; given CKD consider f/u with renal physician ___ on ___: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Docusate Sodium 200 mg PO DAILY 4. Furosemide 60 mg PO DAILY 5. Gabapentin 300 mg PO BID 6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 11. Bisacodyl ___AILY:PRN constipation 12. Fleet Enema ___AILY:PRN constipation 13. Guaifenesin ___ mL PO Q4H:PRN cough 14. Milk of Magnesia 30 mL PO DAILY;PRN constipation 15. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain 16. Senna 8.6 mg PO DAILY:PRN constipation 17. Iron Polysaccharides Complex ___ mg PO DAILY 18. Omeprazole 20 mg PO DAILY 19. Senna 17.2 mg PO QHS 20. Simvastatin 20 mg PO QPM 21. TraMADOL (Ultram) 50 mg PO DAILY 22. Acetaminophen 650 mg PO Q6H:PRN pain, fever 23. QUEtiapine Fumarate 25 mg PO DAILY 24. TraZODone 50 mg PO QHS 25. Divalproex Sod. Sprinkles 250 mg PO TID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, fever 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 3. Aspirin 81 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. Calcitriol 0.25 mcg PO EVERY OTHER DAY 6. Divalproex Sod. Sprinkles 250 mg PO TID 7. Docusate Sodium 200 mg PO DAILY 8. Fleet Enema ___AILY:PRN constipation 9. Furosemide 60 mg PO DAILY 10. Gabapentin 300 mg PO DAILY 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. Metoprolol Succinate XL 50 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. Senna 8.6 mg PO DAILY:PRN constipation 17. Senna 17.2 mg PO QHS 18. Simvastatin 20 mg PO QPM 19. TraMADOL (Ultram) 50 mg PO DAILY 20. Guaifenesin ___ mL PO Q4H:PRN cough 21. Iron Polysaccharides Complex ___ mg PO DAILY 22. Milk of Magnesia 30 mL PO DAILY;PRN constipation 23. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain 24. QUEtiapine Fumarate 25 mg PO DAILY 25. TraZODone 50 mg PO QHS 26. Benzonatate 100 mg PO TID:PRN cough 27. Lactobacillus acidophilus 1 billion cell oral BID 28. Lactobacillus acidophilus 1 billion cell oral BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Pneumonia; Urinary Tract Infection; Metabolic Encephalopathy 2. CKD stage IV (Creatinine baseline ??, previously Diastolic heart failure s/p multiple prior admits for CHF exacerbation Hx of DVT s/p IVC filter Peripheral neuropathy ___ her feet Anemia of iron deficiency Asthma/COPD Abdominal aortic aneurysm Peripheral arterial disease Recurrent UTIs 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. ___, It was a pleasure to take part ___ your care during your stay here at ___. You were brought to the hospital from your rehabilitation ___ facility for low oxygen levels ___ your blood, shortness of breath and confusion. You were found to have an infection ___ both your lungs and ___ your urine. You were initially started on intravenous antibiotics. You responded very well and were transitioned to oral antibiotics. On the day of leaving the hospital you were breathing comfortably off of oxygen without fevers. You felt at your baseline. You should continue to weigh yourself every morning, and your MD should be notified if your weight goes up more than 3 lbs. Thank you for allowing us to participate ___ your care during your stay. Sincerely, Your ___ Team Followup Instructions: ___

19992202-DS-10

DS

2153-03-02 00:00:00

2153-03-02 17:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / lithium / codeine Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ w/ hx of CAD, stroke w/ residual cognitive deficits, bipolar disorder w/ psychotic features, HTN, asthma, hypothyroidism, multiple falls and other issues who presents from ___ with altered mental status, fever, leukocytosis, and an unwitnessed fall. On the evening of ___, she began to complain of abdominal pain per her rehab, with some nausea. She was noted to have T of 100.2 axillary on ___, with tachypnea and tachycardia to 100 (repotedly normal on ___. She had labs drawn at ___ showing WBC of 13.7 w/ 67% PMNs and 21% bands with a dirty UA. She also had an unwitnessed fall on ___, being found on floor around 4:30pm awake but confused, grabbing at staff, nonverbal (At baseline is able to walk with a rolling walker and is verbal, though combative with staff). She was brought to the ED for further evaluation. In the ED initial vitals were: 97.4 94 103/65 18 100%. Exam notable for mental status initially quite altered, pt combative with staff, but later improved and she was cooperative. She was incontinent of a large amount of stool x4, and a foley catheter was placed. Labs were significant for WBC 23.0 w/ 87.8% PMNs, Hgb 12.7, plts 136, INR 1.1, ALT/AST ___, LFTs otherwise WNL, CK 291, Trop 0.06, CK-MB 3, BUN/Cr 48/1.7 (baseline 0.6 in ___, K 8.5 on hemolyzed specimen (recheck 3.9), HCO3 22, Lactate 3.0. UA with 150 WBCs, few bacteria, and positive nitrites. ECG showed new RBBB but no ischemic changes. CT Abd/pelvis showed multiple L-sided non-obstructive renal calculi with perinephric and periureteral stranding. There was no hydronephrosis. Also demonstrated were an L2 compression fracture of uncertain chronicity and moderate cardiomegaly. CT C-spine was unremarkable, CT head showed an 11 x 7 mm meningioma abutting the R temporal bone, and evidence of chronic L inferior frontal and temporal lobe infarctions. CXR was unremarkable. Patient was given Ceftriaxone 1g, 1L NS, Acetaminophen 650 mg PO x2, Quetiapine 50 mg PO x1 and was admitted. Vitals prior to transfer were: 100.3 99 156/80 26 99% RA (Tmax in ED was 102.0). Overnight, the patient was uncooperative with examiner and would not answer questions, though awake (as evinced by forced eye closure and swatting away examiner's hand in response to painful stimuli). This morning when I examined the patient, she was responsive to voice, with coherent speech, asking me to go away and leave her alone. Did say she had abdominal pain when I asked, but then would not describe it to me at all, otherwise says she is fine. Cannot answer where she is, won't tell me her name. Trying to get out of bed, and swatting me away when I try to examine her. Per rehab, baseline MS is combative and uncooperative, frequently refusing medical examination in the past, refusing medications at times, and refusin lab draws at times. Irascible at times, not usually oriented, with deficits in memory and executive function. Is usually verbal, and often yells at staff. Per rehab documentation, is independent with feeding, requires assistance to transfer from bed to chair, with walking, bathing/dressing, and with commode/toilet/bedpan. Review of Systems: Unable to obtain Past Medical History: -CAD -Hx of CVA w/ residual cognitive deficits (L frontal MCA CVA ___ -RBBB, LAFB (Noted previously in ___ ECG) -HLD -HTN -Asthma -Bipolar disorder with psychotic manifestations -Depression -Anxiety -Failure to thrive -Hypothyroidism -s/p parathyroidectomy ___ -OSA not on CPAP -B12 deficiency without anemia, apparently repleted -Meningioma resected in ___ (right frontal brain tumor) -B/L Carotid endarterectomy in ___ -Insomnia -Constipation Social History: ___ Family History: Per records, daughter with paranoid schizophrenia. Otherwise unable to obtain. Physical Exam: ADMISSION PHYSICAL EXAM: =================== Vitals - 99.4 135/80 84 18 96% RA GENERAL: NAD, sleeping but arousable HEENT: AT/NC, MMM dry, fair dentition NECK: nontender supple neck, no LAD, JVD not appreciable CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: No CVA tenderness bilaterally EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: Patient uncooperative with exam SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: =================== PHYSICAL EXAM: VS: 98 175/63 93 98%RA GENERAL: appears well HEENT: Sclera anicteric HEART: RRR, normal S1 S2, no murmurs LUNGS: Clear, no wheezes, rales, or rhonchi, no use of accessory muscles ABD: Soft, BS+, nontender, nondistended EXT: no ___ edema, 1+ DP and ___ pulses NEURO: Does not answer orienting questions Pertinent Results: ==== ADMISSION LABS ==== ___ 07:20PM BLOOD WBC-23.0*# RBC-4.78 Hgb-12.7 Hct-39.0 MCV-81* MCH-26.6* MCHC-32.6 RDW-14.7 Plt ___ ___ 07:20PM BLOOD Neuts-87.8* Lymphs-7.4* Monos-4.4 Eos-0.1 Baso-0.2 ___ 07:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:20PM BLOOD ___ PTT-22.9* ___ ___ 07:20PM BLOOD Glucose-116* UreaN-48* Creat-1.7* Na-134 K-8.5* Cl-101 HCO3-22 AnGap-20 ___ 07:20PM BLOOD ALT-20 AST-74* CK(CPK)-291* AlkPhos-67 TotBili-0.3 ___ 07:20PM BLOOD CK-MB-3 cTropnT-0.06* ___ 07:20PM BLOOD Albumin-3.7 Calcium-10.3 Phos-3.3 Mg-2.4 ___ 07:29PM BLOOD Lactate-3.0* K-6.5* ___ 09:04PM BLOOD K-3.9 ___ 08:55PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:55PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 08:55PM URINE RBC-3* WBC-150* Bacteri-FEW Yeast-NONE Epi-0 ___ 08:55PM URINE CastHy-11* ___ 08:55PM URINE Mucous-RARE ==== INTERIM LABS OF NOTE ==== ___ 10:55AM BLOOD ___ ___ 10:55AM BLOOD Hapto-221* TROPONINS: ___ 07:20PM BLOOD CK-MB-3 cTropnT-0.06* ___ 10:55AM BLOOD CK-MB-2 cTropnT-0.05* BLOOD GASES: ___ 11:55AM BLOOD ___ pO2-68* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 ___ 12:11PM BLOOD Type-ART Rates-/40 pO2-96 pCO2-26* pH-7.49* calTCO2-20* Base XS--1 ___ 03:49PM BLOOD ___ pO2-36* pCO2-34* pH-7.46* calTCO2-25 Base XS-0 Comment-LARGE GREE ___ 05:16PM BLOOD Type-ART Temp-37.2 Rates-/50 pO2-100 pCO2-25* pH-7.53* calTCO2-22 Base XS-0 Vent-SPONTANEOU LACTATE: ___ 07:29PM BLOOD Lactate-3.0* ___ 11:55AM BLOOD Lactate-2.2* ___ 12:11PM BLOOD Lactate-2.6* ___ 03:49PM BLOOD Lactate-2.2* ___ 05:16PM BLOOD Lactate-1.2 ==== DISCHARGE LABS ==== ==== MICROBIOLOGY ==== ___ 7:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) | AMPICILLIN/SULBACTAM-- S CEFEPIME-------------- S CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S TOBRAMYCIN------------ S Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ ___ 9:26AM. ___ BLOOD CULTURES: pending ___ BLOOD CULTURES: pending ___ 8:55 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 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 ___ 1:51 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ==== IMAGING ==== ___ ECG Sinus rhythm with sinus arrhythmia. Right bundle-branch block. Low precordial QRS voltages. No major change from the previous tracing. ___ CXR (PORTABLE) AP portable supine view of the chest. Underlying trauma board is in place. Lungs appear clear. No supine evidence of effusion or pneumothorax. The cardiomediastinal silhouette appears grossly within normal limits. No acute bony injury. IMPRESSION: Limited, negative. ___ CT C-SPINE WO CONTRAST No acute fracture. Degenerative changes with mild anterolisthesis of C4. Lack of prior comparison studies limits evaluation for stability of this alignment abnormality. Please correlate clinically. ___ CT HEAD WO CONTRAST 1. No acute intracranial abnormality. 2. 11 x 7 mm calcified focus at the inner table of the right temporal bone is compatible with a meningioma. 3. Evidence of chronic left inferior frontal and temporal lobe infarction. ___ CT ABD/PELVIS WO CONTRAST 1. Multiple left-sided nephroureteral calculi, with considerable perinephric and periureteral stranding compatible with upper urinary tract infection. 4 mm left UPJ stone does not appear obstructive, as there is no hydronephrosis. Nonobstructive 5 mm lower pole left renal calculus is noted. 2. Compression deformity of the L2 vertebral body appears chronic. Malalignment in lower lumbar spine as noted related to spondylolysis. 3. Moderate cardiomegaly with a small amount of pericardial fluid, and a small left pleural effusion. 4. Probable rectal fecal impaction ___ CXR (PORTABLE) The patient is substantially rotated. No evidence of larger pleural effusions. No pneumonia, no pulmonary edema. Moderate cardiomegaly. Brief Hospital Course: ___ with CAD, CVA, bipolar with psychotic features, admitted with sepsis from Ecoli UTI and E-coli bacteremia # Sepsis/E-coli Bacteremia/Pyelonephritis: Patient found to have pan-sensitive Ecoli UTI and bacteremia. She had CT abd/pelvis which showed non-obstructing stones in her left kidney. She was initially started on cefepime and transitioned to Ceftriaxone and finally to po cipro one day prior to discharge. Last positive blood culture from ___. Her sepsis resolved. Lactate and Cr normalized. She will continue po cipro until ___ # Diarrhea: She had copious amount of diarrhea during this hospital stay. C-diff negative on ___. Repeat C-diff negative from ___. Diarrhea most likely abx associated. Patient started on loperamide with improvement. # Hypertension: She was hypertensive during this hospital stay and intermittent given IV hydralazine. She was continued on her lisinopril and started on 5mg amlodipine on the day of discharge. She will need further monitoring and uptitration of her BP meds. # Encephalopathy: Most likely toxic-metabolic encephalopathy in setting of known sepsis vs underlying mood disorders versus worsening dementia. Her encephalopathy improved wit antibiotics however she intermittently refuses labs, exam and becomes agitated. # ___: presented with ___ with resolved initially with IVF. # s/p fall: Likely occurred in the setting of AMS, but patient with history of multiple falls. CT head/neck negative CHRONIC ISSUES: ================ # Hypothyroidism: Continued home levothyroxine # Bipolar disorder / psych: - Cont home venlafaxine of 150 mg PO QD and 37.5 mg PO QD (total of 187.5mg daily, given all at once). Cont home quetiapine 50 qhs # Hx of stroke: Continued home Aspirin 81 mg PO QD # Osteopenia: continue home Vitamin D (dosed q21 days) TRANSITIONAL ISSUES: ================= # Code: DNR/DNI (per HCP, son ___ ok for ICU, central line, and pressors, per brief discussions with the son on ___ at 12:30pm # Contact: son ___ (___) ___ - Continue po cipro until ___ - Patient having diarrhea likely antibiotic associated. C-diff testing x 2 were negative. Her diarrhea improved with loperamide. - Patient hypertensive during this admission: sh was started on amlodipine on ___. Continue to uptitrate amlodipine as needed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 25 mg PO QHS 2. Simethicone 40 mg PO TID GI upset 3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID:PRN GI upset 4. Venlafaxine 150 mg PO DAILY 5. TraMADOL (Ultram) 25 mg PO QHS:PRN pain 6. Acetaminophen 650 mg PO BID pain 7. QUEtiapine Fumarate 50 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Vitamin D 50,000 UNIT PO EVERY 3 WEEKS 12. Venlafaxine 37.5 mg PO DAILY 13. Acetaminophen 650 mg PO BID:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO BID pain 2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID:PRN GI upset 3. Aspirin 81 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. QUEtiapine Fumarate 50 mg PO QHS 7. TraMADOL (Ultram) 25 mg PO QHS:PRN pain 8. TraZODone 25 mg PO QHS 9. Venlafaxine 150 mg PO DAILY 10. Venlafaxine 37.5 mg PO DAILY 11. Vitamin D 50,000 UNIT PO EVERY 3 WEEKS 12. Amlodipine 5 mg PO DAILY 13. LOPERamide 2 mg PO QID:PRN diarrhea 14. Ranitidine 150 mg PO BID 15. Ciprofloxacin HCl 500 mg PO Q12H Last Day ___ 16. Simethicone 40 mg PO TID GI upset Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Pyelonephritis 2. E-Coli bactermia 3. Diarrhea 4. Hypertension 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 you hospitalization at ___. You were admitted with urinary tract infection and blood infection. You were treated with antibiotics with improvement in your symptoms. Please continue to take your antibiotics until ___. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___

19992365-DS-21

DS

2167-10-28 00:00:00

2167-10-28 15:07:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Augmentin / Clindamycin Attending: ___ Chief Complaint: Nystagmus, ataxia of gait and left arm Major Surgical or Invasive Procedure: none History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 3 minutes Time/Date the patient was last known well: 01:20 ___ ___ Stroke Scale Score: 1 t-PA Administration [] Yes - Time given: [x] No - Reason t-PA was not given/considered: large left cerebellar bleed vs mass I was present during the CT scanning and reviewed the images within 20 minutes of their completion. ___ Stroke Scale - Total [1] 1a. Level of Consciousness - 0 1b. LOC Questions - 0 1c. LOC Commands - 0 2. Best Gaze - 0 3. Visual Fields - 0 4. Facial Palsy -0 5a. Motor arm, left -0 5b. Motor arm, right - 0 6a. Motor leg, left - 0 6b. Motor leg, right - 0 7. Limb Ataxia - 0 8. Sensory - 0 9. Language - 0 10. Dysarthria - 0 11. Extinction and Neglect - 0 HPI: The patient is a ___ year old man with a history of anxiety, COPD, LVH with dystolic dysfunction, left cervical radiculopathy who initially presented to the ED with tachypnea and dyspnea while masturbating earlier today. Neurology evaluation is requested as part of a code stroke at 1:29am after he was found to be lethargic with nystagmus, ataxia of gait and left arm. The patient was last in his USOH this evening. He developed acute onset of tachypnea and dyspnea while masturbating at home. He started gasping and and felt faint. At that point he described brief sensation of room spinning. Also felt generally weak that he had to crawl rather than walk. He called ___ and was taken to ___ ED by ambulance. The patient came to the ___ ED Triage at 1648 ___. Inital exam was unremarkable. He had labs including leukocytosis with left shift, ddimer 598. Cardiac enzymes were flat. Then CTA chest was done which showed pulmonary nodules and absence of PE. While in the ED, he developed acute anxiety again and was given Ativan 1mg IV (double his home dose) at 930pm. Per resident documentation, he was reevaluated at 1145pm and was sleepy able to use his phone. He walked with support around the bed. His gait at that time was characterized as unsteady but narrow based. At 0040 on ___, he had more trouble getting out of bed without assistance and began to complain of nausea. He was ultimately noted to have a change in his neuro exam and nausea. Neurology was called to the bedside, and I ultimately activated a code stroke during my evaluation at 1:25am. The patient was complaining of lethargy and his nausea had resolved. He also was having trouble walking. He denied room spinning, double vision or other neurological deficits. As mentioned below, he had other focal deficits, but was not aware of these: (nystagmus on left gaze and left arm ataxia). Prior to this ED visit, he did intermittently have double vision and was evaluated by an opthalmologist for this. It was not clear that this was monocular vs binocular or occured at near vs far vision. He does wear glasses as forgot to bring them to the ED and felt that evaluation without his glasses was unfair. Also, he alerts me that his left arm is weaker than his right arm at baseline give cervical radiculopathy that is longstanding. He denied other ROS as listed below: On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. On general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: ATTENTIONAL PROBLEMS PSORIASIS ERECTILE DYSFUNCTION LVH WITH BORDERLINE LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION HYPERTENSION OVERWEIGHT SLEEP APNEA SEBORRHEIC DERMATITIS DEPRESSION CHRONIC OBSTRUCTIVE PULMONARY DISEASE H/O LEFT CERVICAL RADICULITIS Social History: ___ Family History: No family history of strokes, seizures. Physical Exam: ADMISSION EXAM: Vitals: 98.0 82 147/87 22 100% RA General: Tired appearing, dissheveled, NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental Status - Initially, he was lethargic appearing, inattentive, preferred to keep eyes closed. But with encouragement, he was oriented x3 and recalled a coherent history. Did not fully recite months of year backwards. Speech is fluent without dysarthria. Repetition and comprehension and naming intact. Normal prosody. No dysarthria. No apraxia. No evidence of hemineglect. No left-right confusion. - Cranial Nerves - PERRL 4->2 brisk. VF full to number counting. EOMI, with left beating nystagmus on left gaze and only fine nystagmus on right gaze that was fatigable. No nystagmus in up or downgaze. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 5 4+ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 - Sensory - No deficits to light touch, pin bilaterally. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. - Coordination - There is marked dysmetria on left FNF, but with encouragement he actually improves on multiple tasks. There is no dysmetria on right FNF. HSH on left also clumsy compared to right. - Gait - No truncal ataxia when seated with arms crossed at edge of bed. He requires 2 person assistance to stand. Gait is wide based. Short stride length, grossly unstable. DISCHARGE EXAM: T 98.6, HR 60-90, BP 110/76, RR 18, O2 95% on RA Gen: NAD, in bed Neuro: Awake, alert, ortiented x3. PERRL 3->2, brisk. VF full. EOMI, eyes conjugate. Nystagmus in primary gaze. Bilateral endgaze horizontal nystagmus L>R. + vertical nystagmus. V1-V3 without deficits to light touch bilaterally. Very mild R facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. Strength ___. Babinskis downgoing. + Left rebound, left dysmetria on FNF, left ataxia on HKS. Pertinent Results: ___ 06:30PM BLOOD WBC-16.5*# RBC-4.92 Hgb-15.1 Hct-44.8 MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt ___ ___ 09:30AM BLOOD ___ PTT-24.4* ___ ___ 06:30PM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-142 K-4.1 Cl-105 HCO3-23 AnGap-18 ___ 06:30PM BLOOD cTropnT-<0.01 proBNP-192* ___ 03:15AM BLOOD CK-MB-6 cTropnT-0.30* ___ 11:45AM BLOOD CK-MB-4 cTropnT-0.16* ___ 03:15AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1 ___ 06:30PM BLOOD D-Dimer-598* ___ 11:45AM BLOOD HIV Ab-NEGATIVE ___ 06:42PM BLOOD Lactate-1.5 ___ 01:07AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 01:07AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG IMAGING: EKG: NSR@80bpm. Q wave in I. ___ CXR Vague opacity suggesting pneumonia or lower airway inflammation or infection in the right upper lobe. ___ CTA Chest 1. No evidence of pulmonary embolism. 2. Centrilobular emphysema with multiple bilateral pulmonary nodules better described on recent dedicated CT dated ___. Recommend imaging follow up in ___ months time. 3. Again identified are hepatic dome hypodensities incompletely characterized on this single phase examination. ___ NCHCT 2.4 x 2.8 cm left cerebellar acute intraparenchymal hemorrhage with mild mass effect and effacement of the fourth ventricle. ___ CTA 1. Stable 2.8x3.3cm left cerebellar acute hematoma, 2.8x3.3cm, with mild surrounding edema and mass effect on the left side of ___ ventricle, similar to the prior study done 8 hr earlier. 2. No obvious aneurysm or AV malformation in the vicinity of the left cerebellar hematoma. Minimally displaced nondilated vascular structures adjacent. Correlate clinically for risk factors. INR/NS consult to decide on further workup/mngt. 3. Atherosclerotic calcifications in the distal vertebral and cavernous carotid segments with contour irregularity on both sides. Patent major intracranial arteries as described above. Right posterior inferior cerebellar and Left superior cerebellar artery not well seen. ___ MRI No significant interval change of a 26 x 24 mm acute left cerebellar intraparenchymal hematoma with associated mass effect and effacement of the fourth ventricle. No definite underlying mass with trace peripheral post gadolinium enhancement likely secondary to bleed. ___ CT Head Stable left cerebellar hematoma with mass effect on the left side of the ___ ventricle; slightly increased mass effect on ___ ventricle. Limited assessment of position of cerebellar tonsils, due to dental artifacts and lack of sagittal and coronal reformations is performed as a portable study. Brief Hospital Course: Mr. ___ is a ___ year old man with a history of anxiety, COPD, LVH with diastolic dysfunction, and left cervical radiculopathy who initially presented to the ED with tachypnea and dyspnea. During his time in the ED, he had intermittent nausea and nystagmus and development of left arm ataxia and an ataxic gait. A code stroke was called and NIHSS was 1 for ataxia of 1 limb. ___ revealed a left cerebellar hyperdensity indicative of IPH. CTA showed no underlying vascular abnormality. MRI showed no enhancing mass. The etiology of his hemorrhage is possibly HTN, occult AVM or occult mass, which is why the patient will have follow up imaging (see below). # Neuro: - Left cerebellar intraparenchymal hemorrhage: etiology unknown, possibly hypertension or occult lesion not seen on MRI - He was admitted to the Neuro ICU for close monitoring for change in exam which could indicate edema/obstructive hydrocephalus. He was on Mannitol Q6 and his exam remained stable, so mannitol was discontinued by hospital day 4. - SBP goal < 140 - Avoid anti-platelets and anticoagulation - repeat MRI/MRA in ___ months - Neurology Stroke Clinic follow up # Cardiopulmonary: - trops 0.01->0.3->0.16, CT chest/EKG neg, no chest pain - Goal SBP<140 - continue lisinopril 10, metoprolol 25 BID - will need follow-up of pulmonary nodules seen on CT chest in ___ months #Psych: - history of anxiety - he had some nausea and vomiting the first day in the ICU secondary to presumed anxiety which quickly resolved when he was put on his home dose of alprazolam 0.25mg BID prn. - continue home lorazepam 0.5mg prn insomnia - continue home alprazolam 0.25 mg BID prn # Transitional Issues: - needs outpatient colonoscopy - needs follow up MRI/MRA Head with contrast in ___ months - will need follow-up of pulmonary nodules seen on CT chest as outpatient in ___ months AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes [performed and documented by admitting resident] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education given (written form in the discharge worksheet)? (x) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 5. Assessment for rehabilitation or rehab services considered? (x) Yes - () No [if no, reason not assessed: ____ ] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. modafinil 200 mg oral QAM and Qnoon 3. Lorazepam 0.5 mg PO HS:PRN insomnia 4. Meladox (melatonin) 3 mg oral QHS PRN insomnia 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 6. ALPRAZolam 0.25 mg PO PRN anxiety 7. Citalopram 20 mg PO DAILY 8. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN Apply to ears 9. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QID 10. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN to face, to penis 11. Patanol (olopatadine) 0.1 % ophthalmic 1 drop in both eyes BID 12. Fish Oil (Omega 3) 1000 mg PO BID Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO BID 3. Ondansetron 4 mg PO Q8H:PRN nausea 4. Citalopram 5 mg PO DAILY:PRN Bipolar symptoms 5. Lorazepam 0.5 mg PO HS:PRN insomnia 6. Meladox (melatonin) 3 mg oral QHS PRN insomnia 7. modafinil 200 mg oral QAM and Qnoon 8. ALPRAZolam 0.25 mg PO PRN anxiety 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 10. Fish Oil (Omega 3) 1000 mg PO BID 11. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN Apply to ears 12. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QID 13. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN to face, to penis 14. Patanol (olopatadine) 0.1 % ophthalmic 1 drop in both eyes BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left cerebellar hemorrhage 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 hospitalized due to symptoms of nausea resulting from an ACUTE HEMORRHAGIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain bleeds. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from bleeding can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Hypertension Please follow your medication list closely. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: ___

19992418-DS-19

DS

2145-01-16 00:00:00

2145-01-22 04:01:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: lidocaine Attending: ___. Chief Complaint: elevated BP Major Surgical or Invasive Procedure: none History of Present Illness: ___ G3P3 POD4 from primary LTCS for arrrest of dilation and fetal intolerance to augmentation of labor c/b gestational hypertension now with severe BP at home. Reports assymetric calf swelling (R>L) starting this morning. Has intermittent shortness of breath, but none now. Endorse + chest pressure which started on arrival to the ED, also comes and goes. Denies substernal chest pain, arm pain, jaw pain, heart pain. Breast nt, feeding and pumping well. incisional pain will controlled at home on tylenol/oxy/ibuprofen with normal lochia. Infant is at home with grandma. Denies headache, vision changes, RUQ pain (subcostal cheat discomfort as above). Remainder of ROS as per HPI. Past Medical History: OBHx: - G1: SVD term, 5#15, pre eclampsia at 40 weeks - G2: SVD term, 9#10oz, gHTN - G3: pLTCS as above GynHx: - No h/o abnormal Pap, fibroids, Gyn surgery, STIs PMH: none PSH: wisdom teeth, cesarean delivery Meds: PNV All: lidocaine (difficulty breathing) Social History: SHx: denies T/E/D Physical Exam: General: NAD CV: RRR Lungs: Nonlabored breathing, CTAB Abd: soft, fundus firm at umbilicus, appropriate fundal tenderness Incision: clean/dry/intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, 1+ edema Pertinent Results: ___ 01:15PM cTropnT-<0.01 ___ 11:04AM ___ PTT-33.7 ___ ___ 10:10AM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-143 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12 ___ 10:10AM ALT(SGPT)-45* AST(SGOT)-45* ALK PHOS-97 TOT BILI-0.3 ___ 10:10AM cTropnT-<0.01 ___ 10:10AM proBNP-257* ___ 10:10AM ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-1.8 ___ 10:10AM URINE HOURS-RANDOM ___ 10:10AM URINE UCG-POSITIVE* ___ 10:10AM URINE UHOLD-HOLD ___ 10:10AM WBC-11.0* RBC-3.67* HGB-10.0* HCT-31.3* MCV-85 MCH-27.2 MCHC-31.9* RDW-16.7* RDWSD-50.5* ___ 10:10AM NEUTS-83.1* LYMPHS-11.7* MONOS-3.6* EOS-0.1* BASOS-0.3 IM ___ AbsNeut-9.14* AbsLymp-1.29 AbsMono-0.40 AbsEos-0.01* AbsBaso-0.03 ___ 10:10AM PLT COUNT-245 ___ 10:10AM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 10:10AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG* ___ 10:10AM URINE RBC-5* WBC-107* BACTERIA-MOD* YEAST-NONE EPI-4 TRANS EPI-2 Brief Hospital Course: Ms. ___ was readmitted on ___ with elevated blood pressures, found to have pre-eclampsia severe by blood pressures. She presented to the ED on post-operative day 4 from primary low transverse cesarean section. She received 20mg IV labetalol was started on 24 hours of magnesium. Her home nifedipine was continued and labetalol was added for better control of her blood pressures. In the ED, she also complained of chest pressure w/ bilateral leg sweeling, bedside echocardiogram was within normal limit and EKG demonstrated NSR. CTA demonstrated no evidence of pulmonary embolism or aortic abnormalities, however ground-glass opacities in dependent areas were noted, that may have represented fluid overload. During her hospital course, she continued to have persistent HA (___). MRI/MRA obtained showed no evidence of ischemia, hemorrhage, or edema. She received acetaminophen, ibuprofen, fioricet, and Compazine. She had elevated liver enzymes which downtrended prior to her discharge. Her anti-hypertensive medications were uptitrated to labetalol 600 q8h and nifedipine 30 mg daily. By hospital day 5, she was stable for discharge. Discussed return precautions included severe range blood pressures and persistent headache. She was discharged home with outpatient follow-up. Medications on Admission: prenatal vitamins Discharge Medications: 1. Labetalol 600 mg PO Q8H RX *labetalol 300 mg 2 tablet(s) by mouth three times a day Disp #*120 Tablet Refills:*1 2. NIFEdipine (Extended Release) 30 mg PO DAILY hypertension hold if bp below 110/70 RX *nifedipine 30 mg 1 tablet(s) by mouth q day Disp #*20 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: post partum pre ecclampsia with headache symptoms pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: rest. take meds. no heavy lifting, exercise, for 4 weeks Followup Instructions: ___

19992507-DS-19

DS

2175-06-30 00:00:00

2175-07-14 08:50:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Zofran Attending: ___ Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: ___ w hx remote colon cancer ___ s/p sigmoid resection c/b leak requiring reoperation/diverting colostomy, s/p takedown, with long-standing incisional hernia, who presents to the ED with 4 days of nausea and bilious emesis, found on CT to have recurrent SBO. Patient reports 4 days ago she noticed cramping abdominal pain associated with nausea, had several episodes of bilious emesis. Did not have any bowel movements for 3 days/flatus x 2 days, however initially tried managing by increasing her stool softeners and starting lactulose 2 days ago. However her nausea/vomiting did not resolve prompting her to present today. A CT scan was done, results detailed below, demonstrating an incarcerated ___ hernia for which we are consulted. Only prior hospitalization for this issue was in ___, at which time she was admitted to ___ service w obstructive symptoms - ACS was consulted several days into her hospital stay but at that point her symptoms had already improved and CT demonstrated partial SBO at most. Given her recurrent lymphoma and plans to perform repeat aSCT she deferred definitive surgical repair - her symptoms resolved with non operative management, did not follow up with surgery as outpatient. Successfully underwent repeat aSCT and has been in remission for ___ years, with last scans ___ showing no evidence of disease recurrence. No recurrent SBO's in the subsequent ___ years until her presentation today. Last colonoscopy ___ which noted several adenomatous polyps, plans for repeat in ___. ROS: (+) per HPI Past Medical History: PAST ONCOLOGIC HISTORY 1. Recurrent marginal zone lymphoma, stage IIIA. --Initially treated with R-CVP, completed in ___ --Relapsed in ___ with extensive adenopathy, treated with total 6 cycles of Rituxan/Bendamustine, completed in ___ --Increasing left breast lesion and skin nodule. Biopsy on ___ showed diffuse large B-cell lymphoma and transformation in the background of a marginal zone lymphoma --4 cycles of DA-EPOCH, followed by high dose Cytoxan and autologous stem cell transplantation(D 0 ___. 2. Colon cancer, status post surgery in ___. She does not remember the stage of her disease, but she did not receive any adjuvant treatment. Colonoscopy needs to be repeated. PAST MEDICAL HISTORY: Osteoarthritis. Adnexal cyst. Hypertension Chemotherapy induced pneumonitis, on steroids with taper. Social History: ___ Family History: Adopted. Family history unknown. Physical Exam: Admission physical exam ======================= Vitals: T98 HR110 BP 130/80 RR 18 ___ 92RA GEN: A&O, NAD, non-toxic appearing HEENT: No scleral icterus, mucus membranes dry CV: mild tachycardia, reg rhythm PULM: unlabored respirations ABD: Soft, morbidly obsese, nondistended, large palpable incisional hernia just to the left of umbilicus with gas-filled small bowel. Tender to palpation over hernia but no diffuse abdominal tenderness, no rebound or guarding. Ext: No ___ edema, ___ warm and well perfused Discharge physical exam ======================== VS: 98.2, 135/75, 87, 20, 95 RA Gen: A&O x3. Ambulatory. In NAD. CV: HRR Pulm: LS CTAB Abd: soft, obese, + large hernia. nontender to palp. Ext: WWP, trace edema Pertinent Results: Admission labs ============== ___ 10:00AM BLOOD WBC-10.5* RBC-5.57* Hgb-16.5* Hct-50.0* MCV-90 MCH-29.6 MCHC-33.0 RDW-13.5 RDWSD-44.5 Plt ___ ___ 10:00AM BLOOD Neuts-74.5* Lymphs-14.2* Monos-9.5 Eos-0.7* Baso-0.5 Im ___ AbsNeut-7.81* AbsLymp-1.49 AbsMono-0.99* AbsEos-0.07 AbsBaso-0.05 ___ 10:00AM BLOOD ___ PTT-27.8 ___ ___ 10:00AM BLOOD Plt ___ ___ 10:00AM BLOOD Glucose-252* UreaN-17 Creat-0.9 Na-141 K-3.8 Cl-97 HCO3-26 AnGap-18 ___ 10:00AM BLOOD Calcium-9.7 Phos-2.7 Mg-1.9 ___ 11:03AM BLOOD Lactate-3.2* ___ 01:48AM BLOOD Lactate-1.2 ___ 06:13AM BLOOD Lactate-1.5 Discharge labs: ___ 05:30AM BLOOD WBC-8.9 RBC-4.13 Hgb-12.4 Hct-40.0 MCV-97 MCH-30.0 MCHC-31.0* RDW-14.3 RDWSD-50.4* Plt ___ ___ 04:50AM BLOOD WBC-10.4* RBC-4.48 Hgb-13.3 Hct-42.9 MCV-96 MCH-29.7 MCHC-31.0* RDW-14.5 RDWSD-50.2* Plt ___ ___ 04:09AM BLOOD WBC-18.9* RBC-4.89 Hgb-14.7 Hct-46.4* MCV-95 MCH-30.1 MCHC-31.7* RDW-14.1 RDWSD-48.9* Plt ___ ___ 05:30AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-143 K-3.7 Cl-105 HCO3-31 AnGap-7* ___ 04:50AM BLOOD Glucose-167* UreaN-12 Creat-0.6 Na-143 K-3.9 Cl-103 HCO3-30 AnGap-10 Imaging ======== CXR ___ PA and lateral views of the chest provided. Port-A-Cath resides over the right chest wall with catheter tip in the mid SVC region. The lungs are clear bilaterally. There is no focal consolidation, large effusion, pneumothorax or signs of edema. Cardiomediastinal silhouette appears stable. Bony structures are intact. No free air below the right hemidiaphragm. CT A/P ___ 1. Small-bowel obstruction due to a left periumbilical small bowel containing hernia. Please correlate for reducibility. No free fluid, free air or bowel wall thickening. 2. Multiple additional fat containing abdominal wall hernias. 3. Right adnexal cystic lesion, previously characterized as hydrosalpinx. 4. Thickened endometrium, measuring up to 2.8 cm, consider nonemergent pelvic ultrasound to further assess. ___ KUB: Multiple air-filled, mildly dilated loops of small and large bowel, compatible with ileus. ___ KUB: Interval decrease in mildly dilated loops of small and large bowel, compatible with improving ileus. ___ CHEST/ABD/PELVIS CT: 1. Left periumbilical incisional hernia with a 4.___ontaining loops of small bowel with interval slight improvement of upstream small bowel dilatation. The oral contrast material has passed through the trapped loops of small-bowel in the incisional hernia, however, given the continued upstream dilation, there appears to be an element of persisting partial obstruction. 2. Thickened endometrium measures 0.9 cm as noted on pelvic ultrasound dated ___. Please correlate with prior endometrial biopsy. 3. Unchanged right hydrosalpinx. 4. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. Brief Hospital Course: ___ y/o F hx marginal zone lymphoma s/p alloSCT x 2, remote colon cancer s/p resection with incisional hernia, admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain, nausea and vomiting. Admission abdominal/pelvic CT revealed a small-bowel obstruction due to a left periumbilical small bowel containing hernia. The patient was hemodynamically stable. She was treated non-operatively with bowel rest, IV fluids, nasogastric tube for decompression, and close monitoring or lab work and abdominal exam. Serial abdominal x-rays showed gradual improvement. The patient eventually began passing consistent flatus. On ___, a repeat CT scan showed no bowel obstruction. NGT was removed and diet was progressively advanced as tolerated to a regular diet with good tolerability. 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. She would follow-up as an outpatient to discuss an elective hernia repair. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acyclovir 400 mg PO Q8H 2. Hydrochlorothiazide 25 mg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID 6. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY 2. Acyclovir 400 mg PO Q8H 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 6. Senna 8.6 mg PO BID 7. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Distal small-bowel obstruction due to a left periumbilical hernia containing multiple small bowel loops Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were admitted to the hospital because recurrent small bowel obstruction and irreducible small-bowel containing incisional hernia. You were managed non-operatively with bowel rest, IV fluids, and nasogastric tube for stomach decompression. A repeat CT scan was done which showed resolution of the obstruction, and you also had begun to have reliable return of bowel function. You have been tolerating a regular diet now, passing flatus and having bowel movements. You are ready to be discharged home to continue your recovery. You can follow-up in clinic to discuss elective hernia repair. 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: ___

19992581-DS-12

DS

2197-03-12 00:00:00

2197-03-12 11:10:00

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: ___ laparoscopic appendectomy History of Present Illness: Mr. ___ is ___ year old male who presented to the ED on ___ with abdominal pain. He was in his usual state of health until 24 hours prior to presentiation when he experienced acute onset non-radiating RLQ pain. He has never experienced this type of pain before and denies trauma to the area. Shortly after the pain began, he had a loose bowel movement and is passing flatus. He endorses subjective fevers, chills, nausea and non-bilious emesis. He denies chest pain or shortness of breath. CT scan in the ED indicated acute, nonperforated appendicitis. Past Medical History: positive PPD, hypercholesterolemia, and chronic low back Social History: ___ Family History: non-contributory Physical Exam: On arrival to ___: Vitals: 99.4 108 118/60 18 94 RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, focally tender to palpation in the RLQ, no rebound or guarding, no palpable masses Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ CT ABD & PELVIS WITH CONTRAST Acute appendicitis. Appendix measures up to 8mm. No abscess, drainable fluid collection or extra-luminal gas ___ 12:30PM WBC-12.5*# RBC-4.70 HGB-13.5* HCT-38.2* MCV-81* MCH-28.8 MCHC-35.5* RDW-12.0 ___ 12:30PM NEUTS-81* BANDS-13* LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-1* ___ MYELOS-0 ___ 12:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 12:30PM PLT SMR-NORMAL PLT COUNT-199 ___ 12:30PM ALBUMIN-4.4 ___ 12:30PM ALT(SGPT)-18 AST(SGOT)-24 ALK PHOS-42 TOT BILI-1.5 ___ 12:30PM LIPASE-19 ___ 12:30PM GLUCOSE-136* UREA N-15 CREAT-1.2 SODIUM-135 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 ___ 03:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: Mr. ___ was admitted under the acute care surgery service for management of his acute appendicitis. He was taken to the operating room and underwent a laparoscopic appendectomy. See operative report by Dr. ___ details of this procedure. He was extubated after the procedure was completed and taken to the PACU for recovery. He remained hemodynamically stable and was transferred to the surgical floor postoperatively. He remained alert and oriented throughout his postoperative course. His pain level was routinely assessed and his pain level was well controlled with oral narcotic pain medication and tylenol as needed. His vital signs were routinely monitored in the postoperative period and he remained hemodynamically stable. Incentive spirometry and pulmonary toileting were encouraged. He was voiding adequate amounts of urine without difficulty. His diet was advanced to a regular diet in the morning of postoperative day #1, which he tolerated well without nausea/vomiting. His appendix was noted to be gangrenous during the operation and so he was started on IV ciprofloxacin and flagyl. On postoperative day #1, he became febrile to 102. Blood and urine cultures were sent at this time and IV fluids were continued. His antibiotics were changed to IV unasyn for empiric coverage and patient was transitioned to 7 days po augmentin for continued treatment. Urine cultures were negative and blood culture had no growth at time of discharge. He was encouraged to mobilize out of bed and ambulated as tolerated postoperatively. Prior to discharge he was out of bed ambulating independently with a steady gait. Mr. ___ was tolerating a regular diet, his pain was well controlled, hemodynamically stable, and out of bed ambulating independently. He expressed the desire to return home and was discharged on 1 week of antibiotics with follow up scheduled with Dr. ___. Medications on Admission: none Discharge Medications: 1. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: Two (2) 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). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with acute appendicitis. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home with the following instructions: 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 6 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. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU MAY FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. 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. It is normal to feel a firm ridge along the incision. This will go away. 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. Ove the next ___ months, your incision will fade and become less prominent. 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: *You are being given a prescription for antibiotics. Take the entire prescription (for 1 week total) as instructed.* 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: ___

19992875-DS-15

DS

2160-04-19 00:00:00

2160-05-06 07:35:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal Attending: ___. Chief Complaint: Reason for MICU transfer: monitoring s/p pericardial drainage Major Surgical or Invasive Procedure: Pericardiocentesis Pericardial Window History of Present Illness: Mr ___ is ___ male with primary biliary cirrhosis on the transplant list presenting with jaundice and abdominal pain; in house found to have cardiac tamponade now transferred to the MICU s/p pericardial drainage. Per review of OMR patient was recently admitted from ___ with jaundice, body aches, and abodminal pain. He was discharged to home. Since return home he notes persistence abdominal pain and worsening jaundice with associated nausea, bodyaches, hotflashes, loose stool. His tmax at home was 99.2. He also had some chest pain which is stabbing and epigastric, and has resolved. He has been using fentanyl patch and breakthrough oxycodone for abdominal pain. On further review, patient endorsed being homeless ___. Also in prison ___. Found to be PPD + in prison and treated with 9 months of INH. Says he completed course and didn't miss doses. Denies pets or travel. No IVDU. HIV neg last in ___. AMA + at 1:320 in past. Past neg SMA, ANCA, ___, Histoplasmosis, quant gold. Endorses a ___ day viral illness with fevers, myalgias, fatigue, cough in ___ of this year. Also reports losing roughly 50lbs unintentionally over last year. Reports dry cough for last few months and consistent night sweats for last week. No known sick contacts and no travel. In the ED, labs were significant for a Hct of 33.8 (down from 40.2 las discharge, but c/w recent prior baselines). INR was up to 4.2 from 2.8 last week. Lytes were significant for Na+ of 132 (from 134 last week), and Cr of 0.7 (stable). AST/ALT were ___ both of which are stable. Tbili wsa 18.1 which is within recent baselines over the past month. CXR was obtained which showed no acute process. Abdominal u/s with dopplers showed no ascites, portal vein patent, + splenomegaly. On ___ patient triggered for tachycardia and low BP, he received IVF as well as albumin. This morning exam notable for pulsus of 15 on exam this morning. EKG with low voltages throughout the pericardium, no alternans. Stat echocardiogram demonstrated Large ?hemorrhagic partially organized pericardial effusion with echocardiographic evidence of impaired filling/tamponade physiology. Decision made to proceed to ___ for drainage. On arrival to the MICU, patient feeling groggy with no new chest pain. Past Medical History: # PBC cirrhosis # History of heavy ETOH use, sober ___ years # Positive PPD with clinical findings consistent with LTBI # Hyperlipidemia # Osteoporosis Social History: ___ Family History: -Father: coronary artery disease, depression, diabetes, and hypercholesterolemia. -Mother had a brain aneurysm and hyperthyroidism. Physical Exam: ON ADMISSION VS: 97.3 114/74 114 18 100%ra pulsus 18 GENERAL: ill, thin appearing, diffusely jaundiced, but NAD HEENT: NC/AT, PERRLA, EOMI, sclerae cteric, MMM NECK: supple, JVP up to tragus LUNGS: mild bibasilar crackles, good air movement, resp unlabored, HEART: tachy, regular, no MRG, nl S1-S2 ABDOMEN: scant bowel sounds, soft, midepigastric and RUQ tenderness. Enlarged liver, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact, no asterixis. moving alle xtremities ON DISCHARGE Pertinent Results: ON ADMISSION ___ 07:00PM WBC-5.2 RBC-3.72* HGB-11.8* HCT-33.8* MCV-91 MCH-31.7 MCHC-34.9 RDW-15.0 ___ 07:00PM NEUTS-75.2* LYMPHS-16.1* MONOS-6.8 EOS-0.9 BASOS-1.0 ___ 07:00PM GLUCOSE-117* UREA N-11 CREAT-0.7 SODIUM-132* POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-20* ANION GAP-17 ___ 07:00PM ALT(SGPT)-99* AST(SGOT)-99* ALK PHOS-774* TOT BILI-18.1* ___ 07:00PM LIPASE-25 ___ 07:31AM ___ PTT-56.6* ___ ___ 07:00PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-2.6* MAGNESIUM-2.2 NOTABLE STUDIES Abdominal US ___. No ascites. 2. Splenomegaly. Cytology Pericardial Fluid NEGATIVE FOR MALIGNANT CELLS. PA/LAT CXR ___. Small right pleural effusion. Right lung base opacity, most likely atelectasis, however, superimposed infection cannot be excluded. 2. Mild cardiomegaly and/or pericardial effusion new since ___. Consider cardiac ultrasound for further assessment. ECHO ___ The left ventricular cavity size is normal. The right ventricular cavity is unusually small. No aortic regurgitation is seen. Physiologic mitral regurgitation is seen (within normal limits). There is a large pericardial effusion most prominent inferior and lateral to the left ventricle and anterior to the right atrium and right ventricle, with minimal around the apical third of the ventricle. There is stranding within the pericardial space c/w organization and some mild "ground glass" appearance suggesting a bloody effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Large ?hemorrhagic partially organized pericardial effusion with echocardiographic evidence of impaired filling/tamponade physiology PERICARDIOCENTESIS ___ FINAL DIAGNOSIS: 1. Successful pericardiocentesis with drainage of 500cc of blood fluid 2. Residual loculated lateral pericardial effusion 3. Drain sutured in place to gravity 4. Surgical evaluation for residual effusion ECHO ___ The left ventricular cavity size is normal. Systolic function is abnormal, but cannot be well characterized due to tachycardia and pericardial effusion. Right ventricular chamber size is normal. Physiologic mitral regurgitation is seen (within normal limits). There is a moderate sized inferolateral pericardial effusion. Compared with the prior study of earlier in the day, the anterior pericardial effusion has largely resolved and the right ventricular cavity is now normal in size. Tamponade physiology is no longer suggested by transmitral Doppler and there is no RA/RV diastolic collapse. The inferolateral effusion appears similar. ECHO ___ Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. with borderline normal free wall function. There is abnormal septal motion/position. There is a moderate sized pericardial effusion. Stranding is visualized within the pericardial space c/w organization. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: There is a residual amount of fluid near the lateral and inferolateral wall - it is similar to the amount of fluid in this area before pericardiocentesis. The lateral wall of the left ventricle moves vigorously towards the centroid of the LV in diastole - this is probably due to left ventricular diastolic "collapse" due to the nearby loculated pericardial flulid. The basal free wall of the right ventricle appears tethered and as a result RV systolic function is mildly impaired. There is no evidence of RV or RA diastolic collapse and the fluid that was previously anterior to the RV has largely resolved. PORTABLE CXR ___ Moderate enlargement of the cardiomediastinal silhouette has minimally improved. There is no evident pneumothorax. Left chest tube and a second tube projecting over the heart are in unchanged position. Enlarged right pleural effusion is grossly unchanged allowing the difference in positioning of the patient associated with adjacent atelectasis. A rounded radiolucency projecting in the right lower hemithorax is again noted, this could be due to air in the pleural space or aerated lung surrounding by atelectasis. CT CHEST ___ IMPRESSION: 1. Moderately large intermediate density pericardial effusion, which is likely hemorrhagic. Adjacent small locules of gas, likely relate to recent procedure. 2. Small left pneumothorax. Left-sided chest tube is in place terminating at the left lung base. 3. Moderate non-hemorrhagic right and small left pleural effusions. Adjacent areas of consolidations most likely represent atelectasis 4. Splenomegaly. Brief Hospital Course: ___ Male with Hx of Primary Biliary Cirrhosis who presented with symptoms of abdominal pain, increased nausea, and loose ___- hospital course c/b tachycardia and hypotension. He was found to have a large hemorrhagic pericardial effusion with tamponade physiology. #Pericardial Effusion with Tamponade Physiology: Patient presented with hypotension and tachycardia that was thought to be from dehydration. ECG showed low voltage and subsequent ECHO showed large loculated effusion with tamponade physiology. Pulsus paradoxis prior to pericariocentesis was 30. Patient underwent pericardiocentesis ___ and 500cc bloody fluid was drained from anterior locuation. There was still residual fluid in lateral and posterior pockets. Patient was monitored overnight in MICU and taken ___ for a pericardial window where the rest of the fluid was removed and two drains were placed. Preliminery fluid results showed no malignant cells, gram staining and culture thus far negative. Patient has a history of a positive PD ___ while in prison. Subsequent Quantiferon test in ___ was negative. Fluid was sent for ___ and ___, which was negative. Given rather unrevealing work up, the hemopericardial efussion was most likely secondary to recent viral infection several weeks prior and elevated INR over 4 in setting of poor GI vitamin absorption. He remained hemodynamically stabe the reaminding of admission. #Pleural Effusion: Patient had R sided pleural effusion on persistent x-rays. X-rays after pericardial window showed "air bubble" within this effusion. Subsequent CT chest showed this was likely a non-hemorrhagic effusion with collapsed lung inside of it. Respiratory status was stable following pericardial window placement. #C DIff Coltis: Patient's stool was sent on admission for his non-specific GI illness and was positive for C Diff. He was treated with a course of PO Vancomycin. Symptoms will be resasess at hepatology follow up in 2 weeks. #Primary Biliary Cirrosis: Patient was admitted with MELD 30. He was placed on Vitamin K 5mg daily for 10 days and Ursodiol dosing was decreased. His decompensated liver disease at admission was thought to be secondary to either congestive hepatopathy from tamponade physiology, lamictal use (d/c'ed ___, increased dosing of ursodiol causing decreased absorption of fat soluble vitamins, C.diff infection, and progression of PBC. His liver disease wsa improving at time of discharge with downtrending bilirubin. He will follow up with the liver ___ further management of disease. #Hyponatremia: Patient was mildly hyponatremic on admission. This improved with albumin and normal saline. Urine lytes suggested element of hypovolemia. #Psych Issues: Patient formerly was on lamictal. He was continued on his home risperidone. Mental status good this admission. #Pain Control: Patient was initially on Dilaudid PCA which was converted to PO oxycodone. He was also maintained on his home fentanyl patch. Pain was well controlled. Transitional Issues -Follow up final staining of pericardial fluid/pericardial tissue -Will complete a 2 week course of PO vancomycin for Cdiff and follow up with hepatology Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gabapentin 150 mg PO TID 2. Omeprazole 20 mg PO DAILY 3. Risperidone 2 mg PO HS 4. Ursodiol 600 mg PO QID 5. Acetaminophen 500 mg PO Q6H:PRN pain Do not take more than 4 pills in 24 hours. 6. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral TID 7. Atorvastatin 20 mg PO DAILY 8. Fentanyl Patch 25 mcg/h TP Q72H 9. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain Do not take more than 4 pills in 24 hours. 2. Gabapentin 150 mg PO TID 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #*42 Tablet Refills:*0 4. Risperidone 2 mg PO HS 5. Ursodiol 300 mg PO QID RX *ursodiol 300 mg 1 capsule(s) by mouth four times a day Disp #*120 Capsule Refills:*0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 7. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 ml by mouth four times per day Disp #*280 Milliliter Refills:*0 8. Phytonadione 5 mg PO DAILY Duration: 10 Days RX *phytonadione [Mephyton] 5 mg 1 tablet(s) by mouth daily Disp #*6 Tablet Refills:*0 9. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth daily Disp #*30 Packet Refills:*0 10. Prochlorperazine 25 mg PR Q12H:PRN Nausea RX *prochlorperazine 25 mg 1 Suppository(s) rectally twice daily Disp #*30 Suppository Refills:*0 11. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet Refills:*0 12. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six hours Disp #*28 Capsule Refills:*0 13. Atorvastatin 20 mg PO DAILY 14. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral TID 15. Outpatient Physical Therapy Please continue to provide acute ___ for deconditioning 3x per week. 16. Fentanyl Patch 25 mcg/h TP Q72H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pericardial effusion with cardiac tamponade primary biliary cirrhosis with cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___. You were admitted because you had worsening skin discoloration, jaundice, and low blood pressure. You were found to have collection of fluid around your heart, and this was drained. The fluid studies and the tissue biopsy of the fluid around your heart did not show infection with bacteria, TB, or fungus and also did not show features concerning for cancer including lymphoma. We think that this happened because of inflammation following a viral upper respiratory tract infection and then a subsequent bleed into the inflamed tissue. Your liver was worse during this admission, which can happen when your body is trying to fight other infections and inflammation as above. The liver tests are starting to slowly improve, but you still have end-stage liver disease and will need a transplant. You should continue to follow-up with the liver transplant doctors. ___, you were found to have an infection in your colon (intestines) which is treated with antibiotics. The name of the bacteria causing this infection is called C. diff. You should take this until ___. Followup Instructions: ___

19992875-DS-16

DS

2160-05-25 00:00:00

2160-05-27 10:16:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal Attending: ___ Chief Complaint: abdominal pain, diarrhea Major Surgical or Invasive Procedure: ___ EGD History of Present Illness: Mr. ___ is a ___ year-old gentleman with a PMH of primary biliary cirrhosis (on the transplant list), hemorrhagic pericarditis s/p pericardial window (___), C. diff colitis (treated with vanc PO in ___, now presenting with nausea, vomiting and diarrhea. Symptoms began 24 hours prior to admission associated with stomach cramping. Has been having ___ BMs / day. Also having N/V states "Can't keep anything down." No melena. Some dark brown, loose stool. No BRBPR. No hemoptysis. No chest pain or shortness of breath. No increase in abdominal girth. Improved jaundice per father. ___ fevers and chills. Pt has been feeling more fatigued over last several weeks. In the ED, triage vitals were: 97.6 67 113/73 17 100%. Labs were remarkable for: WBC 3.4 with Eos 13%, H/H 12.3/37.2, plt 95; ALT 100, AST 102, ALK 568, TBil 14.3; lactate 0.9; ___ 63.3, PTT 64.6, INR 5.8. UA showed: dark amber urine with sp gr 1.006, with no evidence of infection. Bedside abdominal ultrasound showed no evidence of ascites or large pericardial effusion. Patient was given ondansetron 2 mg IV. Hepatology consult recommended checking stool for C. diff, and admission to ___. Prior to transfer, vital signs were: 97.4 61 99/61 18 99%. On arrival to the floor, pt was AOx3 w/o asterixis. He is breathing comfortably and complaining of some abdominal cramping. No evidence of HE on exam. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - primary biliary cirrhosis - hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ - History of heavy ETOH use, sober ___ years - Positive PPD with clinical findings consistent with LTBI - Hyperlipidemia - Osteoporosis Social History: ___ Family History: -Father: coronary artery disease, depression, diabetes, and hypercholesterolemia. -Mother had a brain aneurysm and hyperthyroidism. Physical Exam: On admission: VS: 98.4, 107/64, 62, 20, 98%RA GENERAL: NAD. Jaundiced HEENT: Sclera icteric. MMM. no oral ulcers CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: no ascites on exam, no fluid wave, BS+, generalized TTP EXTREMITIES: no c/c/e NEUROLOGY: no asterixis, concentration and attention normal on exam On discharge: VS: Tc 98.6, 97/113 (97-113) 65 (60-83), 18, 100% RA. GENERAL: NAD. Jaundiced HEENT: Sclera icteric. MMM. no oral ulcers CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: no ascites on exam, no fluid wave, BS+, mild epigastric tenderness EXTREMITIES: no edema, + clubbing of fingernails NEUROLOGY: no asterixis, concentration and attention normal on exam Pertinent Results: On admission: ___ 09:05AM BLOOD WBC-2.7* RBC-4.14* Hgb-12.4* Hct-38.3* MCV-93 MCH-30.1 MCHC-32.5 RDW-17.8* Plt Ct-95* ___ 09:05AM BLOOD ___ ___ 09:05AM BLOOD UreaN-11 Creat-0.7 Na-137 K-4.0 Cl-99 ___ 09:05AM BLOOD ALT-121* AST-117* AlkPhos-578* TotBili-15.6* ___ 05:53PM BLOOD Albumin-3.9 Calcium-9.4 Phos-4.0 Mg-2.2 ___ 09:05AM BLOOD Albumin-4.4 Studies: KUB ___ FINDINGS: A large amount of stool is present throughout the colon extending into the rectosigmoid region. Scattered air-fluid levels are also present within non-distended loops of small bowel. There is no evidence of free intraperitoneal air. Prominent soft tissue in left upper quadrant of the abdomen probably relates to known splenic enlargement reported on prior CT scan. Within the imaged portion of the chest, note is made of interstitial opacities in the mid and lower lungs suggestive of interstitial edema, as well as a more focal opacity at the left lung base, which may reflect atelectasis and less likely a focal pneumonia or area of infarction. Small left pleural effusion is also demonstrated. RUQ U/S ___ IMPRESSION: 1. No sonographic evidence for portal vein thrombosis. 2. Cirrhosis with splenomegaly. No liver lesions or ascites detected. 3. Non-obstructing 1 cm right renal calculus. GI bx pathology: A. Mid-esophagus: Squamous epithelium, within normal limits. Scant detached debris with rare neutrophils. B. Lower esophagus: Mild acute esophagitis. Special stains (GMS, PAS) are negative for fungal organisms. C. Duodenum, second part: Duodenal mucosa within normal limits. ___ EGD Impression: Linear erosive esophagitis involving lower and upper esophagus s/p biopsies. ___ B Normal stomach. Gastic juice was collected for PH testing Atrophic appearing duodenal mucosa with mild blunting s/p biopsies (biopsy) Otherwise normal EGD to third part of the duodenum Micro: C. difficile DNA amplification assay (Final ___: This test was cancelled because a FORMED stool specimen was received, and is NOT acceptable for the C. difficle DNA amplification testing.. TEST CANCELLED, PATIENT CREDITED. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ EKG Sinus bradycardia. Otherwise, probably normal. Since the previous tracing of ___ the rate is slower. Otherwise, no change On discharge: ___ 05:10AM BLOOD WBC-3.0* RBC-3.62* Hgb-11.8* Hct-32.9* MCV-91 MCH-32.8* MCHC-36.0* RDW-17.7* Plt Ct-91* ___ 05:10AM BLOOD ___ PTT-35.5 ___ ___ 05:10AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-136 K-3.7 Cl-97 HCO3-27 AnGap-16 ___ 05:10AM BLOOD ALT-77* AST-80* AlkPhos-466* TotBili-21.3* ___ 05:10AM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.9 Mg-2.2 Brief Hospital Course: Mr. ___ is a ___ h/o of primary biliary cirrhosis (on the transplant list), hemorrhagic pericarditis s/p pericardial window (___), C. diff colitis (treated with vanc PO in ___, now presenting with nausea, vomiting and diarrhea, and epigastric pain. # Nausea / vomiting / Diarrhea (resolved), now constipation: Initially concerning for infectious process especially repeat C.diff infection, though no bowel movements in first ___ days of admission despite aggressive bowel regimen. Patient could not produce loose stool to send off for C. diff. No evidence of peritonitis on exam and normal bowel sounds made SBO less likely. Surgery team recommended empiric PO vancomycin, but Pt w/out fever, leukocytosis, lower abdominal pain. KUB showed p was full of stool. Pt may have had diarrhea secondary to constipation (loose stool traversing past impacted stool). Infectious stool studies were negative. Blood and urine cultures were also negative. EGD showed erosive esophagitis which likely was contributing to nausea. Constipation was the primary process contributing to symptoms as nausea resolved with passing bowel movements (given senna/colace/miralax/lactulose/dulcolax and Moviprep. Patient was not on bowel regimen pre-admission while on fentanyl patch and oxycodone. He was discharged with bowel regimen. # Epigastric pain, Esophagitis: Lipase normal. EKGs were unremarkable. Pt previously had candidiasis of the esophagus on EGD in ___, no varices. He was treated with 10 days of fluconazole. ___ have had worsening partially treated ___ infection. He also has not been taking his prescribed clotrimazole troches and patient was restarted on clotrimazole. Another possibility was GERD/gastritis/esophagitis. EGD showed erosive esophagitis and pathology showed acute esophagitis. Patient was started on omeprazole BID, carafate BID, and ranitidine (added on as patient with severe pain which subsided with ranitidine). Epigastric pain also improved with passing BMs and pt discharged with aggressive bowel regimen. # Primary Biliary Cirrhosis- Pt on transplant list, admission labs concerning for MELD of 36. Last admission pt had MELD of 30. RUQ u/s with dopplers ruled out portal vein thrombosis. No hx per pt of HE, also no h/o ascites or SBP. While inhouse, patient was ordered daily albumin levels given on transplant list. Patient was continued on ursodiol and given lactulose PRN at discharge to prevent further constipation. EGD on ___ did report did not mention varices. #Coagulopathy: Patient with labile INR ranging from ___. Pt with h/o hemorrhagic pericardial effusion s/p pericardial window. Will supplement with Vit K. Patient was given IV Vit K on ___ for INR>5 and started standing PO Vit K 5mg daily thereafter. INR on admission=1.0. # Thrombocytopenia- Plts on admission 95 which was decreased from 200s. Stable in ___. Most likely related to acute worsening of liver function. No petechiae on exam, h/h stable. # HL- continued on atorvastatin. Transitional issues: -Patient discharged with bowel regimen: senna/Miralax standing and lactulose PRN -Patient has follow-up with PCP and hepatology -___ started on standing PO Vit K 5mg daily -Patient started on PPI, H2 blocker and carafate to control acute erosive esophagitis -Patient restarted on clotrimazole troches- patient told to ask outpatient providers on duration of taking troches Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO Q6H:PRN anxiety 2. Fentanyl Patch 25 mcg/h TP Q72H due to be changed on ___. Atorvastatin 20 mg PO DAILY 4. Risperidone 2 mg PO DAILY 5. Ursodiol 300 mg PO QID 6. Calcium Carbonate 500 mg PO TID 7. Vitamin D 400 UNIT PO TID 8. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 9. Gabapentin 300 mg PO TID 10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain hold for sedation or RR <10 Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Calcium Carbonate 500 mg PO TID 3. Fentanyl Patch 25 mcg/h TP Q72H 4. Gabapentin 300 mg PO TID 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 6. Risperidone 2 mg PO DAILY 7. Ursodiol 300 mg PO QID 8. Vitamin D 400 UNIT PO TID 9. Clotrimazole 1 TROC PO QID RX *clotrimazole 10 mg One 10mg troche four times a day Disp #*40 Each Refills:*0 10. Omeprazole 40 mg PO BID RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 11. Phytonadione 5 mg PO DAILY RX *phytonadione [Mephyton] 5 mg 1 tablet(s) by mouth Daily Disp #*20 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by mouth Daily Disp #*20 Each Refills:*0 13. Ranitidine (Liquid) 150 mg PO BID RX *ranitidine HCl 150 mg 1 capsule by mouth twice a day Disp #*40 Capsule Refills:*0 14. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*40 Tablet Refills:*0 15. Sucralfate 2 gm PO BID RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 16. Lorazepam 0.5 mg PO Q6H:PRN anxiety 17. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 18. Lactulose 30 mL PO Q8H:PRN constipation. RX *lactulose 10 gram/15 mL 30 ml by mouth Q8H PRN Disp #*1 Bottle Refills:*0 19. Ondansetron ___ mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg ___ tablet(s) by mouth Q8H PRN Disp #*25 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Erosive esophagitis Constipation Primary biliary cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for diarrhea and we were concerned that you had C. difficile again. Our work-up showed that you had severe constipation which likely allowed liquid stool to pass through your GI tract and thus you presented with diarrhea. The x-ray of your abdomen showed that you had a lot of stool throughout your GI tract. Constipation is a common side effect of taking narcotic pain medications. We are giving you senna and polyethylene glycol [Miralax], which you will have to take on a daily basis to help you pass stools while you are on the fentanyl patch and oxycodone. We are also giving you a prescription for lactulose which you can use as needed if you remain constipated with the two agents above. Please stay hydrated and physically active as well. Your abdominal pain and nausea was likely related to severe constipation and acid reflux. We also saw that you had an inflamed esophagus, likely from excessive stomach acid. We started you on omeprazole, sucralfate and ranitidine to help control your symptoms. START Phytonadione daily to help correct your abnormal clotting from your liver disease. START Senna and Miralax on a regular basis. Take lactulose as needed if you need additional support to help you pass bowel movements. Followup Instructions: ___

19992875-DS-17

DS

2160-06-21 00:00:00

2160-07-01 21:02:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal Attending: ___. Chief Complaint: Abdominal pain, weakness, and lethargy. Major Surgical or Invasive Procedure: None. History of Present Illness: ___ year old male with advanced PBC, listed for liver transplant, and fairly recent hemorrhagic pericarditis s/p pericardial window (___) who presents with abdominal pain, weakness, and lightheadedness. . He was admitted last month from ___ to ___. He was doing well after discharge until earlier today. He was eating brunch when he developed lower abdominal pain, lightheadedness, and fatigue. Usually has ___ abdominal pain but has now been ___. . He called the ___, who recommended that he come to the ___ ED. Since his last admission, he has been on a bowel regimen titrated to ___ BMs a day and has had 3 BMs so far today. He denies any melena or hematochezia. He has alternating diarrhea and constipation which is baseline for him. His stools are gray, which is his baseline. He has noticed that his jaundice and pruritus have been worsening. . He had two episodes of visual disturbance in which he saw black spots while standing up to urinate. He felt lightheaded at the time and these symptoms resolved when he finished urinating and returned to bed. . Initial vitals in ED triage were T 98.8, HR 77, BP 135/65, RR 16, and SpO2 100% on RA. Exam was notable for jaundice. Labs showed pancytopenia similar to recent values. His electrolytes were unremarkable. His coags were elevated with INR 2.0 and PTT 60.9 (normal coags on ___. His LFTs were essentially unchanged from ___, though still elevated compared to his discharge on ___ with ALT 99, AST 130, ALK 384, and TBili 20.5. Albumin was normal at 4.1. Urinalysis was normal except for large bilirubin. No imaging was performed. He was given Oxycodone 10 mg PO for abdominal pain. He was admitted to the ___ service for further management of his abdominal pain and weakness. Vitals prior to floor transfer were T 97.8, HR 63, BP 111/68, RR 16, and SpO2 100% on RA. On reaching the floor, he reported REVIEW OF SYSTEMS: (+) Per HPI; also has had chronic chest discomfort since pericardial window in ___ which has not changed (-) No fevers. No headache. No SOB, cough, dysphagia. No nausea/vomiting, melena, BRBPR. No hematuria, dysuria, frequency. Past Medical History: # Primary Biliary Cirrhosis -- listed for transplant and followed by Dr ___ # Hemorrhagic Pericarditis -- c/b tamponade s/p pericardial window (___) # Positive PPD -- Treated with Isoniazid while incarcerated # Esophageal Candidiasis # Hyperlipidemia -- secondary to PBC # Osteoporosis # Bipolar Disorder Social History: ___ Family History: # Father: coronary artery disease, diabetes, hypercholesterolemia, and depression # Mother: brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.7 114/75 75 18 100%RA Gen: Young male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Icteric sclera. PERRL, EOMI. MMM, OP benign. Neck: Supple, full ROM. No cervical lymphadenopathy. No carotid bruits noted. CV: RRR with normal S1, S2. No M/R/G. No S3 or S4. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Soft bowel sounds, somewhat rigid abdomen without rebound/guarding, no ascites, generalized tenderness to palpation in lower quadrants Ext: No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+. Neuro: CN II-XII grossly intact. Strength ___ in all extremities. No asterixis DISCHARGE PHYSICAL EXAMINATION: VS: 97.7 114/75 75 18 100%RA Gen: Young male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Icteric sclera. PERRL, EOMI. MMM, OP benign. Neck: Supple, full ROM. No cervical lymphadenopathy. No carotid bruits noted. CV: RRR with normal S1, S2. No M/R/G. No S3 or S4. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Soft bowel sounds, somewhat rigid abdomen without rebound/guarding, no ascites, generalized tenderness to palpation in lower quadrants Ext: No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+. Neuro: CN II-XII grossly intact. Strength ___ in all extremities. No asterixis Pertinent Results: ADMISSION LABS =============== ___ 06:00PM BLOOD WBC-2.2* RBC-3.55* Hgb-11.2* Hct-32.9* MCV-93 MCH-31.7 MCHC-34.1 RDW-17.2* Plt ___ ___ 06:00PM BLOOD Neuts-60 Bands-3 ___ Monos-11 Eos-3 Baso-0 ___ Myelos-0 ___ 06:00PM BLOOD ___ PTT-60.9* ___ ___ 06:00PM BLOOD Glucose-93 UreaN-7 Creat-0.6 Na-136 K-3.4 Cl-101 HCO3-23 AnGap-15 ___ 06:00PM BLOOD ALT-99* AST-130* LD(___)-132 CK(CPK)-28* AlkPhos-384* TotBili-20.5* ___ 06:00PM BLOOD Lipase-20 ___ 06:00PM BLOOD Albumin-4.1 OTHER PERTINENT ================ ___ 06:45AM BLOOD TSH-3.3 ___ 06:00PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:45AM BLOOD CK-MB-1 cTropnT-<0.01 DISCHARGE LABS ================ ___ 06:52AM BLOOD WBC-2.2* RBC-3.66* Hgb-11.5* Hct-34.2* MCV-94 MCH-31.4 MCHC-33.6 RDW-16.8* Plt ___ ___ 06:52AM BLOOD ___ PTT-46.8* ___ ___ 06:52AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-136 K-3.9 Cl-100 HCO3-25 AnGap-15 ___ 06:52AM BLOOD ALT-91* AST-105* LD(LDH)-122 AlkPhos-398* TotBili-21.6* ___ 06:52AM BLOOD Albumin-4.1 Calcium-9.1 Phos-2.8 Mg-2.3 URINE ====== ___ 06:00PM URINE Color-AMBER Appear-Clear Sp ___ ___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG MICROBIOLOGY ============= ___ Blood Culture, Routine-FINAL ___ STOOL C. difficile DNA amplification assay-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL ___ Blood Culture, Routine-FINAL ___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL {ENTEROCOCCUS SP.} SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | VANCOMYCIN------------ >256 R ___ URINE URINE CULTURE-FINAL STUDIES ========= EKG === Sinus rhythm. Normal ECG. Compared to the previous tracing of ___ the rate has decreased. Otherwise, no diagnostic interim change. Rate PR QRS QT/QTc P QRS T 68 ___ 36 50 64 RUQ U/S WITH DOPPLERS IMPRESSION: 1. No sonographic evidence for a portal venous thrombosis. Patent portal vein with hepatopetal flow. 2. Cirrhosis with unchanged splenomegaly, no ascites. 3. Incidental, nonobstructing 0.6 cm right renal stone. KUB === FINDINGS: Frontal upright and supine radiographs demonstrate a moderate amount of stool throughout the colon extending to the rectosigmoid junction. There are air-filled loops of small bowel that are mildly distended. There is no abnormal air-fluid levels or evidence of free intraperitoneal air. Prominent soft tissues in the left upper quadrant of the abdomen is due to splenic enlargement. There is a small left pleural effusion. IMPRESSION: Moderate fecal load throughout the colon. No free air identified. Small left pleural effusion. ECHO ==== ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN: ___ Portable TTE (Complete) Done ___ at 11:34:53 AM FINAL Referring Physician ___ ___ of Gastroenterol ___ Status: Inpatient DOB: ___ Age (years): ___ M Hgt (in): 72 BP (mm Hg): 119/69 Wgt (lb): 142 HR (bpm): 81 BSA (m2): 1.84 m2 Indication: Chest pain. Pericarditis. Pericardial effusion. ICD-9 Codes: 786.51, 423.9, 424.0 ___ Information Date/Time: ___ at 11:34 ___ MD: ___ ___, MD ___ Type: Portable TTE (Complete) Sonographer: ___, ___ Doppler: Full Doppler and color Doppler ___ Location: ___ Floor Contrast: None Tech Quality: Adequate Tape #: ___-0:00 Machine: E9-1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Left Ventricle - Stroke Volume: 86 ml/beat Left Ventricle - Cardiac Output: 6.96 L/min Left Ventricle - Cardiac Index: 3.78 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 6 < 15 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: 2.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 19 Aortic Valve - LVOT diam: 2.4 cm Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 201 ms 140-250 ms Findings This study was compared to the prior study of ___. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. ___ LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, there is less mitral regurgitation. A bubble study was not performed. Other findings are similar. Brief Hospital Course: BRIEF HOSPITAL COURSE ====================== Mr. ___ is a ___ year old gentleman with advanced PBC, listed for liver transplant, and fairly recent hemorrhagic pericarditis s/p pericardial window (___) who presented with abdominal pain, weakness, and lightheadedness. His abdominal pain was likely from constipation. His lightheadedness was presyncopal in nature and improved by discharge. ACTIVE ISSUES ============== # Abdominal Pain due to constipation: He reported post-prandial abdominal pain without rebound/guarding. LFTs and Tbili were largely unchanged from baseline, though INR was elevated in the setting of stopping PO vitamin K. He actually had a recent admission with abdominal pain which was attributed to constipation; he had an abdominal x-ray done which showed feces throughout the colon.RUQ ultrasound with doppler was not concerning for thrombotic event. Stool studies, including c. diff, were not revealing. Bowel regimen was uptitrated with BID miralax (for stool bulking), senna, lactulose. # Lightheadedness: He reported presyncopal symptoms on two occasions while urinating, another time while at ___ eating a meal, and once while eating during this admission. History was most consistent with vasovagal symptoms. His orthostatics were negative twice. EKG without new changes. Cardiac enzymes were flat. Given history of hemorrhagic pericarditis s/p window, with coagulopathy, and a great deal of ___ concern regarding lightheadedness, he underwent TTE to evaluate for pericardial effusion, which did not show any accumulation of fluid. Of note he did not have physiology concerning for significant pericardial effusion. He was encouraged to hydrate daily with fluids such as gatorade. CHRONIC ISSUES =============== # Coagulopathy: INR on previous admission ranged ___ but on recent discharge had been 1. He was treated until recently with daily vitamin K (hepatologist discontinued his vitamin K recently). INR elevation likely from discontinuation of vitamin K, though worsening liver synthetic function also possible. # Pancytopenia: CBC, WBC, and platelets were largely within recent baseline. # Primary Biliary Cirrhosis: He has advanced PBC and is currently listed for transplant. His MELD score on admission was 26. Recent EGD on ___ did not show evidence of varices. Albumin 4.1 and his coagulopathy was previously corrected fully with Vitamin K, suggesting relatively intact synthetic function. He was continued on ursodiol 300mg q6h. # Gastritis / Esophagitis: Continued on home omeprazole, ranitidine, sucralfate, and clotrimazole troches. # History of recent hemorrhagic pericarditis: Please see discussion above. He is s/p pericardial window ___ and reports has had chronic chest pain ever since. Avoid NSAIDs due to liver disease. EKG, echo not concerning for repeat effusion/pericarditis. # Hyperlipidemia: He has highly elevated cholesterol due to his PBC, and most recent lipid panel on ___ with TC 724, ___ 311, HDL 12, and LDL 141. The benefit of statins in PBC is unclear, and statins can certainly be associated with liver injury. He reports that his hepatologist discontinued his home atorvastatin, and this was held in house as well. # Vitamin D Deficiency: His last Vitamin D level on ___ was undetectable. He was continued on cholecalciferol and calcium carbonate. # Chronic Pain: There was concern that his narcotics could be contributing to fecal loading despite bowel regimen. He was continued on home regimen, but bowel regimen was uptitrated. He was managed with fentanyl patch, gabapentin, and oxycodone. # Bipolar Disorder: Continued on home risperidone. TRANSITIONAL ISSUES ==================== - Code status: Full code, confirmed. - Emergency contact: Father ___ ___. - Studies pending on discharge: All finalized. - Noted to have constipation, so bowel regimen was increased. - We re-educated on low sodium diet (appears to be not fully compliant with low sodium diet; ie, eating at ___ and ___). Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 20 mg PO DAILY 2. Calcium Carbonate 500 mg PO TID 3. Fentanyl Patch 25 mcg/h TP Q72H 4. Gabapentin 300 mg PO TID 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 6. Risperidone 2 mg PO DAILY 7. Ursodiol 300 mg PO QID 8. Vitamin D 400 UNIT PO TID 9. Clotrimazole 1 TROC PO QID 10. Omeprazole 40 mg PO BID 11. Phytonadione 5 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Ranitidine (Liquid) 150 mg PO BID 14. Senna 1 TAB PO BID 15. Sucralfate 2 gm PO BID 16. Lorazepam 0.5 mg PO Q6H:PRN anxiety 17. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 18. Lactulose 30 mL PO Q8H:PRN constipation 19. Ondansetron ___ mg PO Q8H:PRN nausea Discharge Medications: 1. Calcium Carbonate 500 mg PO TID 2. Clotrimazole 1 TROC PO QID 3. Fentanyl Patch 25 mcg/h TP Q72H 4. Gabapentin 300 mg PO TID 5. Lorazepam 0.5 mg PO Q6H:PRN anxiety 6. Omeprazole 40 mg PO BID 7. Ondansetron ___ mg PO Q8H:PRN nausea 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 9. Ranitidine (Liquid) 150 mg PO BID 10. Sucralfate 2 gm PO BID 11. Ursodiol 300 mg PO QID 12. Senna 1 TAB PO BID 13. Risperidone 2 mg PO DAILY 14. Vitamin D 400 UNIT PO TID 15. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 16. Lactulose 30 mL PO Q8H:PRN constipation 17. Polyethylene Glycol 17 g PO BID You can decrease the frequency of this medicine if you are having loose, watery stools. RX *polyethylene glycol 3350 [Laxative PEG 3350] 17 gram/dose 1 packet by mouth twice a day Disp #*60 Packet Refills:*0 18. Docusate Sodium 100 mg PO BID You can stop this medicine if you are having loose, watery stools. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Constipation . Secondary: primary biliary cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___., It was a pleasure taking part in your care at ___. You were admitted because of abdominal pain and a lightheaded feeling. You underwent studies which showed you did not have any concerning issues with your heart. We checked blood and urine and could not find evidence of infection. Your abdominal studies were not concerning, and we think your abdominal pain was related to constipation. You were monitored and improved. . It is important for you to stay well-hydrated. You should have at leave 2 liters (64oz) or water or Power Aid per day. You also should have a low-salt diet. Be careful when you eat out as most ___ put a lot of salt in their food. Change positions (ie stand up) slowly to prevent feeling lightheaded. Followup Instructions: ___

19992875-DS-18

DS

2160-09-11 00:00:00

2160-09-11 13:36:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / rifampin / Lamictal Attending: ___. Chief Complaint: Elevated INR, Blood coating stools Major Surgical or Invasive Procedure: Liver transplant History of Present Illness: ___ M with Primary Biliary Cirrhosis, Hx of hemorrhagic pericarditis, +PPD s/p INH, esophageal candidiasis, and bipolar disorder currently hospitalized for elevated INR and treated for constipation, now pre-op for liver transplant. He has persistent bilirubinemia and MELD was 20 on ___. He was admitted on ___ with an INR 4.7 and gross blood on rectal exam and given 10mg IV vitamin K and 1 unit FFP in the ED. His INR is now 1. His left sided abdominal pain, likely due to severe constipation, is improving, and he is receiving an aggressive bowel regiment (Moviprep) with 8 non-bloody ___ BMs yesterday. He reports pruritis and dark urine. Eating well and denies N/V or F/C. Past Medical History: primary biliary cirrhosis (on transplant list), hx heavy alcohol abuse (sober 5+ years), recent hemorrhagic pericarditis c/b tamponade s/p pericardial window, hx positive PPD (likely LTB, Tx with INH while incarcerated), hyperlipidemia, osteoporosis, bipolar disorder, ADHD, Hx of alcohol abuse, hemorrhoids s/p pericardial window ___, s/p L leg surgery after MVC, liver biopsy (___) Social History: ___ Family History: No family Hx of liver disease. Father: History of prostate and Head & neck cancer. Mother: ___ from brain aneurysm. Pertinent Results: ___ 05:00AM BLOOD WBC-1.9* RBC-3.37* Hgb-11.1* Hct-32.2* MCV-96 MCH-33.0* MCHC-34.6 RDW-16.2* Plt Ct-93* ___ 05:30AM BLOOD WBC-2.4* RBC-3.29* Hgb-10.7* Hct-31.5* MCV-96 MCH-32.7* MCHC-34.0 RDW-15.8* Plt Ct-99* ___ 05:50AM BLOOD WBC-3.3*# RBC-3.12* Hgb-10.3* Hct-28.7* MCV-92 MCH-32.9* MCHC-35.7* RDW-15.8* Plt ___ ___ 05:13AM BLOOD WBC-2.1* RBC-2.91* Hgb-9.4* Hct-26.7* MCV-92 MCH-32.1* MCHC-35.0 RDW-15.5 Plt ___ ___ 05:36AM BLOOD ___ PTT-26.5 ___ ___ 09:30PM BLOOD ___ PTT-32.3 ___ ___ 12:10PM BLOOD ___ PTT-43.5* ___ ___ 05:30AM BLOOD ___ PTT-36.8* ___ ___ 05:50AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-27 AnGap-13 ___ 09:30PM BLOOD Glucose-224* UreaN-11 Creat-0.6 Na-134 K-4.0 Cl-99 HCO3-23 AnGap-16 ___ 05:30AM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-136 K-3.6 Cl-98 HCO3-23 AnGap-19 ___ 05:50AM BLOOD ALT-217* AST-61* AlkPhos-99 TotBili-4.1* ___ 05:13AM BLOOD ALT-238* AST-75* AlkPhos-92 TotBili-4.8* ___ 05:41AM BLOOD ALT-296* AST-105* AlkPhos-96 TotBili-5.2* ___ 06:02AM BLOOD ALT-300* AST-131* AlkPhos-99 TotBili-6.0* ___ 05:36AM BLOOD ALT-389* AST-257* LD(LDH)-240 AlkPhos-105 Amylase-11 TotBili-8.0* ___ 05:38PM BLOOD ALT-429* AST-355* LD(LDH)-280* AlkPhos-110 Amylase-8 ___ 12:20PM BLOOD ALT-397* AST-376* AlkPhos-117 TotBili-9.9* ___ 03:48AM BLOOD ALT-386* AST-387* AlkPhos-123 TotBili-10.3* DirBili-6.3* IndBili-4.0 ___ 09:30PM BLOOD ALT-422* AST-520* AlkPhos-125 TotBili-11.1* DirBili-6.9* IndBili-4.2 ___ 01:45AM BLOOD ALT-100* AST-125* AlkPhos-256* TotBili-31.7* ___ 05:30AM BLOOD ALT-108* AST-142* AlkPhos-260* TotBili-30.2* Brief Hospital Course: ___ is a ___ year old male with Primary Biliary Cirrhosis, Hx of hemorrhagic pericarditis, +PPD s/p INH, esophageal candidiasis, and bipolar disorder who was hospitalized for elevated INR and treated for constipation, now pre-op for liver transplant. He had persistent bilirubinemia and MELD was 20 on ___. He underwent a deceased donor liver transplant (piggyback, portal vein to portal vein, celiac trunk to replaced right hepatic artery, common bile duct to common bile duct) on ___. The donor was CDC high-risk because of a positive CMV IgM titer with a history of a recent viral illness. Surgeon was Dr. ___ assisted by Dr. ___. Two ___ drains were placed. A lateral drain was placed to the bare area of the liver and the medial drain was behind the porta. During the operation his EBL was 2L, he received 4U PRBCs, 3 platelets, ___ FFP and 3L of IVF. He received induction immunosuppression (SoluMedrol 500mg x1, MMF 1000mg x1). He was transferred intubated to the SICU postop per protocol. He was subsequently extubated the same evening and remained stable. Postop liver duplex demonstrated normal arterial waveforms in the right, main, and left hepatic arteries, and patent portal and hepatic veins. Splenomegaly was unchanged. JP drain outputs were non-bilious. LFTs decreased each day. He was transferred out of the SICU on the following day and began a clear diet. By post-op day 3 his diet was advanced to regular diet and he begain PO pain medication. His medial JP drain was removed on post-op day 4, however, his lateral JP drain continued to have high output (1200cc). Output decreased to less than 500cc/day by postop day 7. JP drain was removed on ___ and site sutured. This remained dry. Incision was open to air and without redness or drainage. ___ cleared him for home. He was ambulating independently. Immunosuppression consisted of Cellcept, steroid taper, and tacrolimus dose-adjusted based on serum levels. He also received prophylaxis Bactrim ss, fluconazole and valgan 900 qD. Valcyte was increased to 900mg bid as donor was CMV positive . A CMV viral load was drawn on ___. ___ followed for hyperglycemia. However, he required minimal sliding scale insulin with glucoses ranging between low 100s and an occasional 170-190. He was provided with a glucometer and was able to do fingersticks. He will log his glucose results. He did well with medication teaching. On the day of discharge (___), Prograf level was 21. 2. He was instructed to hold pm dose ___ and am dose ___ then decrease to 4mg bid with next trough level on am ___ at ___ ___ lab. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Calcium Carbonate 500 mg PO TID 2. Clotrimazole 1 TROC PO QID 3. Fentanyl Patch 25 mcg/h TP Q72H HOLD for sedation, RR < 12 4. Gabapentin 300 mg PO TID 5. Lorazepam 0.5 mg PO Q6H:PRN anxiety 6. Omeprazole 40 mg PO BID 7. Ondansetron ___ mg PO Q8H:PRN nausea 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain HOLD for sedation, RR < 12 9. Ranitidine (Liquid) 150 mg PO BID 10. Sucralfate 2 gm PO BID 11. Ursodiol 300 mg PO QID 12. Senna 1 TAB PO BID 13. RISperidone 2 mg PO DAILY 14. Vitamin D 400 UNIT PO DAILY 15. Lactulose 30 mL PO DAILY 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID Hold if having loose bowel movements 2. Omeprazole 40 mg PO BID 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 hours Disp #*80 Tablet Refills:*0 4. RISperidone 2 mg PO DAILY 5. Vitamin D 400 UNIT PO DAILY 6. Fluconazole 400 mg PO Q24H 7. Mycophenolate Mofetil 1000 mg PO BID 8. PredniSONE 20 mg PO DAILY taper per schedule 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. ValGANCIclovir 900 mg PO BID Duration: 14 Days decrease to daily dosing after ___. Tacrolimus 0 mg PO Q12H Duration: 2 Doses HOLD ___ dose ___ and AM ___. Tacrolimus 4 mg PO Q12H start ___ ___. Gabapentin 300 mg PO BID for neuropathy Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: severe constipation coagulopathy secondary to vitamin K deficiency primary biliary cirrhosis orthotopic liver transplant ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ arranged. You will receive a call to arrange a home visit. Please call the transplant clinic at ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, or any other concerning symptoms. You will have labwork drawn every ___ and ___ at the ___ Lab (First Floor) with results to the transplant clinic. On the days you have your labs drawn, do not take your prograf until your labs are drawn. Bring your prograf with you so you may take your medication as soon as your labwork has been drawn. Please follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. The staples are removed approximately 3 weeks following your transplant. No tub baths or swimming No driving if taking narcotic pain medications Please avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen when you go outdoors. Please drink enough fluids to keep your urine light in color. Your appetite will return with time. Eat small frequent meals, and you may supplement with things like carnation instant breakfast or Ensure. Please check your blood sugars and blood pressure at home. Report consistently elevated values to the transplant clinic Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant Followup Instructions: ___

19992875-DS-21

DS

2160-12-29 00:00:00

2160-12-31 19:20:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo M with PBC s/p liver transplant on ___, c/b lower extremity DVT on ___, currently on coumadin p/w fever, chills and body ache. Patient c/o 3 days of cough, chills and myalgias. Cough is productive of a little sputum, no hemoptysis. He's had chills for the last 3 days, but yesterday recorded fever of 101 at home. He endorses headache and sinus congestion, no neck pain or stiffness. He also c/o sore throat, substernal and epigastric pain/burning that is similar to his past episodes of esophageal candidiasis. No shortness of breath. He denies dysuria, but endorses urinary frequency. He also notes loose stools for the last week, but attributes it to taking scheduled Senna and Colace. He notes some nausea, but no vomiting, no RUQ pain. Denies any increased abdominal girth, melena or bloody stools. He reports compliance with all his medications, no recent travel or sick contacts. He called his transplant coordinator for worsening malaise and fever, and she advised him to come to ___ for evaluation. In the ED intial vitals were: 98.1 140 130/74 22 98% Exam was significant for epigastric and RUQ tenderness. Patient was evaluated by Hepatology and Transplant teams who recommended thorough infectious work-ups. CXR with possible LLL and/or retrocardiac opacity. RUQ U/S with dopplers showed no signs of hemmorhage or abscess. CT Ab/Pelvis with contrast without any acute intrabdominal process. UA w/o pyuria and blood Cx pending. Patient was given 1g vanc, 2g cefe, 500mg azithro for possible HCAP. On the floor, patient c/o general malaise, but remains afebrile. Review of Systems: as per HPI, all other systems reviewed and were negative. Past Medical History: -Primary biliary cirrhosis now s/p orthotopic liver transplant (D+ R + CMV ) -Alcohol abuse (abstinent ___ years) -Hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ -Positive PPD (likely LTB, Tx with INH while incarcerated) -Hyperlipidemia -Osteoporosis -Bipolar disorder -ADHD -Hemorrhoids -s/p L leg surgery after MVC -s/p liver biopsy ___ -s/p liver transplant ___ Social History: ___ Family History: No family Hx of liver disease. Father: History of prostate and Head & neck cancer. Mother: ___ from brain aneurysm. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 97.6 116/85 103 20 100% on RA General- Alert, oriented, no acute distress HEENT- PERLL, Sclera anicteric, MMM, oropharynx clear, no sinus tenderness Neck- supple, JVP not elevated, no LAD, but mild submental TTP Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, mild TTP in epigastrum and RUQ, no rebound or guarding, non-distended, no ascites, bowel sounds present, well-healed scar GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: Vitals- 98.2, 84-93, 117-133/72-79, 99-100 on RA General- Alert, oriented, no acute distress HEENT- PERLL, Sclera anicteric, MMM, oropharynx clear w/o erythema or exudate, no sinus tenderness Neck- supple, JVP not elevated, no LAD, but mild submental TTP Lungs- Clear to auscultation bilaterally, no wheezes CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, nontender, no rebound or guarding, non-distended, no ascites, bowel sounds present, well-healed scar GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ========================= LABS ON ADMISSION: ========================= ========================= LABS ON DISCHARGE: ======================== Brief Hospital Course: Mr. ___ is a ___ gentleman w/ PBC s/p DCD liver transplant ___ c/b ___ DVT and candidal esophagitis admitted due to fever, malaise, and myalgias. # Fever - Symptoms included general malaise and myalgias with mild cough, sore throat, and resolving diarrhea. Exam was non-focal. Resp viral panel was negative. Urine legionella negative. CXR without clear consolidation. CT Ab/Pelvis without signs of abscess or other acute process. Blood cultures negative. CMV VL negative. Urine benign. Stool studies including c. difficile were negative. Symptoms most consistent with respiratory viral infection. Symptoms resolved without antibiotics or intervention. # Neutropenia - Neutropenic with ANC 500 on ___. Pt. has been neutropenic several times since transplant. Most likely cause is valgancyclovir, but may also be due to high doses of immunosuppresants. Given that CMV VL negative and pt. has completed full course of valgancyclovir, valgancyclovir was discontinued. # S/p Liver Transplant for Primary Biliary CIrrhosis - DCD, CMV ab (+) liver transplant ___. Post-transplant course complicated by lower extremity DVT ___ and candidal esophagitis ___. Pt. was continued on immunosuppressive therapy with tacro and Myfortic. He was continued on dapsone prophylaxis. Valgancyclovir discontinued as discussed above. # H/o latent TB - Pt. continued on isoniazid. Pyridoxine added. # DVT - Pt. on coumadin with subtherapeutic INR on admission. Increased coumadin as needed. # Bipolar disorder - Pt. continued on home risperidone. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dapsone 100 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Isoniazid ___ mg PO DAILY 4. Myfortic (mycophenolate sodium) 360 mg oral BID 5. Omeprazole 20 mg PO BID 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. RISperidone 3 mg PO DAILY 8. Tacrolimus 3 mg PO Q12H 9. ValGANCIclovir 900 mg PO Q24H 10. Warfarin 2 mg PO DAILY 11. Senna 1 TAB PO BID 12. Docusate Sodium 100 mg PO BID:PRN constipation Discharge Medications: 1. Dapsone 100 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Isoniazid ___ mg PO DAILY 4. Myfortic (mycophenolate sodium) 360 mg oral BID 5. Omeprazole 20 mg PO BID 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. RISperidone 3 mg PO DAILY 8. Tacrolimus 4 mg PO Q12H RX *tacrolimus 1 mg 4 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 9. Warfarin 3 mg PO DAILY16 RX *warfarin 1 mg 3 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Pyridoxine 50 mg PO DAILY RX *pyridoxine 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Docusate Sodium 100 mg PO BID:PRN constipation 12. Senna 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Presumed viral upper respiratory infection Secondary diagnosis: Status post liver transplant ___ 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 ___ due to fevers. You were initially given antibiotics, but after careful evaluation it was felt your infection was more likely a simple viral infection, and so you were taken off antibiotics. You did well off antibiotics. Your symptoms improved and you had no more fevers. We did notice that at the time of discharge you had a very low white blood cell count. This is likely due to the immunosuppresant medications you are taking to prevent rejection of your transplanted liver. Please avoid uncooked foods and large crowds where you may be exposed to sick individuals. It was a pleasure taking care of you. We wish you all the best. Sincerely, Your medicine team at ___ Followup Instructions: ___

19992875-DS-23

DS

2161-05-16 00:00:00

2161-05-17 07:42:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam Attending: ___ Chief Complaint: Fevers/Chills Major Surgical or Invasive Procedure: none History of Present Illness: ___ hx of PBC s/p liver transplant in ___ donor CMV+ c/b CMV infection and neutropenia (thought to be a result of CMV and immunosuppression after extensive workup). p/w fevers, chills, myalgias, cough in setting of neutropenia (ANC 386 at ___) so patient transferred here. Pt recently completed a course of Valcyte and INH/B6 for treatment of latent TB. Pt is currently on Neupogen 300mcg weekly for known Neutropenia. In the ED, initial vitals were 98.4 88 127/80 18 100%. CBC with pancytopenia, ___, ANC 618. Lytes and LFTs normal. INR 2.5. CXR appeared normal as did RUQ u/s. Patient given 2g Cefepime and admitted to the floor. On the floor, he reports that for 4-days, he has had fevers, chills, cough, runny nose, and watery eyes. Fever peaked at ___. No abdominal pain, chest pain, mouth sores. +occasional diarrhea. Has not had sick contacts. Did not receive the flu vaccine as it is a live virus. ROS: per HPI, denies headache, shortness of breath, chest pain, abdominal pain, nausea, vomiting, BRBPR, melena, dysuria. Past Medical History: -Primary biliary cirrhosis now s/p orthotopic liver transplant (D+ R + CMV ) -Neutropenia c/b neutropenic fever -DVT ___ -Alcohol abuse (abstinent ___ years) -Hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ -Positive PPD (likely LTB, Tx with INH while incarcerated) -Hyperlipidemia -Osteoporosis -Bipolar disorder -ADHD -Hemorrhoids -s/p L leg surgery after MVC -s/p liver biopsy ___ -s/p liver transplant ___ Social History: ___ Family History: Remarkable only for father with history of prostate and head and neck cancer and mother died of brain aneurysm. Physical Exam: ADMISSION: VS: 98.1, 119/70, 80, 20, 100RA General: Pleasant man, lying in bed, NAD HEENT: EOMI, sclera anicteric, MMM without any sores or facial tenderness Neck: No LAD CV: RRR no m/r/g Lungs: CTA b/l no w/r/r Abdomen: Large, well healed scar in URQ. NTND, +BS Ext: No edema Neuro: A and O x3 Discharge: VS:98.4 Tm98.6 67 (60s-100) 103/54 (100-120/50-70) 18 100% RA General: Pleasant thin man, lying in bed, pale, NAD HEENT: sclera anicteric, MMM, no oropharyngeal sores. CV: RRR no m/r/g Lungs: CTA b/l no w/r/r Abdomen: soft NTND large, well healed scar in RUQ. +BS Ext: WWP Neuro: AAO x3, Pertinent Results: ADMISSION: ============ ___ 08:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ ___ 08:30PM NEUTS-34* BANDS-1 ___ MONOS-16* EOS-5* BASOS-3* ___ MYELOS-0 NUC RBCS-1* ___ 08:30PM WBC-1.8* RBC-3.64* HGB-10.5* HCT-31.5* MCV-86 MCH-29.0 MCHC-33.5 RDW-16.0* ___ 08:30PM ALBUMIN-4.3 CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-1.8 ___ 08:30PM LIPASE-20 ___ 08:30PM ALT(SGPT)-18 AST(SGOT)-25 ALK PHOS-91 TOT BILI-0.8 ___ 08:30PM GLUCOSE-116* UREA N-10 CREAT-0.8 SODIUM-133 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12 ___ 08:40PM LACTATE-1.1 ___ 09:30PM ___ PTT-42.6* ___ DISCHARGE: ============= ___ 05:00AM BLOOD WBC-6.7 RBC-3.46* Hgb-10.4* Hct-31.2* MCV-90 MCH-29.9 MCHC-33.3 RDW-16.7* Plt ___ ___ 05:00AM BLOOD Neuts-70 Bands-0 Lymphs-15* Monos-8 Eos-2 Baso-1 ___ Myelos-2* NRBC-2* Other-2* ___ 05:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-3+ Target-OCCASIONAL Ellipto-OCCASIONAL ___ 05:15PM BLOOD ___ 07:20AM BLOOD ___ ___ ___ 05:20AM BLOOD Ret Man-4.4* ___ 05:00AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-138 K-4.0 Cl-103 HCO3-26 AnGap-13 ___ 05:00AM BLOOD ALT-18 AST-33 AlkPhos-107 TotBili-0.7 PERTINENT LABS/MICRO: ======================= CMV Viral Load (Final ___: CMV DNA not detected. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). IMAGING: ============= CXR ___ PA and lateral views of the chest were provided demonstrating no focal consolidation, effusion or pneumothorax. The cardiomediastinal silhouette appears normal. Subtle opacities projecting over the lower lungs are most compatible with subsegmental atelectasis. No effusion or pneumothorax is seen. Biapical pleural parenchymal scarring is noted. RUQ doppler ___ Color Doppler sonogram with spectral analysis of the hepatic vasculature was performed. The main portal vein is patent with normal hepatopetal flow. The left portal, right anterior and right posterior portal veins are patent with normal forward flow. The left, middle and right hepatic veins are patent with normal waveforms. The main hepatic artery has brisk systolic upstroke and forward flow in diastole with RI 0.82, previously 0.63. The right and left hepatic arteries have brisk systolic upstroke with forward flow in diastole with RIs 0.68 and 0.70, respectively, previously 0.62 and 0.56, respectively. The IVC has normal color flow and normal waveform. Brief Hospital Course: ___ yo M with PBC s/p liver transplant on ___, c/b neutropenia and CMV viremia p/w neutropenic fever #) Neutropenic Fever: Patient presented with neutropenic fever with an ANC of 618 that downtrended to a nadir of 60. His viral swab and and blod/urine cultures were negative. His CMV viral load was undetectable and his Valgancyclovir was stopped. He was seen by Heme/onc who performed a bone marrow biopsy. His Neutropenia is thought most likely due to combination of CMV and immunosuppressive effect of medications. He was started on daily neupogen and his ANC trended up. His cefepime and daposone were stopped. ANC on discharge was 4690. He was discharged with once weekly neupogen #) S/p liver transplant ___ PBC: Patient had a transplant in ___. He was continued on tacrolimus with levels checked. He was continued on dapsone for prophylaxis which was then stopped when his ANC improved. #) History of DVT: Chronic. Coumadin was stopped as patient had DVT in post-surgical setting and was maintained on coumadin for >6 months. #) CMV viremia: Viral load was undetectable and his valgancyclovir was stopped. #) Mood disorder: Continued Risperidone 3mg qhs #CODE: Full Name of health care proxy: ___ Relationship: father Phone number: ___ Cell phone: ___ **Transitional Issues** -continue to monitor tacrolimus level -trend ___ and consider further workup of neutropenia if does not improve Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dapsone 100 mg PO DAILY 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Gabapentin 300 mg PO BID 4. Omeprazole 20 mg PO BID 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. RISperidone 3 mg PO HS 7. Tacrolimus 1 mg PO Q12H 8. Warfarin 3 mg PO DAILY16 9. ValGANCIclovir 900 mg PO Q12H 10. Neupogen (filgrastim) 300 mcg/0.5 mL injection 1x/week Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Gabapentin 300 mg PO BID 3. Omeprazole 20 mg PO BID 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Tacrolimus 1 mg PO Q12H 6. Neupogen (filgrastim) 300 mcg/0.5 mL injection 1x/week 7. RISperidone 3 mg PO HS 8. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Neutropenic fever s/p liver transplant h/o CMV viremia Secondary: H/O DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a pleasure taking care of you during your admission. You came to the hospital because you had fever, chills, and malaise. You were found to be neutropenic (low white count). We started you on antibiotics to cover you for an infection. You had several cultures and tests looking for an infection and we did not find a cause of your fever. Your CMV viral load was undetectable and your valcyte was stopped. You had a bone marrow biopsy that is not back yet. You were given a medication to help bring up your white counts and they improved. We stopped your antibiotics including your dapsone. Your warfarin was stopped as you no longer need it to prevent blood clots. Please follow up with your appointments below and continue to get your blood draws as previously scheduled. Please look at your medication list as we have stopped several of your medications including: valcyte, warfarin, and dapsone. Followup Instructions: ___

19992875-DS-30

DS

2162-09-18 00:00:00

2162-09-18 16:32:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam Attending: ___. Chief Complaint: 1 week malaise, diarrhea, on routine lab draw found to have transaminitis Major Surgical or Invasive Procedure: Transjugular liver biopsy Colonoscopy x2 (poor prep the first time) Magnetic resonance cholangiopancreatography History of Present Illness: ___ yo M w/ h/o PBC s/p liver tx ___ from ___+ donor and history of acute rejection ___ sent to the ED after being noted to have elevated transaminases with concern for rejection. Patient presented for routine lab draw and was noted to have new transaminitis, and then over the phone with transplant nurse, he admitted to a week long history of fatigue and two days of malaise with tremors. Pt. also reported abdominal pain, nausea, and loose, black stools, though negative guaiac test in clinic. He denied any fevers or sweats. He has been taking his medications as directed with the assistance of his father. Normal appetite. Labs drawn revealed elevated LFTs (ALT 55, AST 41, AP 171), elevated tacrolimus (7.4 with goal ___, and stable H/H (14.1/40.2). Of note, pt's post-transplant course has been complicated by mild acute cellular rejection in ___ ___s a hemorrhagic pericarditis with recurrent pericarditis. He has also had leukopenia and diarrhea while on CellCept and is currently maintained on tacrolimus and prednisone for his immune suppression. He has also had post-transplant CKD with baseline creatinine of 1.2-1.6. In the ED on ___, initial vitals were 97.7 82 128/93 16 100%. - On labs the following day, pt. was noted to have tacro level 5.5 (after decrease in dose to 1mg BID). - RUQ US with patent hepatic vasculature, CXR w/o acute intrathoracic process. - Pt. received home medications, with tacro dose decreased to 1mg BID, and oxycodone for pain. VS prior to transfer 98.1 64 118/65 18 99% RA. On arrival to the floor, pt. reports feeling well. He has some mild abdominal pain but reports that it is well controlled. Past Medical History: -Primary biliary cirrhosis now s/p orthotopic liver transplant (D+ R + CMV ) -Neutropenia c/b neutropenic fever -DVT ___ -Alcohol abuse (abstinent ___ years) -Hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ -Positive PPD (likely LTB, Tx with INH while incarcerated) -Hyperlipidemia -Osteoporosis -Bipolar disorder -ADHD -Hemorrhoids -s/p L leg surgery after MVC -s/p liver transplant ___ Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION: VS: 97.7, 51, 117/85, 20, 100 on RA GEN: A and O x3; well appearing, comfortable, in no acute distress. HEENT: Eyes are anicteric without conjunctival injection. Oropharynx is clear. Moist mucous membranes. NECK: supple without lymphadenopathy, thyromegaly or thyroid nodules. LUNGS: Clear to auscultation bilaterally. CV: Heart has normal S1, S2. There is no pericardial friction rub heard. ABDOMEN: soft, nontender, nondistended. There is no significant hepatosplenomegaly. EXT: WWP. No lower extremity edema. DISCHARGE: VS: 97.7,110s/70s, 70s, 18, 99 RA GEN: A&O x3; lying in bed, no acute distress HEENT: Eyes are anicteric without conjunctival injection. Oropharynx is clear. Moist mucous membranes. NECK: supple without lymphadenopathy, thyromegaly or thyroid nodules. LUNGS: Clear to auscultation bilaterally. CV: Heart has normal S1, S2. No pericardial friction rub heard. ABDOMEN: soft, mildly tender in epigastric region. No significant hepatosplenomegaly. EXT: WWP. No lower extremity edema. NEURO: A&Ox3, CNII-XII grossly intact, no flapping Pertinent Results: ADMISSION: ___ 12:15AM BLOOD WBC-4.0 RBC-4.67 Hgb-14.1 Hct-40.2 MCV-86 MCH-30.2 MCHC-35.1 RDW-15.0 RDWSD-46.9* Plt Ct-93* ___ 12:15AM BLOOD Neuts-50.8 ___ Monos-9.3 Eos-1.5 Baso-1.8* Im ___ AbsNeut-2.02 AbsLymp-1.42 AbsMono-0.37 AbsEos-0.06 AbsBaso-0.07 ___ 12:15AM BLOOD ___ PTT-28.4 ___ ___ 12:15AM BLOOD Plt Ct-93* ___ 12:15AM BLOOD Glucose-108* UreaN-11 Creat-1.3* Na-140 K-3.8 Cl-107 HCO3-20* AnGap-17 ___ 12:15AM BLOOD ALT-55* AST-41* AlkPhos-171* TotBili-0.4 ___ 12:15AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.8 Mg-1.8 ___ 09:15AM BLOOD tacroFK-5.5 ___ 12:22AM BLOOD Lactate-1.0 Studies: ___ RUQ U/S: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. There is no ascites, right pleural effusion or sub- or ___ fluid collections/hematomas. Patent hepatic vasculature with appropriate waveforms. ___ CXR: No acute cardiopulmonary process. ___ MRCP 1. Status post orthotopic liver transplant with mild intrahepatic biliary ductal dilatation and a transition point identified between the native and transplant bile ducts. It is unclear whether these findings are chronic in nature or could reflect a stricture at the surgical anastomosis. 2. Transplanted liver parenchyma is normal with no focal mass, abscess or biliary collection. 3. Splenomegaly. 4. Persistent increased opacity in the left lower lobe, as seen on CT examination from ___. RECOMMENDATION(S): Consider ERCP for direct assessment of biliary anastomotic caliber if there is clinical suspicion for biliary stricture. ___ transjugular liver biopsy path results: Poor sample; unclear if findings reflect overall picture. No bile ductular proliferation, cholestasis or lymphocytic damage in this biopsy, but some rare neutrophils in portal tracts. No fatty change or viral inclusions. DISCHARGE ___ 04:25AM BLOOD WBC-2.8* RBC-4.18* Hgb-12.5* Hct-36.6* MCV-88 MCH-29.9 MCHC-34.2 RDW-14.9 RDWSD-47.4* Plt Ct-66* ___ 04:25AM BLOOD Plt Ct-66* ___ 04:25AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-140 K-3.6 Cl-105 HCO3-22 AnGap-17 ___ 04:25AM BLOOD ALT-85* AST-72* AlkPhos-144* TotBili-0.4 ___ 04:25AM BLOOD Albumin-3.9 Calcium-9.3 Phos-2.9 Mg-1.6 ___ 04:25AM BLOOD tacroFK-6.7 Brief Hospital Course: Mr. ___ is a ___ y/o gentleman w/ hx hemorrhagic pericarditis s/p pericardial window, PBC s/p liver transplant from CMV+ donor in ___ c/b mild acute rejection ___ and CMV viremia who p/w 1 month intermittent diarrhea and 1 week of abdominal pain and malaise, admitted with new transaminitis and elevated (to 7.4) tacro level. Tacro level was decreased to 1 mg BID, prednisone continued at 5 mg daily. Liver biopsy was poor sample but did not show rejection. Colonoscopy was grossly normal but biopsy results pending. CMV VL < 137, started on valganciclovir 900 mg daily with plan to continue until colonoscopy biopsy results return. MRCP on ___ showed evidence of biliary stricture at site of anastomosis; will be arranged for ERCP as outpatient. # Transaminitis: MRCP showing concern for biliary stricture at anastomosis site - likely etiology. Differential for new transaminitis also includes cellular rejection (liver biopsy ___, path results do not show rejection but poor quality sample), infection (CMV VL <137 but colonoscopy biopsy results pending at time of discharge), or med toxicity (though no significant new meds.) RUQ U/S reassuring with patent hepatic vasculature. Discharging on valgancyclovir 900 mg po qd - can discontinue if pathology results negative. CMV VL level will need to be drawn again on ___. Continued prednisone 5 mg daily and decreased tacro from 1.5 mg BID to 1 mg BID given high levels (___.) # Biliary stricture - mild intrahepatic biliary ductal dilatation and transition point at anastamosis site noted on MRCP on ___. Will follow up with ERCP as outpatient with scheduling arranged by liver transplant team. Will hold aspirin 5 day prior to procedure and a few days after procedure (discussed with cardiologist Dr. ___ and use tramadol for pericarditis pain during that period. # Hx PBC s/p transplant - on tacro and prednisone. Continued prednisone 5 mg daily and decreased tacro from 1.5 mg BID to 1 mg BID given high levels (___.) CHRONIC: # Chronic pericarditis: Recurrent chest pain, full cardiac workup negative, has been on aspirin high-dose three times a day, previously 650 mg three times a day, recently increased to 975 mg three times daily the past week and colchicine 0.6 mg twice a day. - continued home aspirin and colchicine # GERD - continued home omeprazole and ranitidine # Osteoporosis - continued home calcium and vitamin D # COPD (stable, mild) - continued home salmeterol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 500 mg PO DAILY 2. Docusate Sodium 200 mg PO BID:PRN constipation 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 600 mg PO BID 5. Omeprazole 40 mg PO BID 6. PredniSONE 5 mg PO DAILY 7. Ranitidine 75 mg PO HS:PRN heartburn 8. Aspirin 975 mg PO Q8H 9. Prochlorperazine 10 mg PO BID:PRN nausea/vomiting 10. Tacrolimus 1.5 mg PO Q12H 11. Colchicine 0.6 mg PO BID 12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 13. Vitamin D 800 UNIT PO DAILY 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 15. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 2. Calcium Carbonate 500 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Gabapentin 600 mg PO BID 6. Omeprazole 40 mg PO BID 7. PredniSONE 5 mg PO DAILY 8. Ranitidine 75 mg PO HS:PRN heartburn 9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 10. Vitamin D 800 UNIT PO DAILY 11. Docusate Sodium 200 mg PO BID:PRN constipation 12. Aspirin 975 mg PO Q8H 13. Tacrolimus 1 mg PO Q12H RX *tacrolimus 0.5 mg 2 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*11 14. ValGANCIclovir 900 mg PO Q24H RX *valganciclovir 450 mg 2 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 15. Ferrous Sulfate 325 mg PO DAILY 16. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain Duration: 10 Days RX *tramadol 50 mg 1 tablet(s) by mouth q8h prn Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Transaminitis Biliary stricture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you had symptoms of diarrhea, abdominal pain and fatigue with elevated liver function test levels. We were initially concerned about a liver transplant rejection, an infection, or a problem with your biliary system. We did several tests to evaluate for these possibilities. Your liver biopsy did not show rejection. Your tests for infection were negative. You test for CMV showed a very low level of virus in the blood; we started treatment but will only continue it if your biopsy results show evidence of CMV disease. Your colonoscopy results are still pending. You also had an MRCP (magnetic resonance cholangiopancreatography) to evaluate for biliary problems. This showed changes in your biliary ducts that could explain your lab abnormalities and symptoms, we would like to evaluate it further with an ERCP (endoscopic retrograde cholangiopancreatography), a procedure that involves putting a flexible tube in the upper part of your GI tract. This procedure will be done as an outpatient, and it will be arranged for you by the liver team. You will be contacted with the details. We continued your home immunosuppressants tacrolimus and prednisone and are discharging you on your home medications though we decreased the tacro level to 1 mg BID because your level was high. In preparation for the ERCP, you will be asked to stop taking your aspirin for 5 days prior to the procedure and a few days after the procedure, but until you hear the date of the ERCP from the liver team, you can continue to take your home aspirin dose. During the period that you are not taking your aspirin, you can take tramadol instead for pain. We are giving you a prescription for tramadol but please do not take it until you stop taking your aspirin for the procedure. It was a pleasure taking care of you. Sincerely, Your ___ liver team Followup Instructions: ___

19992875-DS-32

DS

2162-11-15 00:00:00

2162-11-19 21:36:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ M w/ hx of PBC (s/p liver transplant), prior DVT (on lovenox), bipolar disorder, hyeperlipidemia and hemorrhagic pericarditis (in ___, s/p pericardial window iso tamponade), who presents with chest pain. Chest pain started suddenly, at rest; pain is constant, worse when sitting up and better when lying down. He denies dyspnea. Pain feels similar to his prior episodes that were provisionally identified as recurrent pericarditis. No new medications started except for Abilify (last week). He denies any preceding fever, but does endorse some chills. No nausea/vomiting/diarrhea. All other ROS negative. Past Medical History: -Primary biliary cirrhosis now s/p orthotopic liver transplant (D+ R + CMV ) -Neutropenia c/b neutropenic fever -DVT ___ -Alcohol abuse (abstinent ___ years) -Hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ -Positive PPD (likely LTB, Tx with INH while incarcerated) -Hyperlipidemia -Osteoporosis -Bipolar disorder -ADHD -Hemorrhoids -s/p L leg surgery after MVC -s/p liver transplant ___ Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.0 degrees Fahrenheit, BP: 133/96 mmHg, HR 63 bpm, RR 16 bpm, O2: 99 % on RA. Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD. Normal carotid upstroke without bruits. No thyromegaly. CV: PMI in ___ intercostal space, mid clavicular line. RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by palpation. EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN ___ grossly intact. PSYCH: Mood and affect were appropriate. DISCHARGE PHYSICAL EXAM: VS: T 97.6-98.2 HR ___ BP ___ RR 18 SpO2 96-99% RA General: Well-appearing in NAD HEENT: Sclera anicteric, conjunctivae noninjected. MMM, no OP lesions CV: RRR, no m,r,g. No tenderness to palpation of chest wall. Lungs: LCTAB. No wheezing, crackles, or rhonchi. Abdomen: Soft, nondistended, tender to palpation in LUQ. No guarding or rebound. Ext: Warm, well-perfused. No ___ edema Neuro: A&O x3. No asterixis. Moving all extremities with purpose, no facial asymmetry. Skin: No overt jaundice. Pertinent Results: ADMISSION LABS ___ 02:42AM BLOOD WBC-2.5* RBC-4.63 Hgb-13.8 Hct-40.5 MCV-88 MCH-29.8 MCHC-34.1 RDW-14.5 RDWSD-46.1 Plt Ct-66* ___ 02:42AM BLOOD Neuts-33.9* ___ Monos-9.9 Eos-2.0 Baso-1.6* Im ___ AbsNeut-0.86* AbsLymp-1.32 AbsMono-0.25 AbsEos-0.05 AbsBaso-0.04 ___ 02:42AM BLOOD Glucose-77 UreaN-13 Creat-1.2 Na-139 K-3.8 Cl-106 HCO3-24 AnGap-13 ___ 02:42AM BLOOD Albumin-4.3 ___ 04:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0 ___ 02:42AM BLOOD ALT-51* AST-38 AlkPhos-82 TotBili-0.3 ___ 02:42AM BLOOD Lipase-23 ___ 09:45AM BLOOD cTropnT-<0.01 ___ 02:42AM BLOOD cTropnT-<0.01 ___ 02:42AM BLOOD tacroFK-4.2* DISCHARGE LABS ___ 05:09AM BLOOD WBC-2.3* RBC-4.43* Hgb-13.3* Hct-39.0* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.6 RDWSD-46.6* Plt Ct-64* ___ 05:09AM BLOOD ___ PTT-57.6* ___ ___ 05:09AM BLOOD Glucose-86 UreaN-10 Creat-1.1 Na-141 K-3.9 Cl-107 HCO3-23 AnGap-15 ___ 05:09AM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.2 Mg-1.9 ___ 05:09AM BLOOD ALT-42* AST-28 LD(LDH)-182 AlkPhos-77 TotBili-0.3 ___ 05:09AM BLOOD tacroFK-4.9* IMAGING Chest X ray ___: FINDINGS: Normal heart size, mediastinal and hilar contours. No focal consolidation, pleural effusion or pneumothorax. Multiple healed right-sided rib fractures are noted which appear new from ___. IMPRESSION: No acute process. Multiple healing right-sided rib fractures. TTE ___: FOCUSED STUDY/LIMITED VIEWS: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the comparable findings are similar. MICROBIOLOGY URINE CULTURE (Final ___: NO GROWTH. 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: ___ is a ___ year old man with h/o primary biliary cirrhosis s/p orthotopic liver transplant from CMV+ donor ___ complicated by mild cellular rejection and bile duct obstruction s/p ERCP ___ who also has a history of idiopathic, hemorrhagic pericarditis/pericardial effusion s/p pericardial window who presented with recurrent chest pain. # Chest pain. His pain was consistent with episodes of pain described in the past. He was on treatment for pericarditis with high dose aspirin (975 mg TID) and colchicine. He was also on prednisone 5 mg daily for his transplant. On presentation, he had negative troponins x2 and an EKG nonconcerning for ACS. Cardiology was consulted in the ED and thought his pain was likely to be noncardiac but recommended a TTE which showed no pericardial effusion and no WMA. He did have a chest X ray showing multiple healed right-sided rib fractures that appeared to be new from ___ but the patient denied any recent trauma and stated he had sustained these fractures many years ago (most from mixed martial arts). Concerning causes of chest pain were ruled out and his pain resolved within a few days of presentation. # Abdominal pain, nausea, diarrhea. Mr. ___ reports a long history of alternating diarrhea and constipation. He complained of diffuse, generally left-sided abdominal pain on admission as well as diarrhea. On the following day, he was complaining of constipation. His liver enzymes were at baseline during the hospitalization. He had a terminal ileum and colon biopsy done ___ showing no abnormalities. Urine culture negative. # Difficulty urinating. On admission, Mr. ___ reported difficulty initiating urination although denied incomplete voiding or dysuria. UA unremarkable and urine culture negative. Symptoms resolved with IV hydration. # History of Liver Transplant secondary to PBC. Transplanted ___. LFTs at baseline. Not concerned for rejection at this time. He was continued on immunosuppression with tacrolimus and prednisone. Chronic issues: # GERD. He was continued on home ranitidine and omeprazole. # Peripheral neuropathy. He was continued on home gabapentin and tramadol. # Iron deficiency anemia. Hgb was above recent baseline. He was continued on iron supplementation. Transitional issues: #CODE STATUS: Full # Patient describes a history of diarrhea and constipation alternating. ___ warrant outpatient evaluation for irritable bowel syndrome. # Patient reported being out of tramadol written by PCP, ___. ___ was written for enough to treat his pain through the weekend until his appointment on ___. # Please follow up CMV viral load Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Calcium Carbonate 500 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Tacrolimus 1 mg PO Q12H 6. Ferrous Sulfate 325 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 600 mg PO BID 9. Omeprazole 40 mg PO BID 10. PredniSONE 5 mg PO DAILY 11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 12. Ranitidine 150 mg PO QHS 13. Vitamin D 800 UNIT PO DAILY 14. TraMADOL (Ultram) 50 mg PO TID:PRN pain 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Aspirin EC 975 mg PO TID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Calcium Carbonate 500 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Ferrous Sulfate 325 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 600 mg PO BID 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. PredniSONE 5 mg PO DAILY 11. Ranitidine 150 mg PO QHS 12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 13. Tacrolimus 1 mg PO Q12H RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 14. TraMADOL (Ultram) 50 mg PO TID:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp #*10 Tablet Refills:*0 15. Vitamin D 800 UNIT PO DAILY 16. Aspirin EC 975 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Chest pain Secondary diagnosis: liver transplant recipient Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care while you were hospitalized at the ___. You were in the hospital because of chest pain. There was no evidence by our test results that you were having a heart attack and your heart looked normal on imaging with no evidence of an effusion. We do not know what is causing your chest pain but are reassured that it is unlikely to be a heart problem. You should continue to take the aspirin and colchicine that you have been taking. Again, it was a pleasure taking care of you. We wish you all the best in the future. Sincerely, Your ___ team Followup Instructions: ___

19992875-DS-34

DS

2163-04-03 00:00:00

2163-04-03 17:04:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone Attending: ___. Chief Complaint: Bright red blood per rectum with abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ gentleman with a history of PBC s/p OLT in ___ and recent admission for BRBPR/abdominal pain found to have an anal skin tag/condyloma on sigmoidoscopy now s/p excision on ___ who presents with one episode of BRBPR. He has not had any recent bleeding. This episode occurred this afternoon and was approximately one cup of bright red blood per rectum not mixed with stool. He then developed lower abdominal cramping. No further BMs or bleeding subsequently. Mild nausea but no vomiting, no fevers. He was seen at ___ and was referred here for further work up as patient is liver transplant recipient. He is followed by Dr. ___ saw him today in clinic for follow up of chest pain. This is thought to be due to chondrochondritis. He is on tramadol, high dose aspirin, and colchicine for this. In the ED, initial vitals were: T 96.6, HR 72, BP 133/88, RR 18, SaO2 100% RA. - Labs were notable for: WBC 3.1 (stable), H/H 13.9/40.8, plts 84 (stable), Cr 1.3 (stable); RUQ with Dopplers showed normal transplanted liver, splenomegaly. - Rectal exam notable for intact suture, no masses or hemorrhoids, dark stool guaiac positive - Patient was given: tacrolimus 1 mg, morphine 4 mg, and Zofran. - Consults: Transplant surgery, who recommended inpatient colorectal surgery consult; GI, who recommended hepatology consult On the floor, patient continued to report mild lower abdominal pain and chest pain. No nausea currently. He does have an appetite but has not eaten today. Review of systems: (+) Per HPI. Chronic chills, chronic shortness of breath. (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, cough, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 97.3, HR 57, BP 114/81, RR 18, 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, severe pain to palpation of right costochondral junctions Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Scar present, soft, bowel sounds present, nondistended, tender to palpation diffusely though no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Rectal: skin tag removal site intact without bleeding or signs of infection, external hemorrhoids appreciated, old blood in rectal vault without masses. DISCHARGE PHYSICAL EXAM: Vitals: T 97.5/97.4, 105-117/59-70, HR 62-80, RR 18, O2 Sat >97% RA General: Well-appearing, NAD. HEENT: MMM, PERRL, EOMI w/o nystagmus. Lungs: CTAB CV: RRR, normal S1 and S2 appreciated. No murmurs, rubs, gallops. Abdomen: Soft, non-distended, mild tenderness to deep palpation of the bilateral LLQ and suprapubic region. Normal bowel sounds. Ext: Warm, well-perfused. No edema. Bilateral pulses +2 Pertinent Results: ADMISSION LABS: ___ 08:25PM BLOOD WBC-3.1* RBC-4.66 Hgb-13.9 Hct-40.8 MCV-88 MCH-29.8 MCHC-34.1 RDW-14.7 RDWSD-46.9* Plt Ct-84* ___ 08:25PM BLOOD Neuts-48.9 ___ Monos-9.7 Eos-3.9 Baso-1.9* Im ___ AbsNeut-1.51* AbsLymp-1.09* AbsMono-0.30 AbsEos-0.12 AbsBaso-0.06 ___ 08:00AM BLOOD ___ PTT-28.9 ___ ___ 08:25PM BLOOD Glucose-91 UreaN-19 Creat-1.3* Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 ___ 08:00AM BLOOD ALT-37 AST-33 LD(LDH)-189 AlkPhos-77 TotBili-0.5 ___ 08:00AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.8 Mg-1.8 ___ 08:00AM BLOOD tacroFK-6.0 IMAGING / STUDIES: RUQ US ___ IMPRESSION: 1. Unremarkable liver transplant with patent hepatic vasculature and normal waveforms. 2. Splenomegaly. GU Ultrasound ___ FINDINGS: The right kidney measures 9.3 cm and contains a simple appearing 1.1 cm lower pole cyst. The left kidney measures 9.7 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is normal in appearance. Postvoid images of the bladder were not obtained secondary to the patient's inability to void. Calculated prostate volume is 22 cc. IMPRESSION: Normal appearance of the bilateral kidneys. DISCHARGE LABS: ___ 08:00AM BLOOD WBC-1.9* RBC-4.43* Hgb-13.3* Hct-40.0 MCV-90 MCH-30.0 MCHC-33.3 RDW-14.6 RDWSD-48.4* Plt Ct-64* ___ 08:00AM BLOOD ___ PTT-27.9 ___ ___ 08:00AM BLOOD Glucose-102* UreaN-20 Creat-1.0 Na-142 K-3.6 Cl-109* HCO3-24 AnGap-13 ___ 08:00AM BLOOD ALT-37 AST-29 AlkPhos-82 TotBili-0.4 ___ 08:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7 ___ 08:00AM BLOOD tacroFK-6.0 Brief Hospital Course: Mr. ___ is a ___ gentleman with a history of PBC s/p OLT in ___ and recent admission for BRBPR/abdominal pain found to have an anal skin tag/condyloma on sigmoidoscopy now s/p excision on ___ who presents with one episode of BRBPR. # BRBPR: Patient with single episode of BRBPR, possibly related to recent excision of anal skin tag/condyloma. Examination of the area showed intact excision site without active bleed. He also had associated lower abdominal pain of unclear etiology. No recent fevers or diarrhea to suggest infectious or inflammatory etiology. After his anal tag excision he reports regular soft stools without straining. H&H on admission at baseline. Potentially diverticular bleed vs. vascular malformation. Rectal exam with old blood in rectal vault without active bleeding or mass. He did not have any further bleeding during admission and his lower abdominal pain was controlled with home tramadol Q6H. Recommend outpatient colonoscopy and continued Metamucil use. His high dose ASA was stopped in the setting of recurrent GI bleeds. # Abdominal pain: Continued despite resolution of BRBPR. Patient with similar presentation in ___ with work-up (CT A/P, stool studies) unrevealing aside from sigmoidoscopy showing rectal erythema and perianal skin tag/condyloma. RUQ ultrasound with Dopplers in the ED was normal. Patient complained of urinary hesitancy on ROS but was voiding without difficulty. GU ultrasound showed normal kidneys bilaterally and bladder with normal prostate mass of 22cc. Post-void bladder was not visualized as patient did not void. Low suspicion for bladder obstruction as cause of supra-pubic pain. He was instructed to seek urology referral should his urinary symptoms persist or worsen. # Acute kidney injury: Patient noted to have mild ___ on admission labs. Likely from hypovolemia in the setting of high dose NSAIDs. Serum Cr normalized to 1.1 on discharge; no evidence of renal pathology on GU U/S (___). He was discharged off aspirin as above. # PBC s/p liver transplant in ___ from CMV+ donor, cellular rejection in ___ ___s a hemorrhagic pericardial effusion with recurrent pericarditis: RUQ ultrasound with Dopplers in the ED was normal. LFTs normal. Continued home tacrolimus 1 mg PO Q12H. Tacro level 6.0 on admission. Continued prednisone 5 mg daily. # Costochondritis: Followed by Dr. ___ in cardiology. On high dose ASA, prednisone, and tramadol, recently increased from TID to QID. Pain is at baseline on admission. His high dose ASA was held and tramadol continued. He was discharged off of aspirin as above. # Pericarditis: Followed by Dr. ___ in cardiology. On high dose ASA and colchicine. Pain at baseline on admission and his colchicine was continued but ASA stopped as above. # Thrombocytopenia: Patient presented with chronic low platelet count around baseline. Chronic thrombocytopenia likely due to liver disease and immunosuppression. His platelets were monitored without acute event. Of note high dose ASA in setting of thrombocytopenia likely contributing to recurrent GIB. # Bipolar disorder: Continued home ARIPiprazole # COPD: Continued home albuterol, salmeterol. # GERD: Continued home omeprazole 40mg BID, ranitidine 150mg qHS # Chronic Neuropathic Pain: Continued Gabapentin 600mg BID TRANSITIONAL ISSUES: - Patient discharged off of aspirin given GIB. Please address restating or alternative therapy at next cardiology appointment. - Recommend outpatient colonoscopy for evaluation of likely distal GIB. Follow up scheduled with GI. - Patient continued on tramadol QID for pain control. - Recommend urology follow up for lower urinary tract symptoms if persistent. - H&H stable throughout admission. Please re-check at GI follow up appointment if continued GI bleeding. - Patient continued on tacrolimus during admission with random level of 6.0. LFTs normal. CODE: Full (confirmed) CONTACT: ___ (father) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Calcium Carbonate 500 mg PO DAILY 4. Colchicine 0.6 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Gabapentin 600 mg PO BID 7. HydrOXYzine 25 mg PO QHS:PRN insomnia 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Ranitidine 150 mg PO QHS 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 12. Vitamin D 800 UNIT PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 15. Tacrolimus 1 mg PO Q12H 16. Aspirin 975 mg PO TID 17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram oral DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Gabapentin 600 mg PO BID 6. HydrOXYzine 25 mg PO QHS:PRN insomnia 7. Omeprazole 40 mg PO BID 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO QHS 11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 12. Tacrolimus 1 mg PO Q12H 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 14. Vitamin D 800 UNIT PO DAILY 15. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram oral DAILY 16. Calcium Carbonate 500 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Gastrointestinal Bleed Abdominal Pain SECONDARY: H/O Primary biliary cirrhosis s/p liver transplant Urinary hesitancy Chronic pericarditis Costochondritis Bipolar disorder COPD GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care here at ___ ___. You were admitted with rectal bleeding and abdominal pain. We checked you blood counts and everything was stable. Your recent skin tag removal site looked good and was not actively bleeding. You did not have another episode of bleeding and recovered without incident. An ultrasound of your liver was normal and you were kept on your home tramadol for pain. You also were noted to have some difficulty initiating urination. You had an ultrasound done of your kidneys and bladder which was also normal. You prostate on ultrasound was a normal size. If you continue to have urinary symptoms please see your PCP about referral to urology. ___ clinic number: ___. You were discharged with the follow up appointments scheduled below,. Please make sure to attend these appointments because you will likely need a colonoscopy aks an outpatient. If you have another single episode of bleeding please call your gastroenterologist. Please continue taking your medications as prescribed but stop taking your aspirin until you see your cardiologist. You can continue taking your tramadol every 6 hours as needed. Thank you for choosing ___ for your healthcare needs. Sincerely, Your ___ Team Followup Instructions: ___

19992875-DS-36

DS

2163-11-13 00:00:00

2163-11-17 11:44:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___ Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M w/ PMH PBC s/p liver transplant ___, pericarditis, bipolar disorder, COPD, with recent admission at ___ for diarrhea who re-presents with ongoing diarrhea and muscle aches. He reports that he is having watery diarrhea ___ per day. He has aches all over his body and feels weak. He also endorses tinnitus. He says this feels similar to when he had CMV infection in the past. He did not hear the results of his colonoscopy yet. Of note, his colonoscopy biopsies showed active colitis throughout the colon. CMV testing was pending. In the ED, initial vitals were: T97.0 HR67 BP115/96 RR18 O2Sat100% RA. Labs notable for WBC 2.9, ANC 1260, Plt 93, Cr 1.1, HCO3 21. Patient was given 4 mg IV morphine and 4 mg Zofran. Decision was made to admit for continued diarrhea. Vitals prior to transfer: T98.4 HR50 BP112/82 RR16 O2Sat100% RA. On the floor, he reported that he had ongoing abdominal pain, nausea, and body aches. He reports that he has not started any new medications except for 1 dose of Adderall last week. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ================ ADMISSION EXAM: ================ Vital Signs: 97.6 115/77 53 18 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, most tender over epigastric area and LLQ with voluntary guarding, but diffusely mildly tender to palpation, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. ================ DISCHARGE EXAM: ================ VS - T 97.9 HR 67 BP 110/78 RR 18 02 99% sat on 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: +BS Soft, mild diffuse tenderness to palpation most in epigastric region, minimal distension, no organomegaly, no rebound or guarding . Large RUQ scar. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, No focal deficits. Pertinent Results: ================ ADMISSION LABS: ================ ___ 08:05PM WBC-2.9* RBC-5.05 HGB-15.0 HCT-42.9 MCV-85 MCH-29.7 MCHC-35.0 RDW-15.7* RDWSD-47.9* ___ 08:05PM NEUTS-43.1 ___ MONOS-10.3 EOS-1.7 BASOS-1.4* IM ___ AbsNeut-1.26*# AbsLymp-1.25 AbsMono-0.30 AbsEos-0.05 AbsBaso-0.04 ___ 08:05PM ___ PTT-28.2 ___ ___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:05PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:05PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-120 TOT BILI-0.4 ___ 08:05PM LIPASE-24 ___ 08:05PM ALBUMIN-4.3 ___ 08:05PM GLUCOSE-88 UREA N-15 CREAT-1.1 SODIUM-137 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 ================ DISCHARGE LABS: ================ ___ 04:40AM BLOOD WBC-3.2* RBC-4.71 Hgb-13.9 Hct-40.7 MCV-86 MCH-29.5 MCHC-34.2 RDW-15.4 RDWSD-48.0* Plt Ct-78* ___ 04:40AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-139 K-3.9 Cl-102 HCO3-25 AnGap-16 ___ 04:17AM BLOOD ALT-34 AST-32 LD(LDH)-192 AlkPhos-110 Amylase-23 TotBili-0.4 ___ 04:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9 ___ 04:40AM BLOOD tacroFK-6.3 ============== MICROBIOLOGY: ============== ___ 5:05 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ 10AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. 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. ___ CRYSTALS PRESENT. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. O&P MACROSCOPIC EXAM - WORM (Final ___: NO WORM SEEN. ___ 8:25 pm BLOOD CULTURES x2 **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ================= IMAGING/STUDIES: ================= EKG ___: Sinus rhythm with non-specific T wave flattening in leads aVL and V2. There is early R wave progression in the precordium. Compared to the previous tracing of ___ the previously seen T wave inversions are no longer present. KUB ___ FINDINGS: There is gas distending the colon. The colon does not exceed 4.5-5 cm in caliber. There is gas in scattered nondilated small bowel loops. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. A surgical clip is seen in the right upper quadrant. There are degenerative changes in the femoroacetabular joints. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No radiographic evidence of toxic megacolon. Brief Hospital Course: ___ y/o M with ___ PBC s/p liver transplant in ___, bipolar disorder, pericarditis p/w worsening abdominal pain, chest pain, diarrhea. Patient was recently admitted and discharged from ___ for the same complaint on ___. Colonoscopy was performed on ___ and showed colitis. Stool studies were positive of C diff on this admission (previously negative on prior admission). Therefore, patient was started on vancomycin PO on ___ for treatment of C diff colitis with plans to complete a 14-day total course. Abdominal pain and diarrhea gradually improved during the admission. Patient maintained good PO intake throughout admission. # Diarrhea ___ to C diff Colitis: Patient presented again to the ED on ___ for worsening abdominal pain, nausea, diarrhea (7 watery BMs daily). He was recently discharged on ___ for the same complaint. Repeat stool studies were obtained that returned positive for C diff on ___. CMV stains of colonoscopy specimens were negative. Antibiotic therapy was started with PO vancomycin since patient had no elevated WBC count or ___. Nausea was managed with PRN Zofran with good effect. During admission, patient had gradual improvement in abdominal pain/diarrhea. KUB was ordered to r/o toxic megacolon and showed only distended bowel loops with gas. Gradually pain improved with PRN acetaminophen, simethicone, dicyclomine, tramadol. On discharge, patient was tolerating regular diet with good PO intake and diarrhea/abdominal pain were improving. He was discharged with a script to complete a full 14-day course of PO vancomycin at home. ================ Chronic Issues ================ #PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: No active issues while inpatient. Patient continued on home tacrolimus/prednisone doses and daily tacro levels were appropriate. Daily LFTs were also WNL. #THROMBOCYTOPENIA. Stable throughout admission. Patient has known chronic thrombocytopenia likely due to liver disease vs immunosuppression. #BIPOLAR DISORDER. No acute issues. Recently off of Abilify. Monitored without need to restart therapy. #GERD: Stable. Possibly contributing to abdominal pain as described above with C diff infection. Continued on home omeprazole 40mg BID, ranitidine 150mg qHS. #CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin 600mg BID #COPD: No SOB throughout admission. Continued home albuterol prn TRANSITIONAL ISSUES: [ ] Complete Vancomycin 125 mg PO Q6H x 14 days (___) [ ] Follow up with PCP, ___. [ ] Full Code (confirmed) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Omeprazole 40 mg PO BID 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. PredniSONE 5 mg PO DAILY 7. Ranitidine 150 mg PO QHS 8. Tacrolimus 1 mg PO QPM 9. Tacrolimus 1 mg PO QAM 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 11. DICYCLOMine 20 mg PO TID abdominal pain 12. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain Discharge Medications: 1. Simethicone 80 mg PO QID pain RX *simethicone 80 mg 1 tablet by mouth QID PRN Disp #*60 Tablet Refills:*0 2. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*40 Capsule Refills:*0 3. DICYCLOMine 20 mg PO TID abdominal pain You may continue to take this medication as needed for abdominal pain. RX *dicyclomine [Bentyl] 20 mg 1 tablet(s) by mouth TID PRN Disp #*30 Tablet Refills:*0 4. Aspirin 650 mg PO BID 5. Colchicine 0.6 mg PO BID 6. Gabapentin 600 mg PO BID 7. Omeprazole 40 mg PO BID 8. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO QHS 11. Tacrolimus 1 mg PO QAM 12. Tacrolimus 1 mg PO QPM 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 14. HELD- IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain This medication was held. Do not restart IBgard until you discuss this with your transplant doctor. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: C. diff Colitis SECONDARY DIAGNOSES: PBC s/p liver transplant ___, Neutropenia, DVT ___, HLD, HLD, Osteoporosis, Bipolar disorder, Hemorrhoids, ADHD, PTSD 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 ___. Why you were in the hospital: - You were having abdominal pain and diarrhea and your colonoscopy results showed inflammation in your colon. This was due to an infection in your colon with C. Diff. What was done while you were in the hospital: - You were started on an antibiotic called vancomycin and were given medications for your nausea and pain. What you need to do when you go home: - You will continue taking antibiotics for your C. diff infection through ___ (10 more days). - Please follow up with your primary ___ doctor's office on ___. - Please also follow up with your liver transplant doctor, ___. ___ on ___. It was a pleasure taking ___ of you at ___ Deaconess. ___, Your ___ ___ Team Followup Instructions: ___

19992875-DS-38

DS

2163-12-26 00:00:00

2163-12-26 17:13:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with PBC s/p liver transplantation in ___ (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea, nausea, vomiting, and abdominal pain. He reports that his diarrhea had improved by the time of his last discharge from the hospital. However, it started to increase in frequency once he got home. He reports that he did not change his diet at all. No sick contacts. Has not consumed any raw or undercooked shellfish or other food. His bowel diarrhea is watery and non-bloody. He reports he has anywhere from ___ bowel movements per day. He reports his vomit is non-bloody and non-bilious. Denies fever, chills, chest pain, shortness of breath. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM ===================== VITAL SIGNS - 97.7 PO 104 / 69 L Lying 60 18 98 RA GENERAL - Appears stated age in NAD HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or supravlavicular LAD. mucous membranes dry. CARDIAC - S1/S2, bradycardic, regular rhythm PULMONARY - CTAB ABDOMEN - one large surgical scar on L side of abdomen. Well healed. Tender to palpation in the epigastric area and the LUQ EXTREMITIES - No edema, well-perfused SKIN - no bruising or notable rashes. NEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and lower extremities DISCHARGE PHYSICAL EXAM ====================== VITAL SIGNS - 97.5 PO 121 / 85 56 18 97 ra GENERAL - lying in bed, sleeping HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or supravlavicular LAD. Area of mild erythema periortibally on lateral left eye has resolved. Mild tenderness to palpation over erythema and also posterior auricular lymph nodes have resolved. CARDIAC - S1/S2, bradycardic, regular rhythm PULMONARY - CTAB ABDOMEN - one large surgical scar on L side of abdomen. Well healed. Tender to palpation in the epigastric area and the LUQ EXTREMITIES - No edema, well-perfused SKIN - no bruising or notable rashes. NEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and lower extremities Pertinent Results: ADMISSION LAB RESULTS =================== ___ 09:00AM BLOOD WBC-3.1* RBC-4.93 Hgb-15.0 Hct-43.7 MCV-89 MCH-30.4 MCHC-34.3 RDW-15.2 RDWSD-48.1* Plt ___ ___ 09:00AM BLOOD Neuts-49.3 ___ Monos-10.3 Eos-1.6 Baso-2.3* Im ___ AbsNeut-1.53* AbsLymp-1.10* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.07 ___ 09:00AM BLOOD ___ PTT-25.7 ___ ___ 09:00AM BLOOD Glucose-77 UreaN-11 Creat-1.2 Na-136 K-4.4 Cl-103 HCO3-16* AnGap-21* ___ 09:00AM BLOOD ALT-25 AST-34 AlkPhos-98 TotBili-0.8 ___ 09:00AM BLOOD Albumin-4.0 Calcium-8.9 Mg-1.9 ___ 09:12AM BLOOD Lactate-1.0 DISCHARGE LAB RESULTS ==================== ___ 04:52AM BLOOD WBC-3.3* RBC-4.65 Hgb-13.9 Hct-40.1 MCV-86 MCH-29.9 MCHC-34.7 RDW-14.5 RDWSD-45.1 Plt Ct-96* ___ 04:52AM BLOOD ___ PTT-32.1 ___ ___ 04:52AM BLOOD Glucose-77 UreaN-10 Creat-1.3* Na-137 K-4.6 Cl-101 HCO3-25 AnGap-16 ___ 04:52AM BLOOD ALT-18 AST-18 AlkPhos-98 TotBili-0.6 ___ 04:52AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 MICROBIOLOGY ============ ___ Stool Culture FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. ___ C diff: Negative ___ Urine culture: Negative ___ Blood culture: Pending IMAGING ======= ___ Chest X-Ray: Faint linear densities in the lower lungs likely reflect platelike atelectasis. The lungs are otherwise clear. There is stable prominence of the mediastinal silhouette, which has been previously assessed by CT chest from ___. The heart size is normal. Bony structures are intact. No free air below the right hemidiaphragm. ___ Abdominal X-Ray: Supine and upright views of the abdomen pelvis were provided. Bowel gas pattern is unremarkable without signs of ileus or obstruction. No free air is seen below the right hemidiaphragm. No worrisome calcifications. The imaged osseous structures appear intact. There is a mild dextroscoliosis of the thoracolumbar spine, apex at L1. A clip again noted in the right upper quadrant. ___ RUQ Ultrasound with Doppler: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 24. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.74, and 0.79, respectively. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. Brief Hospital Course: Mr. ___ is a ___ man with PBC s/p liver transplantation in ___ (on tacrolimus/prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with worsening diarrhea, n/v, and abdominal pain. # Diarrhea, Nausea, Vomiting: The patient initially presented with abdominal pain, vomiting x3 the night prior to admission, and reports of increase in diarrhea. There was initial concern for toxic megacolon or SBO. However, ___ ruled out those etiologies. It was thought that this may either be viral gastroenteritis or relapsed C. Diff infection. Flex sigmoidoscopy on previous hospitalization showed active colitis with focal superficial features suggestive of a component of ischemic type injury. Stool studies were sent including norovirus NAAT, and C. Diff which were negative. The patient's last bowel movement was in the emergency department. He did not have one for three days after that. The patient had still not had a bowel movement on the day of discharge, so he was given senna, colace, and miralax. #Cellulitis: The patient had some erythema and swelling without warmth over the lateral left ___ area. He remained afebrile. ID was consulted for questionable cellulitis since the patient was at a higher risk for infection given immunosuppression. A diagnosis of pre-septal cellulitis was made, and the patient was started on Bactrim. He was sent home on Bactrim 1 DS tab BID x 7 days to finish the course for facial cellulitis. # PBC s/p orthotopic liver transplant with CMV+ donor complicated by cellular rejection: The patient was continued on his home tacrolimus/prednisone and tacrolimus troughs were checked daily; they ranged from ___. # Normocytic Anemia: The patient's hemoglobin dropped from 15 to 12.8 the day after admission. This was likely dilutional given that the patient received IV fluids in the ED. Hemolysis labs were negative. Iron deficiency labs ___ ferritin, but otherwise normal. # Thrombocytopenia: Patient has known chronic thrombocytopenia likely due to liver disease, immunosuppression and hypersplenism. # Bipolar Disorder: The patient was recently taken off Abilify. He was monitored during his hospitalization, and there were no acute issues. # GERD: Stable. Possibly contributing to abdominal pain as described above. He was continued on his home ranitidine 150mg qHS, maalox PRN. # Chronic neuropathic pain: He was continued on his home Gabapentin 600mg BID. # COPD: There was no SOB throughout the admission. He was continued on home albuterol PRN TRANSITIONAL ISSUES ==================== -Patient will follow up with Dr. ___ as outpatient to monitor alternating diarrhea and constipation. -Consider follow up colonoscopy in several months to monitor for resolution of active colitis. -Patient will be discharged on Bactrim 1 DS tab BID for total course of 7 days (end date ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. PredniSONE 5 mg PO DAILY 5. Ranitidine 150 mg PO QHS 6. Tacrolimus 1 mg PO QPM 7. Tacrolimus 1 mg PO QAM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*45 Capsule Refills:*0 2. Senna 8.6 mg PO BID RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*45 Tablet Refills:*0 3. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 4. Aspirin 650 mg PO BID 5. Colchicine 0.6 mg PO BID 6. Gabapentin 600 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Tacrolimus 1 mg PO QPM 11. Tacrolimus 1 mg PO QAM 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Diarrhea SECONDARY DIAGNOSIS ==================== Chronic pain Primary Biliary Cirrohsis S/P Liver Transplant Cellular Rejection Anemia Bipolar Disorder Gastroesophageal Reflux Disease Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___. Why were you admitted? ====================== You had abdominal pain, diarrhea, nausea and vomiting What did we do for you? ======================= -We gave you fluids because of dehydration from diarrhea and vomiting. -We sent off tests of your stool to ensure you do not have another infection. The tests that did come back were negative. Some of the other cultures were still pending at time of discharge. What should you do when you get home? ===================================== -Continue to take your anti-nausea medication before meals when you are feeling nauseous. -We suggest that you follow the "BRAT" diet until you feel better. This consists of bananas, rice, applesauce and toast. You can advance your diet when you feel you are able -Expect to have loose stools, up to 1 or 2 per day, for the next few months. Your colon is still recovering from your Clostridium difficile infection in ___. - Call the doctor if you have 6 or more loose stools per day. - Attend a follow-up appointment with your primary care doctor. - Attend a follow-up appointment with your liver transplant doctor. - Consider seeing a pain specialist to help treat your multiple causes of pain. It was a pleasure taking part in your care. Your ___ Team Followup Instructions: ___

19992875-DS-43

DS

2166-04-30 00:00:00

2166-04-30 19:01:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms / propofol Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: Endoscopy ___ colonoscopy ___ History of Present Illness: Patient is a ___ male with a past medical history significant for liver transplant in ___ for PBC, hemorrhagic pericarditis in ___ status post pericardial window, MI x2 in ___, IBS versus Crohn's, osteoporosis with multiple pathological fractures presenting to the emergency department with generalized weakness and found to have an ___. Patient had a colonoscopy performed approximately 2 weeks ago. At this time the patient did receive propofol. Per review of records, it seems that the patient became hypoxic and the colonoscopy was not performed. Upon awakening, the patient noted some chest pain and shortness of breath. For this the patient was taken to ___. He was observed for 1 day from the fifth to the sixth of this month. At that time, the patient's creatinine was noted to be 1.6. The patient was discharged in stable condition. Patient states that today he developed generalized weakness. He does not note any focal weakness. The patient describes dizziness upon standing up quickly. This dizziness is not related to rapid movements of the head. The patient does not have dizziness here in the emergency department. The patient notes that he has not been eating or drinking well for the past 2 weeks and that he has had some diarrhea over the past two weeks. The patient does not note any new cough or any urinary changes. He does have some nausea but no vomiting. The patient has some chills but no fever. Patient does not have any chest pain. He does describe some shortness of breath. Patient presented to an outside hospital where he was noted to have an increase in his creatinine to 2.0. Patient was transferred here for further workup given this was where he had his liver transplant. Patient presents to us in no acute distress. He states that he has been compliant with all of his medications. He is on immunosuppression at this time consisting of tacrolimus and prednisone. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in ___ - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in ___, recurrent pericarditis in ___ - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant - PULMONARY NODULE - CHRONIC OBSTRUCTIVE PULMONARY DISEASE - ALTERNATING CONSTIPATION/DIARRHEA, ?IBS vs chrons - HISTORY OF CAD W/ MI x2 in ___ - T1 COMPRESSION FRACTURE, T6 BURST FRACTURE Social History: ___ Family History: Noncontributory to the patients current admission, Father passed away from head and neck cancer Physical Exam: Admission Exam: ================== VITALS: Reviewed in OMR ___: Weight: 172.2 GEN: Alert, cooperative, no distress, appears stated age HENT: NC/AT, MMM. Nares patent, no drainage or sinus tenderness. no teeth, and normal gums normal. EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. NECK: No cervical lymphadenopathy. No JVD, Neck supple, symmetrical, trachea midline. LUNG: CTA ___, good air movement, no accessory muscle use HEART: RRR, Normal S1/S2, No M/R/G BACK: Symmetric, no curvature. ROM normal. No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; midline well healed scar, no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, no edema, tender to palpation over the left shin, no cyanosis, positive ___ pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact grossly. Moving all extremities, strength, sensation equal and intact throughout. PSYC: Mood and affect appropriate Discharge Exam: ================ Gen: NAD HENT: NC/AT, sclerae anicteric, normal conjunctivae, oropharynx clear, MMM LUNG: CTAB, no increased work of breathing HEART: RRR, normal S1/S2, no m/r/g ABD: Soft, non-tender, non-distended EXTRM: Warm, DP pulses 2+ bilaterally, no edema SKIN: Well-healed scar along upper spine, well-healed scar over RUQ of abdomen NEUR: AOx3 Pertinent Results: Admission labs: ================== ___ 11:15PM BLOOD WBC-2.8* RBC-4.67 Hgb-10.8* Hct-36.8* MCV-79* MCH-23.1* MCHC-29.3* RDW-17.4* RDWSD-49.3* Plt ___ ___ 11:15PM BLOOD Neuts-36.2 ___ Monos-15.2* Eos-5.1 Baso-2.2* Im ___ AbsNeut-1.00* AbsLymp-1.11* AbsMono-0.42 AbsEos-0.14 AbsBaso-0.06 ___ 11:15PM BLOOD Plt ___ ___ 11:15PM BLOOD Glucose-87 UreaN-15 Creat-1.7* Na-142 K-4.3 Cl-109* HCO3-24 AnGap-9* ___ 11:15PM BLOOD ALT-20 AST-24 CK(CPK)-33* AlkPhos-131* TotBili-0.3 ___ 11:15PM BLOOD Lipase-19 ___ 11:15PM BLOOD cTropnT-<0.01 ___ 06:15PM BLOOD cTropnT-<0.01 ___ 11:15PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.5 Mg-1.8 ___ 04:27AM BLOOD calTIBC-283 VitB12-440 Folate-8 Hapto-47 Ferritn-23* TRF-218 ___ 11:15PM BLOOD Osmolal-283 ___ 06:13AM BLOOD TSH-2.6 ___ 06:13AM BLOOD Cortsol-<0.3* ___ 05:20PM BLOOD Cortsol-0.5* ___ 07:45PM BLOOD Cortsol-0.8* ___ 09:38AM BLOOD tacroFK-2.9* Key labs: =================== ___ 04:27AM BLOOD Ret Aut-2.2* Abs Ret-0.09 ___ 05:20PM BLOOD Cortsol-0.5* ___ 07:45PM BLOOD Cortsol-0.8* ___ 04:36AM BLOOD tacroFK-3.3* ___ 11:23AM BLOOD CMV VL-DETECTED, ___ 05:31AM BLOOD CMV VL-DETECTED, ___ 07:45PM BLOOD ALDOSTERONE-Test ___ 05:20PM BLOOD ALDOSTERONE-Test ___ 05:20PM BLOOD ACTH - FROZEN-Test Discharge labs: ====================== ___ 04:36AM BLOOD WBC-3.6* RBC-4.32* Hgb-9.8* Hct-33.0* MCV-76* MCH-22.7* MCHC-29.7* RDW-17.8* RDWSD-48.1* Plt Ct-95* ___ 05:31AM BLOOD Neuts-44.3 ___ Monos-12.9 Eos-1.2 Baso-1.6* Im ___ AbsNeut-1.13* AbsLymp-1.00* AbsMono-0.33 AbsEos-0.03* AbsBaso-0.04 ___ 04:36AM BLOOD Plt Ct-95* ___ 04:36AM BLOOD Glucose-106* UreaN-13 Creat-1.4* Na-138 K-4.4 Cl-107 HCO3-21* AnGap-10 ___ 05:09AM BLOOD ALT-18 AST-21 AlkPhos-109 TotBili-0.4 ___ 04:36AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9 Imaging: ==================== ___ Dupplex abdominal Doppler 1. Patent hepatic vasculature with appropriate waveforms. Please note that the left hepatic artery was not able to be visualized secondary to poor acoustic windows and patient breathing. 2. Splenomegaly. ___ TTE Prominent epicardial fat without clear pericardial effusion. Mild global right ventricular hypokinesis. Low normal global left ventricular systolic function. ___ EGD Ring in the distal esophagus Normal mucosa in the whole stomach normal mucosa in the duodenum ___ Colonoscopy High residue material and unable to visualize adequately Normal as far as visualized. Not adequate for screening purposes. Terminal ileum was not intubated due to patient discomfort Path: ===================== ___ GI mucosal biopsy 1. Terminal ileum: Terminal ileal mucosa, within normal limits. 2. Colon: Colonic mucosa with patchy moderately active colitis (multiple neutrophilic crypt abscesses), focal basal crypt regeneration, and scattered prominent basal apoptotic debris; no definitive evidence of chronic colitis, granulomas, or viral inclusions/cytopathic effect are identified. Immunostain for cytomegalovirus is in progress and the results will be reported in a revised report. Note: The colonic mucosal biopsy findings are favored to represent an acute infectious colitis versus a drug-induced change. Correlation with clinical and laboratory findings is needed. ___ GI biopsy 1. Esophagus, biopsy: - Squamous mucosa with active erosive esophagitis. - Numerous Herpes simplex virus viral cytopathic changes (confirmed by HSV I/II immunostain) . 2. Stomach, biopsy: - Antral and corpus mucosa within normal limits. ___ GI Biopsy 1. Duodenum, biopsy: -Duodenal mucosa with crypt regeneration (non-specific), otherwise within normal limits. -CMV immunostain highlights rare positive cells in the lamina propria (see note). Note: The clinical significance of this finding is uncertain, since no significant duodenitis is identified. 2. Random colon, biopsy: -Colonic mucosa within normal limits. -Immunohistochemical stain for CMV is negative with adequate controls. Brief Hospital Course: PATIENT SUMMARY ================= Patient is a ___ male with a past medical history significant for liver transplant in ___ for PBC, hemorrhagic pericarditis in ___ status post pericardial window, MI x2 in ___, IBS versus Crohn's, osteoporosis with multiple pathological fractures who presented to the emergency department with generalized weakness and was found to have an ___. Diagnosed with secondary adrenal insufficiency and CMV. Treated for both. Colonoscopy and EGD unrevealing. Transitional Issues =================== [] Prednisone course: 7.5mg for three days (___) then 5mg daily [] Will need f/u CMV viral titers until negative [] discharge tacro dosing of 1 mg BID discharge tacro level of 3.3 [] Patient ASA reduced to 325mg daily from BID dosing and continue colchicine 0.6 bid due to his history of pericarditis. Will need follow up arranged with Dr. ___ likely discontinuation or downtitration of medications. Unable to reach via E-mail ============== Active Issues ============== #Weakness #Anemia #Orthostasis #Exertional dyspnea Patient presented with recent weakness, exertional dyspnea, with initial differential including worsening anemia, dehydration, infectious process, cardiac etiology, and adrenal insufficiency. Patient has baseline pancytopenia (see below) but with an acute drop in Hgb shortly after admission from 11 to 9.5, and from recent baseline ~13 in ___. Remained hemodynamically stable. No overt bleeding, melena, or hematochezia. EGD and colonoscopy on ___, revealing no inflammation or source of bleeding. Alternating diarrhea and constipation chronic ("since forever") per patient, with no acute change.. CXR and abdominal US unremarkable (aside from splenomegaly on US). AM cortisol <0.3, with further testing consistent with adrenal insufficiency that may be have contributed to overall weakness. #CMV Viremia #CMV Duodenal infection Patient presents with the symptoms, discussed below, raising concern for CMV infection. CMV titer returned as detectable, but below 1.7 on two separate titers which does not meet criteria for induction therapy. Endoscopic biopsy of the duodenum revealed positive staining for CMV without evidence of inflammation, which is of unclear significance. Given the overall clinical picture discussed below, in addition to the CMV viral load and biopsy findings, valganciclovir treatment was initiated with 450mg bid (dose reduced for renal function) for 28 days as is recommended for treatment. #Secondary Adrenal insufficiency Low morning cortisol, low ACTH and cosyntropin stimulation test results obtained when he received corticosteroids on the day of the stim test, and values were also obtained 2 hours after adminisration of cosyntropin, making these less reliable. However it seems very likely that he is adrenally insufficient. We ultimately increased his prednisone dosing to 10mg daily while treating for CMV with slower taper to 7.5mg x3 days and back to 5mg daily given worsening nausea with quick taper. ___ Patient admitted with ___, pre-renal in setting of poor PO intake and diarrhea. Peaked at 2.0, subsequently downtrended to 1.4. Baseline appeared to range 0.6 to 0.9. No major electrolyte abnormalities. Per Dr. ___ for discharge with current Cr elevation with follow up outpatient. #PBC s/p DDLT #immunosuppression #Leukopenia/pancytopenia Patient reported he has had pancytopenia since his liver transplant ___ years ago. This is likely immunosuppressive effect from his Tacrolimus resulting in chronic iatrogenic myelosuppression. He had a workup for this including BM-biopsy in ___ iso CMV viremia, which was non-revealing. CMV viral load this admission was Detected, discussed above. Acute on chronic anemia was further evaluated as above. #Hx pericarditis with loculated pericardial effusion Patient has a history of hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ and recurrent pericarditis ___ and moderate pericardial effusion seen on TTE on ___. The patient has no new chest pain or pressure symptoms and does not endorse any tachycardia or palpitations. Repeat TTE showed no effusion. Patient was continued on colchicine and ASA though dose of ASA reduced to 325mg daily for GI protection as unclear why such high dose has been maintained and unable to reach outpatient providers. ============== Chronic Issues ============== #Osteoporosis Per OMR review, has had since before his liver transplant so likely not related to prednisone. #Bipolar Continued home bupropion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO BID 2. Atorvastatin 10 mg PO QPM 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Colchicine 0.6 mg PO BID 5. DICYCLOMine 20 mg PO TID:PRN diarrhea 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 7. Gabapentin 800 mg PO BID 8. Pantoprazole 40 mg PO Q12H 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO DAILY 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 13. Tacrolimus 0.5 mg PO QPM 14. Tacrolimus 1 mg PO QAM 15. Naloxone Nasal Spray 4 mg IH ONCE MR1 Discharge Medications: 1. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. ValGANCIclovir 450 mg PO Q12H Duration: 28 Days RX *valganciclovir 450 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Aspirin 325 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. PredniSONE 7.5 mg PO DAILY RX *prednisone 5 mg 1.5 tablet(s) by mouth once a day for 3 days then one tablet daily thereafter Disp #*30 Tablet Refills:*0 6. Tacrolimus 1 mg PO QAM RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 7. Tacrolimus 1 mg PO QPM 8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 9. Atorvastatin 10 mg PO QPM 10. BuPROPion (Sustained Release) 300 mg PO QAM 11. Colchicine 0.6 mg PO BID 12. DICYCLOMine 20 mg PO TID:PRN diarrhea 13. Naloxone Nasal Spray 4 mg IH ONCE MR1 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Ranitidine 150 mg PO DAILY 16. HELD- Gabapentin 800 mg PO BID This medication was held. Do not restart Gabapentin until seen by PCP ___: Home Discharge Diagnosis: #Adrenal Insufficiency #Anemia #CMV viremia #CMV duodenitis 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 part in your care here at ___! Why was I admitted to the hospital? - You were admitted for weakness What was done for me while I was in the hospital? We found that your adrenal glands were not working very well and we gave you steroid medication We performed an endoscopy and colonoscopy to look for evidence of inflammation in you GI tract We found that you are infected by a virus that can cause GI symptoms and started you on the appropriate treatment What should I do when I leave the hospital? -Please take all of your medications and keep all of your appointments - Dr. ___ will contact you with an appointment - The Endocrinology department is working on scheduling an earlier appointment for you as well. *****Prednisone course**** 7.5mg for three days (___) then 5mg daily Sincerely, Your ___ Care Team Followup Instructions: ___

19992875-DS-44

DS

2166-07-19 00:00:00

2166-07-19 18:48:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms / propofol Attending: ___ Chief Complaint: Generalized Weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with a past medical history significant for liver transplant in ___ for PBC, hemorrhagic pericarditis in ___ s/p pericardial window, MI x2 in ___, IBS vs Crohn's disease, osteoporosis with multiple pathological fractures who presents for generalized weakness. Notably, the pt was admitted recently to ___ ___, at which time his presenting symptoms was also weakness. Work up was significant for ___, adrenal insufficiency, and CMV viremia. He underwent a colonoscopy and EGD that were unrevealing. The pt was treated w/ steroids and valganciclovir and his Cr improved to baseline by time of discharge. The pt now complains of about 2 days of generalizes weakness and fatigue. Prior to that, he was in his usual state of health. Also endorses low appetite, nausea, and some abdominal discomfort without vomiting or change in bowel movements. The pt was initially seen at ___ where labs, flu swab, UA, and CXR were reportedly unremarkable with the exception of elevated Cr to 1.8. He was given 100 mg of Hydrocort for concerns of adrenal insufficiency. The pt was then transferred to ___ for continued care. In the ED, initial VS were T 96.7, HR 64, BP 140/70, RR 16, O2 98% on RA. Exam was notable for diffuse abdominal tenderness. Labs were significant for: - Pancytopenia with WBC 2.7, Hbg 9.0, Plts 89 - Otherwise normal chemistry panel (Cr 1.2) LFTs, coags, lactate, and U/A negative Studies included: - CT A&P with no acute intra-abdominal process - RUQ US w/ doppler with high resistance waveform in the main hepatic artery with diminished antegrade diastolic flow as well as interval decrease in peak systolic velocity (31.3 cm/s); nonvisualization of the right or left hepatic arteries; patent portal veins; and splenomegaly The pt was continued on his home medications. He was transferred to the Heparorenal service for further management. On arrival to the floor, the pt endorsed the above history. Aside from the weakness, nausea, and abdominal pain, the pt denied having and fevers, chills, vomiting, cough, or urinary frequency. He also denied any new medications, recent travel, or sick contacts. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: - Attention deficit hyperactivity disorder - Bipolar disorder - Hemorrhoids - History of alcohol abuse - History of deep vein thrombosis in ___ - History of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in ___, recurrent pericarditis in ___ - History of neutropenia complicated by neutropenic fever - History of positive tuberculin skin test status post INH - Hyperlipidemia - Osteoporosis - Primary biliary cirrhosis status post orthotopic liver transplant - Pulmonary nodule - COPD - Alternating constipation/diarrhea, ? IBS vs Crohn's Disease - CAD s/p MI x 2 in ___ - T1 compression fx, T6 burst fracture - T4-8 FUSION (___) - LIVER TRANSPLANT (___) Social History: ___ Family History: Noncontributory to the patients current admission, Father passed away from head and neck cancer Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 97.9, BP 137/90, HR 75, RR 18, O2 98% on RA GENERAL: Alert and interactive, NAD CARDIAC: RRR, no m/r/g LUNGS: CTAB, no wheezes or crackles ABDOMEN: Soft, tenderness to palpation diffusely, worse in midline, nor rebound or guarding, BS+ EXTREMITIES: Trace edema in ___ SKIN: Warm, no rashes NEUROLOGIC: AOx3, CNII-XII intact, moving extremities, gait deferred DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 812) Temp: 97.5 (Tm 98.6), BP: 138/97 (114-139/83-97), HR: 67 (61-74), RR: 18 (___), O2 sat: 98% (97-98), O2 delivery: Ra HEENT: NC/AT EOMI sclera nonicteric MMM no oropharyngeal erythema Neck: No thyromegaly, no thyroid nodules CV: RRR S1/S2 normal RESP: CTAB ABD: TTP periumbilical. soft, nondistended. BACK: Diffuse tenderness to palpation at flanks, paraspinal, spinous processes inferior to rib borders EXT: No C/C/E Pertinent Results: ADMISSION LABS: =============== ___ 05:40AM tacroFK-3.2* ___ 03:04AM LACTATE-1.1 ___ 03:00AM CK(CPK)-38* ___ 03:00AM cTropnT-<0.01 ___ 03:00AM TSH-3.2 ___ 03:00AM T4-3.9* T3-68* ___ 01:30AM ___ PTT-26.8 ___ ___ 12:05AM URINE HOURS-RANDOM ___ 12:05AM URINE UHOLD-HOLD ___ 12:05AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 10:30PM GLUCOSE-95 UREA N-15 CREAT-1.2 SODIUM-143 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-10 ___ 10:30PM estGFR-Using this ___ 10:30PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-106 TOT BILI-0.3 ___ 10:30PM LIPASE-18 ___ 10:30PM cTropnT-<0.01 ___ 10:30PM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.9 ___ 10:30PM WBC-2.7* RBC-4.11* HGB-9.0* HCT-31.4* MCV-76* MCH-21.9* MCHC-28.7* RDW-16.6* RDWSD-45.4 ___ 10:30PM NEUTS-48.9 ___ MONOS-12.5 EOS-1.1 BASOS-1.1* IM ___ AbsNeut-1.33* AbsLymp-0.98* AbsMono-0.34 AbsEos-0.03* AbsBaso-0.03 ___ 10:30PM PLT COUNT-89* PERTINENT STUDIES: ================== ___ DOPP ABD/PEL 1. High resistance waveform in the main hepatic artery with diminished antegrade diastolic flow as well as interval decrease in peak systolic velocity (31.3 cm/s), represents a change from ultrasound of ___ and is concerning for possible occlusion. Recommend clinical correlation with LFTs and CT angiogram. 2. Patent portal veins. 3. Splenomegaly. ___ ABD & PELVIS WITH CO 1. No acute intra-abdominal process. 2. Unremarkable appearance of the liver transplant. The transplant main hepatic artery appears patent to level of the liver hilum. Suboptimal evaluation of the hepatic arterial vasculature on this non dedicated study. 3. Splenomegaly. ___ ABD & PELVIS 1. Main, left and right hepatic arteries are patent and appear similar to CTA from ___ with no evidence of focal stenosis. 2. Stable pancreatic cystic lesion is likely a side-branch IPMN and can be re-evaluated at next follow-up. Brief Hospital Course: ___ is a ___ year-old male w/ hx of PBC s/p liver transplant (___), hemorrhagic pericarditis s/p window, CAD c/b MI x 2 (___), IBS vs Crohn's disease, OA, and pancytopenia who presented with generalized weakness, malaise, and dyspnea on exertion. Of note this is his second hospitalization for similar presentation in the last several months. Workup here as detailed below was largely unremarkable, with greatest suspicion for endocrine or psychosomatic etiology of his weakness. TRANSITIONAL ISSUES: ==================== [ ] Consider broader endocrine workup for fatigue including testosterone testing, FSH/LH [ ] If workup for other organic causes is negative, consider psychiatric etiology given recent life stressors and possible referral to psychiatry [ ] We were unable to provide an appointment with cardiology while inpatient; please ensure patient follows up with cardiology for his history of pericarditis and reported MI history [ ] Recommend ___ week follow-up of thyroid function tests [ ] For sick day dosing, recommend prednisone increase from 5 to 10mg dosing for ___ days, after which he can be tapered back to 5mg. ACUTE ISSUES: ============= #Fatigue Patient presented with several weeks of worsening fatigue without frank weakness, associated with vague diffuse aching and tenderness across his torso. This is his second admission in several months for similar complaints. During his prior admission, there were concerns for adrenal insufficiency given low AM cortisol and ACTH levels although these were checked at suboptimal timings around the time of steroid administration. For this hospitalization, he presented to ___ where due to concern of adrenal insufficiency he was given 100mg hydrocortisone and transferred to ___ for further management and continuity of care. Workup here notable for low repeat AM cortisol (although now in setting of hydrocortisone administration), normal TSH with low T3/T4, negative CMV viral load and culture data. He additionally had CTA abdomen to evaluate hepatic vasculature (admission RUQ US with decreased velocities) which was unremarkable. Other endocrine etiologies were currently left unexplored. He has had prior cardiac coronary cath in ___ which was unremarkable. Of note, patient's father recently passed away ~3 months ago which has been a significant life stressor and associated with subjectively depressed mood, anhedonia, sleep disturbance, and decreased energy levels. - Started on prednisone 10mg on date of admission for sick day dosing. He was told to taper back to 5mg over two days at discharge. #Acute Kidney Injury Patient with baseline serum creatinine of 1.0, increased to 1.6 which resolved with IV albumin administration, and subsequently again to 1.3 with IVF administration. Likely in setting of poor PO intake and unrelated to ongoing above pathology. Not on diuretics. #Primary Biliary Cirrhosis s/p Deceased Donor Liver Tx ___ Maintained on tacrolimus 1mg BID. Prednisone dosing as above. CHRONIC ISSUES: =============== # H/o pericarditis Pt found to have hemorrhagic pericarditis c/b tamponade s/p pericardial window in ___ with recurrent pericarditis in ___ and moderate pericardial effusion seen on TTE in ___. Resolved on recent TTE ___. - Continue home colchicine 0.6mg BID - Continue home ASA (full dose) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. BuPROPion (Sustained Release) 300 mg PO QAM 3. Colchicine 0.6 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 5. Pantoprazole 40 mg PO Q24H 6. Ranitidine 150 mg PO DAILY 7. Tacrolimus 1 mg PO QAM 8. Tacrolimus 1 mg PO QPM 9. Senna 8.6 mg PO BID 10. DICYCLOMine 20 mg PO BID diarrhea 11. Gabapentin 800 mg PO BID 12. Naloxone Nasal Spray 4 mg IH ONCE MR1 13. Aspirin 325 mg PO DAILY 14. PredniSONE 5 mg PO DAILY 15. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 17. DICYCLOMine 10 mg PO DAILY:PRN Abd pain/cramping Discharge Medications: 1. Ursodiol 500 mg PO BID 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. BuPROPion (Sustained Release) 300 mg PO QAM 5. Colchicine 0.6 mg PO BID 6. DICYCLOMine 20 mg PO BID diarrhea 7. DICYCLOMine 10 mg PO DAILY:PRN Abd pain/cramping 8. Gabapentin 800 mg PO BID 9. Naloxone Nasal Spray 4 mg IH ONCE MR1 10. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 12. Pantoprazole 40 mg PO Q24H 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 14. PredniSONE 5 mg PO DAILY Please start this on ___. Ranitidine 150 mg PO DAILY 16. Tacrolimus 1 mg PO QAM 17. Tacrolimus 1 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: #Fatigue Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thank you for coming to ___ for your care. Please read the following instructions carefully: Why was I admitted to the hospital? -You were admitted to the hospital because you have been having shortness of breath with activities, general feelings of weakness, and pain throughout her back and abdomen. What was done for me while I was here? -We performed several blood tests and a CAT scan to ensure that there are no serious or life-threatening causes of your symptoms -We believe that the issues you are currently having will be better addressed with the doctors in ___ What do I need to do when I leave the hospital? -Please take your medications as listed below -Tomorrow, please take 7.5mg of prednisone, and you can resume your normal dose of 5mg daily on ___ -Please keep your appointments as listed below -It is very important that you continue to follow with the cardiologist due to your history of pericarditis. The information to contact their office is below We wish you the best with your care! - Your ___ care team Followup Instructions: ___

19994233-DS-9

DS

2184-02-16 00:00:00

2184-02-16 16:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right-sided weakness, speech difficulty Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an ___ year old woman who presents with acute onset right sided weakness and speech difficulty since this evening. She has a history of AF on warfarin, prior "stroke" (that was a "bleeding" type without residual deficits), HTN, HL, reportedly dementia, and left-sided breast cancer. She was well earlier today but supposedly had fallen: she has a small laceration overlying her right eyebrow, but she did not recall how or when she fell or any details of this (she could not describe them to her daughter or subsequently to me). She went to a medical appointment with her daughter at 4PM when her INR was checked and was 1.7. Her daughter reports that the physicians have been aiming for a number on the lower end of the therapeutic range, so no dose change was made. She returned home with her daughter who left her in her room around ___. A few minutes later (sometime before ___), her daughter her a "thud." She went to her mother's room and found her on the floor, unable to move her right side or speak clearly. EMS was called and brought her to the ED immediately. She arrived as a Code Stroke and was found to have a large left frontal parietal hemorrhage. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Endorses dysarthria. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, or dysphagia. Endorses muscle weakness. Endorses loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: -ICH (___): unknown location, no residual deficits -Dementia -AFib (on Coumadin) -HTN -Hyperlipidemia -h/o left BrCa (surgically resected) Social History: ___ Family History: Unknown whether there is h/o stroke or other neurologic illness Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VS T: unmeasured HR: 83 BP: 132/87 RR: 12 SaO2: 100% RA General: NAD, lying in bed with hard collar, elderly woman. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: hard collar in place Cardiovascular: Irregularly irregular rhythm, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: Dry, excoriated; left breast surgically removed ___ Stroke Scale - Total [14] 1a. Level of Consciousness - 0 1b. LOC Questions - 0 1c. LOC Commands - 0 2. Best Gaze - 1 3. Visual Fields - 2 4. Facial Palsy - 3 5a. Motor arm, left - 0 5b. Motor arm, right - 4 6a. Motor leg, left - 0 6b. Motor leg, right - 2 7. Limb Ataxia - 0 8. Sensory - 1 9. Language - 0 10. Dysarthria - 1 11. Extinction and Neglect - 0 Neurologic Examination: - Mental Status - Awake, alert, oriented x name, age, month. Attention to examiner easily attained ___ requires effort to maintain. Structure of speech demonstrates diminished fluency with single words and short phrases, intact repetition, and possible diminished verbal comprehension of commands and questions. Content of speech demonstrates intact naming (watch, glasses) and no paraphasias. Normal prosody. Moderate dysarthria. No evidence of hemineglect. - Cranial Nerves - [II] PERRL 2->1 brisk. Diminished blink to threat on the right upper and lower quadrants - right homonymous hemianopia. [III, IV, VI] Some right horizontal gaze limitation, conjugate, otherwise EOMI, no nystagmus. [V] Corneals present bilaterally, but pin/pain sensation diminished on the right face. [VII] Right forced eyelid closure weakness, right lower face paralysis with volitional smile. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline. - Motor - Normal bulk, flaccid left arm. Right arm and right leg drop to the bed immediately when testing drift. No tremor or asterixis on the left. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5- 5 5 5 5 5- 5 5 R 0 0 0 0 0 2 2 1 1 1 2 - Sensory - Diminished sensation to pin/pain on the right face and arm, withdraws to noxious stimuli in the right leg. Left face/arm/leg sensation intact. Unable to test proprioceptive due to inattention versus verbal comprehension deficit. - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L 2 2 2 2 0 R 2 2 2 2 0 Plantar response extensor on right, mute on left. - Coordination - Unable to assess at the time of examination due to inattention versus verbal comprehension deficit. - Gait - Unable to assess at the time of examination. ======================== DISCHARGE PHYSICAL EXAM: ======================== More awake, answering questions in ___ word sentences. Still demonstrates left gaze preference but able to cross midline and looks rightward. Spontaneous movement of the left extremities at least antigravity, with some spontaneous movements of her Right Lower Extremity (able to wiggle toes, internally rotate her foot; RUE remained plegic. Lungs now clear in all fields. Pertinent Results: ADMISSION LABS: -WBC-10.2 RBC-4.25 Hgb-13.3 Hct-40.1 MCV-94 MCH-31.4 MCHC-33.3 RDW-13.2 Plt ___ -Neuts-82.9* Lymphs-11.1* Monos-5.3 Eos-0.3 Baso-0.4 -___ PTT-34.0 ___ -Glucose-115* Na-142 K-4.2 Cl-96 calHCO3-30 UreaN-21* -ALT-18 AST-22 AlkPhos-58 TotBili-0.4 -cTropnT-<0.01 -UA: Color-Yellow Appear-Clear Sp ___ Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 Mucous-RARE STROKE LABS: -%HbA1c-6.8* eAG-148* -Triglyc-114 HDL-56 CHOL/HD-2.7 LDLcalc-72 -TSH-3.8 NCHCT (___): Limited evaluation due to patient's positioning. Large intraparenchymal hemorrhage centered in the left frontoparietal region with associated vasogenic edema, and adjacent subarachnoid and subdural hemorrhage. There is mild associated mass effect with 3 mm rightward shift of normally midline structures. ___ consider MRI for further charaterizaion to exclude underlying mass, if clinically indicated. CT C-SPINE (___): 1. No evidence of acute fracture or malalignment. Multilevel degenerative disc disease. 2. Heterogeneous, enlarged thyroid gland likely reflective of multinodular goiter. Clinical correlation recommended. MRI W/WO GAD ___, prelim): Large left parietal intraparenchymal hematoma with subarachnoid and subdural blood products without evidence of definite underlying mass. At least 2 foci of chronic intraparenchymal hemorrhagic products and old subarachnoid blood products. The presence of these findings suggest amyloid angiopathy, however other etiologies such as hypertensive hemorrhage is also possible. However, a follow-up after resolution of the blood products is advised to exclude an underlying lesion. CXR (___): Heart size is top-normal. The thoracic aorta is mildly tortuous with atherosclerotic mural calcifications. Lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: Ms. ___ is an ___ yo RH F with h/o AFib (on Coumadin, INR 1.7), dementia, prior ICH (no residual deficits), HTN, HLD and left BrCa who presented with right sided weakness and speech difficulty starting at 1730 on ___, found to have a large left front-parietal intraparenchymal/lobar hemorrhage. # NEURO: NCHCT on arrival to the ED showed a large left-sided intraparenchymal/lobar hemorrhage. INR was 1.7 on admission, so anticoagulation was aggressively reversed with Profilnine, 10 units vitamin K and 2 units FFP while in the ED. She was admitted to the Neuro ICU for further monitoring. Follow-up MRI showed a large left parietal IPH with subarachnoid and subdural blood products, as well as at least 2 foci of chronic IPH and old SAH, supporting amyloid angiopathy as likely etiology of the bleed. Overnight in the ICU her neurologic exam remained stable. On HD #2 she was transferred to the floor where repeat head CT showed a stable IPH and stable ventricular size. Her neurologic exam was initially notable for significant somnolence (able to open eyes to vigorous stimulation and lift left hand but otherwise unable to follow commands), but by discharge was more awake, answering questions in ___ word sentences. Left gaze preference was still noted but is able to cross midline to gaze rightward. Spontaneous movement of the left extremities at least antigravity. Some spontaneous movements of Right Lower Extremity (wiggling toes), internal rotation; RUE plegic. Lungs clear. # CARDIAC: In the ICU, home medications were held, but after transfer to the floor, Mrs. ___ home cardiac medications (Lasix, atenolol and lisinopril) were restarted via NGT. She did have one episode of desaturations and respiratory distress and responded well to Lasix IV boluses. # RENAL: The patient initially had low UOP in ICU, likely related to CHF and this improved with initiation of Lasix. Her K was repleted as needed. # ENDO: The patient was started on an insulin sliding scale but had normal serum glucose. Her serum HgbA1C% was 6.8. Her statin was held while here given the concern it could increase the risk of intracranial hemorrhage but was restarted at discharge. # PULM: The patient had no active respiratory issues in the ICU but on the floor did have desaturations one evening that responded to IV Lasix. In addition, there was concern for an aspiration PNA based on CXR so the patient was started on a 10 day course of Unasyn (1st dose ___ which was then changed to Augmentin and Azithromycin PO on ___ for 5 additional days. # ID: The patient had a fever on ___, with negative urine and blood cultures but CXR concerning for a retrocardiac opacity. Given the concern for an aspiration PNA based on CXR between ___ and ___, the patient was started on the above 10d regimen. # FEN/GI: The patient initially was given IVF and then an NGT was placed. The patient passed the speech and swallow for pureed foods and nectar thickened liquids. # TRANSITIONS OF CARE: - Will restart ASA 81mg daily on ___, which is 10 days after bleed. Coumadin will not be continued due to unfavorable risk/benefit ratio given that she has amyloid angiography and hx of two ICH. - Completing 10 day course of antibiotics for concern for aspiration PNA. Changed from 5 days of Unasyn to Augmentin/Azithromycin for 5 more days. - Will follow up with Dr. ___ ___ on Admission: Warfarin 2.5 and 3 mg alternating daily doses Furosemide 40mg daily Digoxin 125mcg daily Simvastatin 20mg daily Atenolol 50mg daily Lisinopril 20mg daily Donepezil 10mg daily Discharge Medications: 1. Digoxin 0.125 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Potassium Chloride (Powder) 40 mEq PO DAILY Hold for K > 6 6. Nystatin 500,000 UNIT PO Q8H 7. Heparin 5000 UNIT SC TID 8. Insulin SC Sliding Scale Fingerstick QACHS, Insulin SC Sliding Scale using REG Insulin 9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 10. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 5 Days 11. Azithromycin 250 mg PO Q24H Duration: 5 Days 12. ASA 81mg to be restarted on ___ Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: 1) Intraparenchymal hemorrhage 2) Amyloid angiopathy Secondary: 1) Hypertension 2) Hyperlipidemia 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 ___, ___ were admitted because ___ had right sided weakness and difficulty speaking and ___ were found to have a bleed in your brain. We think the most likely reason ___ had the bleed was because ___ have a condition called amyloid angiopathy that makes your blood vessels very fragile. ___ cannot cure this condition but ___ can try to prevent further bleeds by controlling your blood pressure and staying off medications that thin your blood, like Coumadin. As ___ have heart problems, we would like ___ to restart Aspirin 81mg about 10 days after your bleed. We also noted that on ___, your chest x-ray demonstrated pneumonia that may have been due to the aspiration of gastric contents. We started ___ on IV antibiotics which were able to be changed to oral antibiotics on your discharge. Otherwise, please continue your medications as prescribed and follow-up with your primary care doctor and neurologist. Followup Instructions: ___

19994379-DS-14

DS

2131-05-21 00:00:00

2131-05-21 15:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / oxycodone Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: ___: Thoracentesis w chest tube insertion ___: Thoracentesis w chest tube insertion History of Present Illness: ___ male history of afib, ___, previous lumbar and cervical spine surgeries by Dr. ___ osteomyelitis ___, and HFrEF who presents now with one half weeks of worsening back pain. He was seen prior to arrival at ___ ___ emergency room where he was found to have had a CT of lumbar spine concerning for discitis at L1-L2 with epidural abscess and probable to level as well as the pathologic fractures involving the L1-L2 vertebral bodies. Patient transferred to ___ for further management. Workup prior to arrival notable for white blood cell count 7.96, hemoglobin 11.6, hematocrit 34.6, MCV 107, platelet count 178, neutrophils 81%, ESR 17, normal range ___, GFR 38, BUN 49, glucose 110, creatinine 1.76, calcium 8.9, sodium 142, potassium 4.1, chloride 105, bicarb 25, bilirubin 0.6, alk phos 168, AST 11, ALT 15, CRP 36.6. He was transferred from OSH after CT L-spine showed L1-2 discitis, osteomyelitis and pathologic fracture. He presents today with low back and hip pain for the past several months which has worsened over the past 4 days. He reports intermittent weakness of the left lower extremity when changing from seated to standing which resolves with ambulation. Denies paresthesias or other weakness, intermittent bowel incontinence at baseline and no other bowel/bladder symptoms. Denies fevers/chills. He has recent falls due to losing his balance while walking and carrying large items but is unable to elaborate on this. Patient states he has a long history of chronic hip/back pain. His typical pain is bilateral hip, front think and buttock "shock like pain" without radiation that is daily, intensifies with movement (worst in AM when getting out of bed and out of a chair) and when laying flat. He typically takes ___ advil in the morning before he gets out of bed but this doesn't help very much. He reports he has never tried typical neuropathic pain agents. He describes worsening of the pain for the last ___ months without a clear provoking etiology. For the last ___ days, he has noted working shock like pain especially in hips and a mild ache in his mid back. He does report he fell up the stairs 3 weeks ago while carrying packages (the weight carried him forward) and he landed on his chest but did not note worsening in his chronic pain at that time. He specifically denies chest pain, dyspnea, jaw/arm pain, diaphoresis, nausea recently or today. He denies recent fevers, chills, night sweats, weight loss. He reports he has had two episodes of spinal infection and was unsure of his symptoms at that point. Patient denied any saddle anesthesia, urinary retention, bowel or bladder incontinence, or fevers. Patient did describe intermittent weakness of left lower extremity and numbness of the whole leg that occurs with position but none now. Past Medical History: Afib on warfarin CAD s/p stent placement CHF with EF ___ mitral valve prolapse HTN HLD depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery Social History: ___ Family History: Mother: alive, age ___. Macular degeneration Father: deceased in ___. ?brain tumor and heart issues Physical Exam: ADMISSON PHYSICAL EXAM ===================== VITALS: 98.1 110 / 61 87 20 97 2LNc GENERAL: Alert and interactive. In no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: No JVD. CARDIAC: Irreg irreg rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout, patient grimacing when checking hip flexion. Normal sensation. AOx3. DISCHARGE PHYSICAL EXAM: ========================= VITALS: 97.7 PO 99/61 L Lying 80 18 92 2L GENERAL: Laying in bed, NAD HEENT: EOMI grossly, anicteric sclera, MMM HEART: Irregular rhythm, normal S1/S2, no murmurs, gallops, or rubs. LUNGS: Diffusely decreased breath sounds ABDOMEN: Normoactive bowel sounds. Soft, distended, tympanic, nontender in all quadrants, no rebound/guarding. EXTREMITIES: no cyanosis, clubbing, or edema, moving all 4 extremities with purpose, warm w good cap refill NEURO: A/O X3 (person, place, time) Pertinent Results: ___ ===================== ___ 11:30PM BLOOD WBC-7.3 RBC-3.18* Hgb-11.5* Hct-34.1* MCV-107*# MCH-36.2*# MCHC-33.7 RDW-16.2* RDWSD-62.9* Plt ___ ___ 11:30PM BLOOD Neuts-77.1* Lymphs-10.3* Monos-10.0 Eos-1.4 Baso-0.8 Im ___ AbsNeut-5.63 AbsLymp-0.75* AbsMono-0.73 AbsEos-0.10 AbsBaso-0.06 ___ 11:30PM BLOOD ___ PTT-28.8 ___ ___ 11:30PM BLOOD Glucose-102* UreaN-44* Creat-1.5* Na-144 K-3.5 Cl-103 HCO3-24 AnGap-17 ___ 01:35PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.2* ___ 01:35PM BLOOD VitB12-321 ___ 07:12AM BLOOD TSH-1.6 ___ 11:30PM BLOOD CRP-50.0* ___ 05:30PM BLOOD Cortsol-19.6 ___ 07:56PM BLOOD CK-MB-3 cTropnT-0.46* ___ ___ 06:27AM BLOOD ALT-30 AST-27 AlkPhos-191* TotBili-0.5 ___ 03:00PM BLOOD calTIBC-251* Ferritn-829* TRF-193* ___ 01:35PM BLOOD SED RATE- 46 MICROBIOLOGY ===================== ___ 2:00 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 2:33 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ STOOL C. difficile DNA amplification assay- POSITIVE ___ 2:35 pm PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ MRSA SCREEN- NEGATIVE ___ Blood Culture x2: NO GROWTH ___ 10:35 am PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ Blood Culture x2: NO GROWTH, Routine-FINAL INPATIENT ___ URINE CULTURE- NO GROWTH ___ Blood Culture x2 NO GROWTH PLEURAL FLUID ANALYSIS: ======================= ___ 10:35AM PLEURAL TotProt-2.4 Glucose-90 Creat-3.5 LD(___)-104 Albumin-1.2 ___ Misc-BODY FLUID ___ 10:35AM PLEURAL TNC-62* RBC-___* Polys-4* Lymphs-75* Monos-8* Atyps-8* Macro-5* Other-0 ___ 02:35PM PLEURAL TotProt-1.7 Glucose-89 Creat-1.6 LD(___)-103 Albumin-1.1 Cholest-20 ___ 02:35PM PLEURAL TNC-49* ___ Polys-23* Lymphs-74* Monos-2* Macro-1* ___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS. ___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS. DISCHARGE LABS: ================ ___ 04:35AM BLOOD WBC-7.1 RBC-2.53* Hgb-8.8* Hct-27.3* MCV-108* MCH-34.8* MCHC-32.2 RDW-16.7* RDWSD-66.0* Plt ___ ___ 04:35AM BLOOD Glucose-88 UreaN-20 Creat-1.2 Na-140 K-4.1 Cl-100 HCO3-26 AnGap-14 ___ 04:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 IMAGING ====================== MRI spine ___ IMPRESSION: 1. Study is degraded by motion and by lumbar spinal fusion hardware artifact. 2. Cervical degenerative disc disease as detailed above, without high-grade spinal canal narrowing or cord signal abnormality. There is severe neural foraminal narrowing at multiple levels. 3. Mild thoracic degenerative disc disease, without high-grade spinal canal or neural foraminal narrowing. 4. Loculated right pleural effusion basilar right lower lobe could reflect atelectasis, however pneumonia cannot be excluded. Chest CT is suggested. 5. Instrumented lumbar fusion at L4-S1, interbody fusion graft at L3-4 with partial osseous fusion, and solid osseous fusion of the L2-3 level as detailed above. 6. L1-2 disc extrusion with superior migration results in severe spinal canal narrowing. There is probable impingement of the traversing L2 and possibly other nerve roots. Allowing for difference technique, finding may be slightly progressed compared to ___ prior exam. 7. Within limits of study, no definite evidence of discitis-osteomyelitis, or epidural abscess. 8. Probable subacute to chronic oblique fracture of the superior endplate of L2 with lateral extension through the lateral vertebral body. 9. Right L1-2 and bilateral L2-3 Severe neural foraminal narrowing. CXR ___ IMPRESSION: There is a mild to moderate layering right pleural effusion. There is dilation of colon at the splenic fracture. CT A/P ___ IMPRESSION: 1. Volume loss in the right lower lobe may represent atelectasis or infection. Please correlate with clinical status. 2. No retroperitoneal hematoma or free intra-abdominal fluid. 3. Intermediate density fluid in the bladder may represent delayed excretion of iodinated contrast from prior CT study or hemorrhage products. Please correlate with visual inspection of the urine or urinalysis. 4. Moderate right pleural effusion. TTE ___ IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD (mid-LAD distribution vs. Takotsubo CM). Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild-mderate tricuspid regurgitation. Abdominal x-ray ___ IMPRESSION: Gaseous distension of the colon, appearing unchanged compared to the recent CT scan DX PELVIS & FEMUR ___: No fracture of the bilateral femurs. CT CHEST ___: 1. Mild to moderate right pleural collection containing loculated fluid and air with a chest tube in situ. Mild-to-moderate free-flowing left pleural effusion. 2. Bilateral patchy peripheral ground-glass opacities are concerning for an atypical infection. Presence of interlobular septal thickening may be secondary to pulmonary edema. Clinical correlation is recommended. 3. Mild mediastinal and hilar lymphadenopathy is nonspecific and could be related to infections. PORTABLE ABDOMEN ___ Interval improvement of dilation of large bowel, however large bowel dilation has not resolved. There is no evidence of intraperitoneal free air. Brief Hospital Course: PATIENT SUMMARY: ================ Mr. ___ is a ___ year old man with w/ HFrEF, CAD s/p stent, atrial fibrillation on Xarelto, ___ syndrome, CKD, chronic neck pain ___ cervical disc disease and multiple spine surgeries including fusion of L-S1 laminectomy who presented to OSH with ___ weeks of worsening back pain and left hip pain, transferred for spine eval, with MRI negative for infection, admitted for pain management. Hospital course was complicated by oliguric renal failure in setting of contrast load on ___ and NSAID use, and hypotension in setting of receiving entresto and diuresis, requiring transfer to the MICU for worsening hypoxia and persistent hypotension. He was found to have R side pleural effusion with improvement after chest tube placement x2 ___, removed, replaced ___. Further hospital course complicated by C difficile. ACUTE ISSUES: ============= #Hypoxemia #Right pleural effusion #Concern for RLL PNA #Trapped lung On arrive to ED at ___, pt noted to be developing progressive hypoxemia requiring nasal cannula in setting of developing oliguric renal failure. Suspected multifactorial due to PNA, pleural effusion, & pulmonary edema from volume overload. Effusion likely chronic per review of imaging, and potentially has formed fibrosis causing trapped lung. s/p R side chest tube ___, which was removed same day after minimal draining, replaced ___ for reaccumulation and quickly removed again. CT chest ___ also indicated possible atypical PNA, completed 7 day course of cefepime for HAP (___), transitioned briefly to ceftriaxone/azithro (___). He was also found to have e/o volume overload in setting of diuretic held and receiving IVF for hypotension. Hypoxia improved somewhat with gentle diuresis, and home Lasix was restarted three days prior to discharge with stable volume status and oxygen requirement. At time of discharge, he is still requiring oxygen although has decreased from 4L to 1.5-2L. Likely will remain dependent on oxygen until decortication after rehab. Eventual plan is to likely decortication per IP, who will follow outpt with patient in 4 weeks, when he will also receive a chest CT. #Hypotension #History of Hypertension Initially suspected PNA & Entresto use I/s/o sepsis. Entresto and diuretics were held. Per nephrology, sacubitril's inhibition of neprilysin leads to increase in several vasoactive substances including BNP and bradykinin which are vasodilators, and likely culprits for what appears to be his prior distributive hypotension. Metoprolol succinate home dose is 225 mg; he was switched to metoprolol succinate 50mg daily with good blood pressure and HR control. BP remained stable 99-103/62-70 since ___. Discussed ___ meds with outpatient cardiologist Dr. ___ requested that patient remain on BB and at least a low-dose ACEi if tolerated. Started lisinopril 2.5mg daily on ___, patient tolerating well on discharge. Holding home entresto on discharge. #C difficile infection Pt w frequent loose stools that developed during hospitalization, found to be cdiff+ on ___ and started on PO vanc ___. Switched to PO flagyl (___) as infection not considered to be complicated, for 10d course ending ___. ___ #?CKD Likely multifactorial from CIN (given contrast on ___ at OSH), NSAID-use, valsartan in Entrosto +/- ATN. Cr 1.5 on admission ___ and peaked to 3.4. Creatinine stable around 1.2-1.4 for the week prior to discharge, baseline unknown but likely has some underlying mild CKD. #Acute on chronic back pain #Hip/leg pain Patient with hx of multiple prior spinal surgeries with hardware in place and spinal osteomyelitis/discitis/epidural abscess in ___. He presented with 4 days of worsening back pain. CRP 50, concerning for infectious process, however MRI showed no e/o infection. Spine surgery consulted and no acute intervention needed. XR b/l femur showed generalized degenerative changes throughout b/l SI joints, hip joints, and pubic symphysis. No fracture. Etiology of pain unclear but likely multifactorial from DJD and frequent surgeries. Managed with lidocaine patches, acetaminophen standing, and tramadol PRN. CHRONIC ISSUES: =============== #HFrEF, CAD #Troponinemia Pt with hx of CAD and HFrEF 35%, likely iCMP. Troponins mildly elevated in setting ___ to 0.46 without CK-MB elevation or ischemic changes on EKG. Continued home ASA 81mg and atorvastatin 10mg PO QD. For preload, held home metolazone given hypotension, diuresis as above. Home metop dosing was changed as above. Held home entresto given ___ and hypotension as above, started 2.5mg lisinopril for afterload mgmt per outpatient cardiologist. Will have outpatient followup. #Afib (CHADS2VASC = 3) Anticoagulation was briefly held for chest tube placement, after which home Xarelto was held. Home metoprolol changed as above, discharged on 50 mg succinate daily with good rate control. ___ syndrome Pt dx during an admission in ___. Was monitored during hospitalization, especially in setting of receiving narcotics, with some abdominal distension noted. KUB obtained ___ showed interval improvement in colonic distention from prior imaging. #Gout: Continued home allopurinol ___ mg QD #Depression: Continued home sertraline 50 mg PO QD #GERD: Continued home omeprazole 20 mg PO QD #Acute on chronic macrocytic anemia MCV elevated from last admission: Continued Ferrous Sulfate 65 mg PO DAILY TRANSITIONAL ISSUES: ====================== NEW MEDICATIONS -Acetaminophen 1g TID (for pain) -Calcium carbonate 500mg QID PRN (heartburn) -Ipratropium-Albuterol Neb Q4H PRN (SOB, wheezing) -Lidocaine 5% patch QPM (for pain) -Lisinopril 2.5mg PO daily (for CHF, HTN) -Flagyl 500mg PO Q8H (cdiff, abx course ___ -Ondansetron ODT 8mg PO Q8H PRN (nausea, vomiting) -Tramadol 50mg PO Q4H PRN (moderate pain) -Tramadol 50mg PO BID PRN (severe pain) -Oxygen support (usually on ___ NC) CHANGED MEDICATIONS -Metoprolol succinate XL 50mg PO daily (changed from 125 QAM and 100 QPM given hypotension) STOPPED/HELD MEDICATIONS -Metolazone 2.5mg PO every other day (held for hypotension, ___ -Sacubitril-Valsartan 24mg-26mg BID (held for hypotension, ___ OTHER: [ ]Will follow-up with interventional pulm and Thoracics in 4 weeks for chest CT and to discuss need for decortication of fibrotic trapped lung [ ]S/P R side chest tube ___ [ ]Please discuss mgmt. of patient's HTN and CHF, his BPs remained soft (100s/50s) throughout hospitalization despite ___ agents had been held for a week. [ ___ appt w PCP/cardiology Dr. ___ on ___ [ ___ appt with IP to be scheduled, likely ___ as pt has chest CT scheduled that day [ ]Pt being discharged to rehab on oxygen ___ NC). If unable to wean at rehab, will need home O2 as well. [ ___ need further titration of pain medication with increased activity at rehab. #code status: full #contact: ___ ___ (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 10 mg PO QPM 4. Sertraline 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Metolazone 2.5 mg PO EVERY OTHER DAY 7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 8. Metoprolol Succinate XL 125 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO QHS 10. Ferrous Sulfate 65 mg PO DAILY 11. magnesium chloride 1250 oral DAILY 12. Rivaroxaban 20 mg PO DAILY 13. Furosemide 80 mg PO QAM 14. Furosemide 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 4. Lidocaine 5% Patch 1 PTCH TD QPM 5. Lisinopril 2.5 mg PO DAILY 6. MetroNIDAZOLE 500 mg PO Q8H ___ - ___ 7. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity hold for somnolence or RR<12 RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*18 Tablet Refills:*0 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Allopurinol ___ mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 10 mg PO QPM 13. Ferrous Sulfate 65 mg PO DAILY 14. Furosemide 80 mg PO QAM 15. Furosemide 40 mg PO QPM 16. magnesium chloride 1250 oral DAILY 17. Omeprazole 20 mg PO DAILY 18. Rivaroxaban 20 mg PO DAILY 19. Sertraline 50 mg PO DAILY 20. HELD- Metolazone 2.5 mg PO EVERY OTHER DAY This medication was held. Do not restart Metolazone until until you talk to your cardiologist 21. HELD- Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID This medication was held. Do not restart Sacubitril-Valsartan (24mg-26mg) until you talk to you cardiologist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary -Acute hypoxemic respiratory failure -Chronic pleural effusions -Trapped lung, R side -Hypotension -Acute kidney injury -Cdiff infection -Acute on chronic back, hip pain SECONDARY -Heart failure with reduced ejection fraction -Coronary artery disease -Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You came to the hospital because you were having terrible back pain and the doctors at the ___ hospital were concerned you might have an infection in your back. While you were here, we did not see any evidence of infection in your back, but we did notice you had fluid behind your lungs (pleural effusions). We drained these, treated you for pneumonia, and gave you oxygen to support your breathing. We also noticed that your blood pressure was very low. We stopped your blood pressure medications for a little while, and restarted some of them at lower doses. Your cardiologist should talk to you about these at your follow-up appointment next week. When you leave, you will go to rehab to work on your strength and mobility. You will continue to use your oxygen until you feel more comfortable off of it. It was a pleasure to care for you. We wish you the best in your recovery. ___ Medicine Care Team Followup Instructions: ___

19994379-DS-15

DS

2131-06-21 00:00:00

2131-06-21 14:52:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / oxycodone Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ YO M with afib on rovarozaban, CAD s/p stent placement, HFrEF (EF ___, mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from rehab with dyspnea, felt to be in acute heart failure exacerbation ___ holding of diuretic regimen at rehab in setting of hypotension. He brought in from rehab with concern of shortness of breath and increased pleural effusion on CXR at rehab. Per ED notes: He's had recent hospitalization for hypoxemia, pneumonia and right sided pleural effusion. He had a chest tube placed x2 by IP with fluid consistent with HF and concern for trapped lung as well. Patient treated with abx for presumed pneumonia and discharged to rehab on 1.5-2L NC. While in rehab weaned off O2 by ___ but started to have new O2 requrimenet yesterday that increased to 2L NC again today. SOB worse with movement. No chest pain, fever/chills/ night sweates or new cough. Notes increase in abdominal distension though diarrhea has improved now while he remains on antibiotics for c.diff. Notes weight gain of ~15 lbs with dry weight of 205 and 220 this am at rehab In the ED initial vitals were: 97.9 86 107/57 22 99% 2L NC ED exam notable for: Gen:NAD, breathing comfortably on 2L O2, AOx3 CV: irregularly irregular, no murmurs, JVD to jawline Pulm: Decreased right sided lower breath sounds, no crakcles Abd: soft, significantly distended, no peritoneal signs, non-tender, ___: 3+ edema bilaterally up to the low thigh Labs/studies notable for: 6.7 > 8.___.7 < ___ ------------<116 AGap=14 5.4 23 1.1 Trop-T: <0.01 proBNP: ___ Lactate:2.6 CXR notable for: FINDINGS: AP portable upright view of the chest. No significant change from recent prior exam with loculated right pleural effusion tracking circumferentially with a similar overall pattern. Opacities within the right lung again noted. Left lung is grossly clear. The heart appears mildly enlarged. Mediastinal contour stable. Imaged bony structures are intact. Multiple surgical anchors are noted at bilateral humeral heads. IMPRESSION: No significant interval change. Patient was given: ___ 16:28 IV Furosemide 80 mg Patient was seen by cardiology: Per Cards ED evaluation: "Patient presenting with likely primarily CHF exacerbation. Patient unclear if he has been taking diuretics appropriately, which could be precipitant. Given this is the primary reason for admission, his reduced EF, and some concern that diuresis was being held at rehab due to hypotension." Recommended admission to Cardiology. Per ED assessment: "Likely HFrEF exacerbation with weight gain and increase in shortness of breath and ___ edema. AM Lasix held for a few days while in rehab given soft BP that may have caused volume overload. Will touch base wit IP re worsening shortness of breath and history of concern for trapped lung and placement of chest tube. CXR without evidence of new consolidation or significantly worsening pulm edema though has right sided pleural effusion tracking circumferentially. Clinically without fever, new cough, or sputum production concerning for pneumonia. No evidence of pericardial effusion on bedside echo. No ascites on bedside echo either. Abdominal distenstion without n/v and with regular bowel movement unlikely caused by obstruction though has history of ___ syndrome." Of note, patient is s/p discharge on ___ after presenting to OSH with ___ weeks of worsening back pain and left hip pain, transferred for spine eval, with MRI negative for infection, admitted for pain management. Hospital course was complicated by oliguric renal failure in setting of contrast load on ___ and NSAID use, and hypotension in setting of receiving entresto and diuresis, requiring transfer to the MICU for worsening hypoxia and persistent hypotension. He was found to have R side pleural effusion with improvement after chest tube placement x2 ___, removed, replaced ___. Further hospital course complicated by C difficile. Vitals on transfer: 97.6 109 100/76 22 94% 3L NC On the floor... He reports he was at rehab and things were going fairly well. He reported they took him off O2 on ___ through the weekend until ___ (back on O2). He reports that he didn't have much activity over the weekend, but this Am he reported that he felt more SOB and was sent back. He reports he feels "bloated" but denies weight gain; he reports his weight at rehab was 223-224; he doesn't remember what his weight was when he got to rehab (?220). He reports his dry weight is about 205 lbs. He reports his SOB has been going on "for a long time"; he first noticed it a few months. He reports some improvement after his chest tubes; he reported once he was active at rehab his respiratory symptoms had improved. Denies CP, but does report occasional "palpitations" but he denies attributing this to his afib (and reports it has seemed to have gotten better.) Rpeorts some lightheadedness this AM. Denies LOC. Reports significant leg swelling. Denies recent infections, cough or cold symptoms. Denies abd pain, n/v but reports some nausea with c diff medication but none in the past two days. Reports + diarrhea at admission today x2. He reports this seems like his C. diff symptoms. Denies dysuria. Denies blood in stool or urine. Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD s/p stent placement - CHF with EF ___ - Afib on warfarin - mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery c diff infection ___ Social History: ___ Family History: Mother: alive, age ___. Macular degeneration Father: deceased in mid ___. ?brain tumor and heart issues Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: Temp: 98.4 (Tm 98.4), BP: 103/74 (90-134/49-87), HR: 111 (111-148), RR: 26 (___), O2 sat: 93% (86-97), O2 delivery: 2LNC (2LNC-3L), Wt: 218 lb/98.88 kg GENERAL: Well developed, well nourished M, sitting at bedside in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI grossly. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to angle of mandible at 90 degrees CARDIAC: PMI located in ___ intercostal space, midclavicular line. irregularly irregular rate, Tachycardic. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. diminished lung sounds R lung extending up to mid lung fields. no crackles appreciated bilaterally; no wheezes. ABDOMEN: Soft, non-tender, mildly distended EXTREMITIES: extremities slightly cool perfused. 3+ pitting edema to knees bilaterally DISCHARGE PHYSICAL EXAMINATION: ================================= PHYSICAL EXAM: VS: 98.3 90/52 89 18 94% Ra GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric NECK: supple, JVP to 10 cm LUNGS: Decreased BS in RLL, no wheezing CV: Irrregular, tachycardic, ___ pansystolic murmur at apex and LLSB ABD: mild distention, non-tender, and soft, normoactive BS EXT: Warm, non-edematous bilaterally, non-tender NEURO: No gross motor or coordination abnormalities Pertinent Results: ADMISSION LABS ======================== ___ 12:50PM BLOOD WBC-6.7 RBC-2.63* Hgb-8.9* Hct-27.7* MCV-105* MCH-33.8* MCHC-32.1 RDW-16.2* RDWSD-62.4* Plt ___ ___ 12:50PM BLOOD Neuts-76.2* Lymphs-7.2* Monos-13.8* Eos-1.4 Baso-0.9 Im ___ AbsNeut-5.08 AbsLymp-0.48* AbsMono-0.92* AbsEos-0.09 AbsBaso-0.06 ___ 12:50PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-135 K-5.4* Cl-98 HCO3-23 AnGap-14 ___ 12:50PM BLOOD CK(CPK)-42* ___ 06:20AM BLOOD ALT-<5 AST-9 LD(LDH)-180 AlkPhos-94 TotBili-0.7 ___ 12:50PM BLOOD CK-MB-2 proBNP-6666* ___ 12:50PM BLOOD cTropnT-<0.01 ___ 09:35PM BLOOD Calcium-8.9 Phos-2.6* Mg-1.2* ___ 01:11PM BLOOD Lactate-2.6* K-5.1 ___ 01:34PM BLOOD Lactate-1.8 PERTIENT LABS ======================== ___ 06:20AM BLOOD calTIBC-212* VitB12-498 Folate-3 Ferritn-500* TRF-163* ___ 06:50AM BLOOD Vanco-66.0* DISCHARGE LABS ======================== ___ 08:10AM BLOOD WBC-7.2 RBC-2.55* Hgb-8.2* Hct-26.0* MCV-102* MCH-32.2* MCHC-31.5* RDW-17.0* RDWSD-63.9* Plt ___ ___ 08:10AM BLOOD Plt ___ ___ 08:10AM BLOOD ___ PTT-35.1 ___ ___ 08:10AM BLOOD Glucose-93 UreaN-31* Creat-1.7* Na-136 K-3.9 Cl-93* HCO3-30 AnGap-13 ___ 02:11AM BLOOD ALT-<5 AST-11 LD(LDH)-217 AlkPhos-79 TotBili-1.0 DirBili-0.4* IndBili-0.6 ___ 08:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7 IMAGING ======================== CXR ___ AP portable upright view of the chest. No significant change from recent prior exam with loculated right pleural effusion tracking circumferentially with a similar overall pattern. Opacities within the right lung again noted. Left lung is grossly clear. The heart appears mildly enlarged. Mediastinal contour stable. Imaged bony structures are intact. Multiple surgical anchors are noted at bilateral humeral heads. CT CHEST ___ Persistent large and probably loculated right hydropneumothorax, probably reflecting chronic restrictive right pleural thickening, in combination with severe lower lobe atelectasis. No contributory bronchial obstruction. Severe coronary atherosclerosis. Mild cardiomegaly. Substantially improved bilateral airspace pulmonary abnormality, nature indeterminate, could be post infectious or slow to resolve hemorrhage. KUB ___ Colonic obstruction, worse than on prior examination. There is an abrupt cutoff of the colonic dilatation in the proximal descending colon, as on prior CT. The possibility of a stricture at this level is suggested. No free air on supine. CT A/P ___. Colonic distension is minimally increased since the prior study measures approximately 8.1 cm, previously measured 7 cm with smooth tapering in the proximal descending colon is suggestive ___ syndrome. No gross stricture identified. 2. Small bowel is normal caliber. No evidence of bowel obstruction. 3. Air-fluid levels within the colon suggests a diarrheal state. 4. Partially visualized known right hydropneumothorax. 5. Ground-glass opacifications in the visualized central left lower and anterior left upper lobe are nonspecific and may reflect an infectious or inflammatory process. CT CHEST ___. Extensive progression of more confluent areas of ground-glass opacification in a peribronchovascular distribution involving the entire left lung since the prior study of ___, raises concern for infection. Asymmetric pulmonary edema could also be considered.. 2. Overall stable appearance moderate right hydropneumothorax and associated collapse of the left lower lobe. 3. Slightly increased size of small left pleural effusion. CXR ___ FINDINGS: The heart size is enlarged, stable in appearance as compared to ___. Re-demonstrated are bilateral parenchymal opacities, unchanged with associated air bronchograms, more prominent on the right. There is a loculated right pleural effusion, no left pleural effusion. There is near complete atelectasis with the right lower lobe. There is unchanged over distention of the stomach. There is no pneumothorax. IMPRESSION: In comparison to the prior radiograph dated ___, there is stable appearance of near complete right lower lobe atelectasis with a now larger loculated right pleural effusion. Persistent bibasilar opacities. MICROBIOLOGY ======================== Blood Cx ___: No growth Blood Cx ___: No growth Blood Cx ___: No growth Urine Cx ___: No growth MRSA Screen ___: Negative C. Difficile ___: Negative Brief Hospital Course: BRIEF HOSPITAL COURSE =================================== ___ yo M with atrial fibrillation on rivaroxaban, CAD s/p stent placement, HFrEF (EF ___, mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from rehab with dyspnea and weight gain consistent with acute heart failure exacerbation likely secondary to missed diuretic doses at rehab (held for SBP < 100), treated with a Lasix drip to euvolemia. Once euvolemic, he still required 2L O2 and thoracic surgery was consulted for possible intervention for trapped lung. While awaiting intervention, patient had a vagal episode followed by hypotension and bradycardia requiring ICU admission. There was suspicion of GI bleed and he was transfused 2u pRBCs. He was briefly on pressors but was able to be quickly weaned. On transfer back to the floor, he continued diuresis but repeat chest CT showed increased ground glass opacities of the left lung concerning for infection versus pulmonary edema, so he was treated for HAP with vancomycin, ceftazidime and azithromycin. With antibiotics and diuresis, his dyspnea, hypoxia improved. ___ Course: Mr. ___ is a ___ man with A fib on rivaroxaban, CAD s/p PCI/stent, chronic systolic congestive heart failure (LV EF ___, mitral valve prolapse, hypertension, hyperlipidemia, and other issues admitted with acute pulmonary edema attributed to acute on chronic systolic congestive failure, with his hospital course complicated by GI bleeding and vasovagal event resulting in bradycardia to ___ when using the commode on ___. He recovered spontaneously without atropine. He subsequently became progressively hypotensive to ___, lactate 6.9, hgb drop 6.1 from 7.4. Dark brown, guaiac + stool. GI and ACS were consulted who did not recommend immediate intervention. KUB w/o free air. On arrival to the MICU, patient was awake and mentating well. Complaining mostly of back pain. Cdiff was ordered given for significant abdominal distention. Norepinephrine max 0.15 mcg/kg/hr, nurse was able to quickly wean to .04 prior to receiving blood. He was transfused with 2uPRBC and 1U FFP, chased with 100 mg Lasix. He was weaned off Levophed prior to transfer.) =============== ACTIVE ISSUES: =============== #Heart failure with reduced ejection fraction, acute decompensation: Patient with history of heart failure with reduced ejection fraction secondary to ischemic cardiomyopathy. Patient presented with >20lbs weight gain from dry weight and increased SOB, consistent with heart failure exacerbation likely secondary to missed diuretic doses at rehab (held for SBP < 100). He was treated with a lasix drip 20 mg/hr and lasix boluses of 160 mg IV to euvolemia. He was unable to tolerate a Persantine MIBI due to back pain, despite pre-medication. He was changed to Torsemide 60mg daily and remained euvolemic, however this dose was changed to 40mg daily given creatinine up to 1.7 (from baseline 1.2). He was discharged on diuretic regimen torsemide 40 mg daily. His metoprolol was uptitrated and he was discharged on metoprolol succinate XL 50 mg BID. Lisinopril 2.5 mg daily was HELD due to ___ on CKD (see below). Spironolactone could not be added on to regimen due to low blood pressure and increase in creatinine after two doses. #Hypoxemia: #Right pleural effusion/Trapped lung: #Pneumonia: Patient developed trapped lung as complication of anterior approach to L2-L3 fusion. Patient was hypoxic during last admission due in part to trapped lung and right sided pleural effusion, and he had chest tube placed x 2. Thoracic surgery was consulted, and deferred intervention urgently given poor clinical status. ___ benefit from VATS vs possible open thoracotomy decortication of entrapped right lung. Toward end of hospital course, patient developed more SOB and hypoxia requiring up to 4L NC. Repeat CT chest suggested increased ground glass opacities of left lung concerning for infection vs pulmonary edema, stable hydropneumothorax. Completed a course of vancomycin/ceftazidime/azithromycin (___). MRSA screen was negative. After management with antibiotics and diuresis, patient's oxygen requirement decreased to 96% RA. However, patient did occasionally require ___ with exertion (desat to 87%). Thoracic surgery and IP will follow up as outpatient. #Atrial fibrillation: Patient's rates were well controlled after up-titrating metoprolol to succinate XL 50 mg BID (HR ___, peaked in 130s with significant exertion). Patient was on metoprolol XL 225mg daily prior to last admission, which was decreased to 50mg daily at discharge ___. This had been further reduced to 12.5mg at rehab prior to this admission. He was continued on Rivaroxaban 20 mg PO QHS and Metop XL 50mg BID. #C diff infection: Patient was diagnosed with C. difficile during last admission, and planned to complete PO flagyl 10 day course on ___. Per rehab records, it was unclear whether he completed this course. Given he reported ongoing diarrhea on admission, he was treated with a second 10 day course of PO vancomycin to ensure complete treatment, with course from ___. C. diff negative on ___. #Abdominal distention with Ogilvies: Pt with known history of ___ syndrome. He was noted to have prominent abdominal distention without pain, constipation, or other concerning signs. Had CT abdomen consistent with Ogilvies. A bowel regimen was continued. Abdominal distention improved. ___ on CKD: Baseline 1.2, initially uptrended in the setting of diuresis despite appearing overloaded on exam, possibly related to ATN in setting of transient hypotension from valsalva, bradycardic episode. Cr improved later with continued diuresis but increased again on ___ possibly in the setting of starting spironolactone, which was discontinued. On ___, a vancomycin level was checked which was elevated at 66. Creatinine started to increase 48 hours after this, and additionally patient was given Spirinolactone x 2 days. Likely both of these insults explain the worsening ___. His lisinopril was stopped and Torsemide was decreased to 40mg daily. On discharge, Cr 1.7 (baseline 1.2). Patient euvolemic and I/Os and weight stable, however Torsemide was decreased due Cr 1.7. It is expected that patient's creatinine will start to improve ___ weeks after Vancomycin, Spirinolactone, Lisinopril were stopped, and Torsemide decreased. A post void residual was 21. Patient should avoid all NSAIDs going forward. #Macrocytic Anemia: Noted to have macrocytic anemia with hemoglobin ___ during admission. Prior to transfer to ICU, he was noted to have guaiac positive stool with hemoglobin drop and was transfused 2u pRBCs. Iron studies showed an Fe/TIBC 22%, consistent with mild iron deficiency. B12 and folate were normal. Methylmalonic acid was WNL. His Ferrous Sulfate 325 mg PO DAILY was continued at discharge. Please re-check iron studies to ensure no iron toxicity on supplemental iron and discontinue supplemental iron when iron replete. If within goals, pt may be further evaluated for MDS. # Shock, hypotension, lactic acidosis (resolved): Patient developed hypotension and bradycardia in setting of valsalva c/w vagal event. However, had persistent hypotension after event with elevated lactate to 6.9 and hgb drop to from 7.4 to 6.1, guaiac positive stools, cool extermities, and volume overload with elevated JVP. Initially, concern for hemorrhagic shock (Hgb drop and guaiac positive stools) vs abdominal ischemia (distended abdomen, lactate) vs cardiogenic shock (cool, elevated JVP, increased BNP). Levophed was maxed, but rapidly weaned off prior to any other treatments. Lactate also resolved prior to any other treatments. ACS and GI were consulted for concern for abdominal compartment syndrome vs ischemia, but felt that exam was not concerning. He received 2U pRBC and 1U FFP chased with 100mg IV lasix with good Hgb response. No further signs of bleeding. Weaned off of pressors and was warm on exam. ================ CHRONIC ISSUES: ================ #Chronic back pain: #Hip/leg pain: Per last discharge summary, patient has history of multiple prior spinal surgeries with hardware in place. No evidence of infection during last admission. Etiology of pain is unclear but likely multifactorial from degenerative disc disease and frequent surgeries. He was continued on lidocaine patches, acetaminophen standing, gabapentin, and tramadol prn. His neurologic exam was intact. Consider chronic pain clinic outpatient for possible injection/nerve block. #Gout: Continued allopurinol ___ mg daily #Depression: Continued Sertraline 50 mg PO DAILY TRANSITIONAL ISSUES: ============================= [ ] DISCHARGE WEIGHT: 89.3 kg (196.87 lb) [ ] DISCHARGE DIURETIC: Torsemide 40 mg daily [ ] DISCHARGE ANTICOAGULATION: Rivaroxaban 20 mg PO QHS [ ] DISCHARGE BUN/CR: ___ [ ] FOLLOW UP LABORATORY TESTING: Recheck Chem 10, monitor lytes and creatinine ON ___. [ ] If Cr continues to uptrend, >2, would refer to Nephrology. [ ] Please continue to monitor weights and volume overload. Call Cardiology office with > 3 lb weight change. [ ] Please ensure follow-up with thoracic surgery and interventional pulmonology (appointments scheduled) for trapped lung. [ ] Please continue to monitor heart rates and atrial fibrillation. Metoprolol was uptitrated with improvement in rates (final dose Metop XL 50mg BID). [ ] Torsemide reduced to 40 mg daily due to uptrending Cr [ ] Rivaroxaban dosing continued given GFR > 50, but may need to reduce dose if Cr continues to uptrend >1.7. [ ] Holding lisinopril due to ___ on CKD. Please restart lisinopril 2.5mg daily if Cr normalizes. [ ] Please re-check iron studies to ensure no iron toxicity on supplemental iron and discontinue supplemental iron when iron replete. [ ] Follow up on macrocytic anemia with further work up (?MDS). [ ] Please continue to counsel patients to avoid NSAIDs given his heart failure diagnosis and history of NSAID implicated acute tubular necrosis during last admission. [ ] Consider adding spironolactone as tolerated by creatinine to optimize HF regimen. [ ] Please note that Tramadol and Gabapentin were decreased given delirium earlier in hospitalization; pain was appropriately controlled at these smaller doses. [ ] Atorvastatin was increased to 40mg QPM this hospitalization. # CODE STATUS: FULL CODE # CONTACT: Name of health care proxy: ___ Relationship: daughter Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Furosemide 80 mg PO QAM 5. Furosemide 40 mg PO QPM 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Rivaroxaban 20 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. Acetaminophen 1000 mg PO TID 10. Calcium Carbonate 500 mg PO QID:PRN heartburn 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. Lisinopril 2.5 mg PO DAILY 14. MetroNIDAZOLE 500 mg PO Q8H 15. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 16. TraMADol 100 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 17. Ferrous Sulfate 325 mg PO DAILY 18. Pantoprazole 40 mg PO Q24H 19. Hydrocerin 1 Appl TP DAILY dry skin 20. Cholestyramine 2 mg gm PO BID 21. Gabapentin 300 mg PO TID 22. Milk of Magnesia 30 mL PO QHS:PRN constipation 23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 24. Bisacodyl ___AILY:PRN constipation 25. Docusate Sodium 100 mg PO TID:PRN constipation 26. Senna 17.2 mg PO QHS:PRN constipation 27. melatonin 3 mg oral QHS:PRN 28. Vancomycin Oral Liquid ___ mg PO Q6H 29. Magnesium Oxide 400 mg PO DAILY 30. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat Discharge Medications: 1. Torsemide 40 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 300 mg PO BID 5. Metoprolol Succinate XL 50 mg PO BID 6. TraMADol 75 mg PO BID:PRN Pain - Moderate 7. Acetaminophen 1000 mg PO TID 8. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 9. Aspirin 81 mg PO DAILY 10. Bisacodyl ___AILY:PRN constipation 11. Calcium Carbonate 500 mg PO QID:PRN heartburn 12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 13. Cholestyramine 2 mg gm PO BID 14. Docusate Sodium 100 mg PO TID:PRN constipation 15. Ferrous Sulfate 325 mg PO DAILY 16. Hydrocerin 1 Appl TP DAILY dry skin 17. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 18. Lidocaine 5% Patch 1 PTCH TD QPM 19. Magnesium Oxide 400 mg PO DAILY 20. melatonin 3 mg oral QHS:PRN 21. Milk of Magnesia 30 mL PO QHS:PRN constipation 22. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 23. Pantoprazole 40 mg PO Q24H 24. Rivaroxaban 20 mg PO QHS 25. Senna 17.2 mg PO QHS:PRN constipation 26. Sertraline 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: ============= - Heart failure with reduced ejection fraction, acute on chronic - Atrial fibrillation - Trapped lung, right pleural effusion - Pneumonia - Anemia - ___ syndrome - Acute on chronic kidney disease Secondary: ================== - C. difficile colitis - Chronic back pain - Gout - 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. ___, You were admitted to the hospital because you were short of breath. What happened while I was in the hospital? - You were found to have a lot of extra fluid in your body, so you were started on Lasix (a water pill). The fluid built up in your body because of your heart failure. - The thoracic surgery team evaluated your lung, and you should follow-up with them to discuss possible surgery for your lung. - You were treated with an antibiotic for a c. diff infection in your bowel. - You were briefly treated in the intensive care unit for low blood pressure and low heart rates. - You developed a pneumonia in the hospital, which was treated with antibiotics. What should I do when I go home? - Please take all your medicines as described in this discharge paperwork. - Please keep all your appointments with your doctors, as listed below. - You should not take any Advil, ibuprofen, Aleve or other pain relievers in the medication family called NSAIDS (non-steroidal anti-inflammatory drugs). - Please weigh yourself every morning, and call MD if weight goes up more than 3 lbs in 1 day or is steadily increasing. Your weight at discharge was 89.3 kg (196.9 lb). It was a pleasure to participate in your care, and we wish you all the best. Sincerely, Your ___ team Followup Instructions: ___

19994505-DS-13

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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Face pain and bleeding status post fall, Subarachnoid Hemorrhage Major Surgical or Invasive Procedure: Right lateral canthotomy History of Present Illness: HPI: ___ w DM, CHF w ___ placement, PVD s/p R BKA on ASA/plavix xfer from OSH s/p unwitnessed fall at nursing home with +LOC c/b severe oropharyngeal/sinus hemorrhage. Patient found down at nursing home with copious blood from nose and oropharynx. Taken by ambulance to ___ for evaluation. On arrival, patient A&Ox3 with non-focal examination however, continued to have profuse hemorrage from oropharynx and emergently intubated for airway protection and worsening hypotension (SBP ___. Notably, patient DNR/DNI at nursing home but participated in coherent conversation with ED attending regarding rescinding his DNR/DNI in this acute setting with which his wife concurred via telephone. Coffee ground material suctioned upon OGT placement. Also noted to have severe R proptosis w elevated IOP for which he received R lateral canthotomy. Resuscitated with 4 pRBC, 1 PLT, ___ FFP and 3L crystalloid with stabilization of BP. Subsequent radiographic studies demonstrated multiple R sided facial fx's and small R SAH. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia 2. CARDIAC HISTORY: - Cardiomyopathy LVEF 35% - LBBB type intraventricular conduction delay - Transient complete heart block 3. OTHER PAST MEDICAL HISTORY: - PVD - s/p R BKA - GERD - Cataract - Glaucoma Social History: ___ Family History: Father died at ___, Mother died of cancer. Physical Exam: On D/C, physical Exam: T Ax 94.5 HR 62 BP 106/60 RR 14 100 RA O2 Sa Gen: AO to person, unaware of location or date. Interactive but poor attention span HEENT: Patient has diffuse bruise, swelling over right perioribital area. Has improved markedly from admission. Unable to ascertain vision or color acuity due to mental status. PERRLA. Subconjunctival hemorrhage present in Right eye. CV: RRR, distant heart sounds, ___ S2 murumur Chest: Lungs CTA-B, slight bruises diffusely Abd: Soft, non tender, nondistended. Normoactive bowel sounds. Ext: R BKA. Bruises in various locations. Neuro: AOx1, moves all exts independently and with ___ strength. Skin: Diffuse bruises over significant portion of body. Improving over past week. Pertinent Results: ICD was interrogated by EP on ___. Normal ICD function and lead parameters. No ventricular arrhythmia >194bpm were recorded. No AT/AF episodes were recorded. TTE: ___ The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15%) secondary to severe hypokinesis to akinesis of all segments and relative preservation of the basal-mid lateral wall. A left ventricular mass/thrombus cannot be excluded CT SINUS/MANDIBLE/MAXIL ___ IMPRESSION: 1. Bilateral medial maxillary sinus wall fractures, right anterior maxillary sinus wall fracture, right orbital floor fracture, and right orbital hematoma. 2. Radiopaque density in the right facial soft tissues may represent a radiopaque foreign body. CT C-Spine W/o contrast ___: FINDINGS: There is no acute fracture or malalignment. The vertebral heights are preserved. There is no prevertebral soft tissue abnormality. The patient is intubated. Blood/mucus is seen in the nasopharynx, oropharynx and hypopharynx. There are moderate degenerative changes of the cervical spine, most prominent at C5-6 to C6-7. The visualized lung apices are grossly clear. The thyroid is unremarkable. There is opacification of the right mastoids. IMPRESSION: No fracture or malalignment. Moderate degenerative changes. CT Head w/o Contrast ___: FINDINGS: There is a small right temporal subarachnoid hemorrhage (601B, 77). No other areas of hemorrhage are identified. Hypodense area in the right frontal lobe reflect a chronic infarction. Periventricular white matter hypodensities are most consistent with chronic small vessel ischemic disease. The ventricles and sulci are enlarged consistent with atrophy. The fractures of the bilateral medial maxillary sinus walls and right anterior maxillary sinus wall and right orbital floor are better seen on dedicated facial CT. The mastoid air cells are well aerated. The ventricles and sulci are mildly enlarged consistent with atrophy. IMPRESSION: 1. Small subarachnoid hemorrhage in the right temporal lobe. 2. Hypodense area in the right frontal lobe represents a chronic infarction. CT Chest/Abd/Pelvis ___: FINDINGS: Thyroid is normal. There is no axillary, mediastinal or hilar lymphadenopathy. The heart is moderately enlarged and there are pacemaker wires in place. The aorta is normal in caliber and there is no evidence of dissection. There is no central filling defect in the pulmonary arteries. No pericardial effusion. The esophagus is normal and contains an enteric tube. There are dependent streaky consolidation, which may represent a combination of atelectasis and aspiration. No pneumothorax or pleural effusion. ABDOMEN: The liver is normal in appearance without evidence of injury. The gallbladde contains gallstones, but otherwise unremarkable. The spleen is normal. The adrenal glands are normal. The right kidney has a scarring at the lower pole. There is a small subcentimeter hypodensity in the left kidney, too small to characterize. No hydronephrosis. No evidence of kidney injury. The pancreas is normal. The stomach is normal. The small bowel is normal. he colon is unremarkable. The appendix is normal. There is no free fluid. No free air. No mesenteric or retroperitoneal lymphadenopathy. PELVIS: The bladder is normal. It contains a Foley catheter. The rectum is normal. There is no free fluid in the pelvis. The prostate and seminal vesicles are normal. No pelvic or inguinal lymphadenopathy. There is moderate atherosclerotic disease of the aorta but the aorta is normal in caliber. BONES: No fracture is identified. IMPRESSION: No injury to the chest, abdomen or pelvis. Streaky opacities in the lungs bilaterally may represent a combination of atelectasis and aspiration. ___ Swallow Evaluation: SUMMARY / IMPRESSION: Pt presents with decreased alertness/responsiveness and overt s/sx of aspiration during today's bedside swallowing evaluation. Pt does not yet appear safe for PO intake. We will follow up to repeat the bedside swallow evaluation. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 01:33 10.3 3.23* 10.2* 30.8* 95 31.5 33.0 15.5 173 ___ 01:33 ___ 19.1* PTT 28.4 INR 1.8 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 01:33 135*1 42* 1.5* 150* 4.0 111* 25 18 ___ 05:30PM CK(CPK)-46* ___ 05:30PM CK-MB-3 cTropnT-0.01 ___ 01:59PM TYPE-ART PO2-108* PCO2-45 PH-7.46* TOTAL CO2-33* BASE XS-6 ___ 01:59PM GLUCOSE-155* K+-4.0 ___ 01:59PM GLUCOSE-155* K+-4.0 ___ 01:59PM freeCa-1.15 ___ 09:39AM CK-MB-3 cTropnT-<0.01 ___ 09:39AM CK-MB-3 cTropnT-<0.01 ___ 02:57AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-50 PO2-195* PCO2-41 PH-7.46* TOTAL CO2-30 BASE XS-5 -ASSIST/CON INTUBATED-INTUBATED ___ 02:57AM LACTATE-1.3 ___ 02:57AM LACTATE-1.3 ___ 02:57AM freeCa-1.09* ___ 02:42AM GLUCOSE-180* UREA N-31* CREAT-1.1 SODIUM-140 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13 ___ 02:42AM CK-MB-3 cTropnT-<0.01 ___ 02:42AM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-2.0 Brief Hospital Course: Mr. ___, an ___ w DM, CHF w ___ placement, PVD s/p R BKA on ASA/plavix xfer from OSH s/p unwitnessed fall at nursing home with +LOC c/b severe oropharyngeal/sinus hemorrhage on ___. Patient found down at nursing home with copious blood from nose and oropharynx. Taken by ambulance to ___ for evaluation. On arrival, patient A&Ox3 with non-focal examination however, continued to have profuse hemorrage from oropharynx and emergently intubated for airway protection and worsening hypotension (SPB ___. Notably, patient DNR/DNI at nursing home but participated in coherent conversation with ED attending regarding rescinding his DNR/DNI in this acute setting with which his wife concurred via telephone. Coffee ground material suctioned upon OGT placement. Also noted to have severe R proptosis w elevated IOP for which he received R lateral canthotomy. Resuscitated with 4 pRBC, 1 PLT, ___ FFP and 3L crystalloid with stabilization of BP. Subsequent radiographic studies demonstrated multiple R sided facial fx's and small R SAH. Details of these studies can be found in the results section Mr. ___ was admitted to the ICU on ___. ICD was interrogated by EP on ___. Normal ICD function and lead parameters. No ventricular arrhythmia >194bpm were recorded. No AT/AF episodes were recorded. He remained on a ventilator and pressors overnight in the ICU while neurochecks were done every 4 hours to monitor his status. On ___ an attempt to extubate Mr. ___ was made, but he was reintubated in the evening due to mental status changes. On ___, a repeat head CT scan demonstrated no bleeding or CVA. A bronchoscopy done at this time demonstrated a moderate sized blood clot in left bronchus, otherwise the airways were clear without mucous or erythema. On this day the patient was also weaned from his pressors, and given 20 mg of Lasix for diuresis. On ___. The patient self extubated himself and was able to tolerate this without incident. He was AO x1-2, and was aware of his own name and his wife's. Plastic surgery signed off stating no need of operative repair of facial fractures or to repair right lateral canthotomy unless symptomatic while recovering. Pt may follow up in plastic surgery clinic ___ weeks after discharge. On ___ following a family discussion with the ICU team, a decision was made to make the patient DNR/DNI. A CT-scan on ___ showed no fracture or malalignment in the patient's c-spine. On ___, the patient was transferred to a regular floor. He was still on unasyn and NPO. Per a family discussion with Dr. ___ patient was made CMO. The patient also failed a bedside speech and swallow evaluation on ___. Following a second family meeting on ___, where the family's wishes in the patient's best interests were again explored, it was determined the family wished to continue with CMO, and in spite of the risk of aspiration, continue feeding him in order to make him as comfortable as possible. Case management began searching for a nursing home facility or hospice to transition him from the hospital to an environment mroe conducive to the family's wishes. On discharge it was determined that the patient would be CMO, and was attempting a regular diet in spite of a failed speech/swallow test. He may follow up as needed with various services, though no definite follow up appointments have been arranged. Ophtho evaluated the patient prior to his discharge, and recommended Erythromycin ointment BID to both eyes and to R lateral canthotomy site. Only as requested or tolerated as patient is comfort measures only. No acute ophthalmic interventions indicated. Family advised of patient condition and expectations and is in agreement with plan for CMO, DNR/DNI. Pt discharged on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Furosemide 80 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Lumigan (bimatoprost) 0.03 % ophthalmic QPM 8. TraZODone 50 mg PO HS 9. Finasteride 5 mg PO DAILY 10. Carvedilol 6.25 mg PO BID 11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 12. Docusate Sodium 100 mg PO BID 13. Restasis (cycloSPORINE) 0.05 % ophthalmic Q12 HRS 14. Gabapentin 100 mg PO TID 15. Klor-Con (potassium chloride) 20 mEq oral BID 16. Timolol Maleate 0.25% 1 DROP BOTH EYES BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Restasis (cycloSPORINE) 0.05 % ophthalmic Q12 HRS 5. Carvedilol 6.25 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Finasteride 5 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Klor-Con (potassium chloride) 20 mEq oral BID 10. Furosemide 80 mg PO DAILY 11. TraZODone 50 mg PO HS 12. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 13. Simvastatin 40 mg PO DAILY 14. Omeprazole 20 mg PO DAILY 15. Lumigan (bimatoprost) 0.03 % ophthalmic QPM 16. Lisinopril 2.5 mg PO DAILY 17. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID Duration: 7 Days ___ also apply to right lateral canthotomy site Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subarachnoid Hemorrhage, Retrobulbar hematoma status post lateral canthotomy, Right orbital floor fracture. Discharge Condition: Fair, Family requests Comfort Measures Only Mental Status: Confused - always. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Lethargic but arousable. Discharge Instructions: 1. Safest diet recommendation remains NPO 2. Given goals of care and family wish to try "comfort feeding", offering Pt a modified PO diet to reduce but not eliminate aspiration risk, suggest: - PO diet: nectar thick liquids and pureed solids - PO medications : crushed in puree 3. Strict aspiration precautions: a. 1:1 supervision with all PO's b. DO NOT FEED Pt during apneic moments c. sit fully upright d. have suction present at bedside during all PO trials e. make sure Pt is fully awake, alert, and attentive prior to offering PO's f. only offer small single bites/sips 4. Aggressive Q4 oral care 5. If plan to d/c home, family/caregivers ___ need education to carryover modified diet and aspiration precautions at home - if to be d/c's home Pt should obtain home suction Followup Instructions: ___

19994588-DS-10

DS

2194-07-07 00:00:00

2194-07-07 22:38:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: confusion, worsening weakness Major Surgical or Invasive Procedure: Therapeutic thoracentesis ___ History of Present Illness: ___ F w/ PMHx of Stage IV NSCLC (adenoCA) s/p whole brain radiation (completed 1 week ago) brought in from home by her son and ___ because of somnolence and increased shortness of breath. All history is from her daughter (primary caregiver) and son (at the bedside), as patient unable to answer questions. Since radiation, patient has had a progressive functional decline, requiring help to sit up and assistance walking (person and cane). One month ago she could walk with assistance, but this has declined to the point that she has not been out of bed for a couple of days. She is not on home oxygen. Family has noticed increased frequency of her chronic cough, now wet sounding, but patient has not been able to cough up sputum. No fever, though patient continuously complains of cold. ___ edema, rashes. No headaches. No dysuria, hematuria, but has new incontinence to urine x2 days. + diarrhea with incontinence. No melena. Has stopped eating x2 days, and has very little fluid intake. . Of note, she was seen in clinic ___ when her exam was notable for a marked decrease in her performance status, attributed to whole-brain radiation. She was advised to continue erlotinib, but deemed not a candidate for other chemotherapy. Past Medical History: Past Oncologic History: - presented with cough in ___. Due to marked dyspnea on exertion and persistent cough, she had CT in ___ which showed a hilar soft tissue mass, right pleural effusion and bilateral pulmonary nodules. - She underwent EBUS/biopsies and pathology demonstrated non-small cell lung cancer favoring adenocarcinoma. - PET/CT scan demonstrated her pulmonary disease and multiple osseous metastases. Brain MRI was negative. She was found to have 2 EGFR mutations: G719A mutation in Exon 18 and S768I mutation in Exon 20. She began erlotinib in ___. - After complaining of a headache in ___, MRI brain demonstrated brain metastases. She completed whole brain radiation with Dr. ___ on ___. - Admitted for confusion and weakness after completing whole brain radiation therapy, found to have UTI. After a family meeting, discharged home with home hospice. Other PMH: - Meningioma - GI bleed - Thyroid nodule - Hypertension - hypercholesterolemia - tremor - right total knee replacement - s/p thyroid surgery, recently being treated for hyperthyroidism - tremor predominant ___ disease, managed on zonesamide Social History: ___ Family History: There is no family history of lung cancer or any major history of disease. Most of her family lives in ___ and she is not aware of their health status. Physical Exam: Vitals - T: 97.5 BP: 124/62 HR: 80 RR: 18 02 sat: 100% on RA GENERAL: Lying in bed mumbling answers to son, does not obey any commands. Opens eyes with stimulation of extremities. SKIN: warm and well perfused, no excoriations or lesions, no rashes. No pressure ulcers. HEENT: AT/NC, pupils reactive when eyes opened, tracks movement, anicteric sclera, pink conjunctiva, patent nares. Dry mucous membranes, will not open mouth, has apparent poor dentition. NECK: supple, no LAD, JVP flat at 45 degrees CARDIAC: RRR, S1/S2, no mrg. Has pain with palpation of sternum. LUNG: poor effort, clear anteriorly, decreased at bilateral bases posteriorly ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: will not obey any commands. Toes downgoing bilaterally. Withdraws all extremities to stimuli. Normal tone. . Vitals 98 110/56 70 16 96% RA GENERAL: Lying in bed, alert and awake, smiles when she sees the medical team. SKIN: warm and well perfused, no rashes. HEENT: pupils reactive, tracks movement. poor dentition. CARDIAC: RRR, S1/S2, no mrg. LUNG: poor effort, clear anteriorly, decreased at bilateral bases ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities but moving upper extremities more than lower extremities, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: increased tone in lower extremities bilaterally. Will obey simple commands such as squeezing fingers but does not consistently follow other commands. Pertinent Results: admission labs: ___ 11:15AM BLOOD WBC-7.4 RBC-3.93* Hgb-12.5 Hct-39.1 MCV-99* MCH-31.8 MCHC-32.0 RDW-13.5 Plt ___ ___ 11:15AM BLOOD Neuts-83.9* Lymphs-9.7* Monos-4.5 Eos-0.8 Baso-1.2 ___ 11:15AM BLOOD ___ PTT-27.3 ___ ___ 11:15AM BLOOD Glucose-119* UreaN-19 Creat-0.7 Na-139 K-4.0 Cl-108 HCO3-21* AnGap-14 ___ 11:15AM BLOOD ALT-26 AST-49* AlkPhos-93 TotBili-0.9 ___ 11:15AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.2 Mg-2.1 ___ 08:14AM BLOOD Hapto-218* ___ 11:15AM BLOOD TSH-0.54 microbiology: ___ 01:40PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-8* pH-7.0 Leuks-SM ___ 01:40PM URINE RBC-<1 WBC-41* Bacteri-MANY Yeast-NONE Epi-1 UCx ___: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S 128 R TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S BCx ___: negative x2 Pleural fluid ___ : GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Cytology Pleural Fluid ___: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic adenocarcinoma. IMAGING: ___ CXR: Large right-sided pleural effusion. Suspicious nodule projecting over the right upper lobe. ___ CTA chest: 1. No evidence of pulmonary embolism. 2. Large right-sided pleural effusion, but not significantly changed, with associated atelectasis involving portions of the right lung. Small pericardial and left-sided pleural effusions are also present. 3. Widespread blastic metastases and suspected malignant involvement of the mediastinum and right hilum, but assessed very recently with PET-CT imaging where the degree of disease activity was more optimally characterized. 4. Secretions or debris in the trachea. 5. Vascular calcifications including coronary artery calcifications. 6. Large left-sided thyroid nodule. ___ CT head: 1. No acute intracranial process. 2. Stable olfactory groove meningioma. 3. Bone metastasis in the right parietal bone. Parenchymal brain metastases are not explicitly demonstrated on this study because it is a non-constrast examination, but there is no evidence for significant edema or mass effect. ___ MR thoracic/lumbar spine: 1. No evidence of cord compression. 2. Limited evaluation of the spine demonstrates new lesions at T6, T12, L4, L5 and S1 vertebral bodies, highly suspicious for metastatic disease. 3. Multilevel degenerative changes of the lumbar spine as described above, worse at L4-L5 and L5-S1 levels. 4. Large right pleural effusion and small left pleural effusion. ___ CXR: As compared to the previous radiograph, the patient has undergone right thoracocentesis. Right pleural effusion has substantially decreased. The remaining effusion is limited to the costophrenic sinus. There is no evidence of pneumothorax or other complications. Brief Hospital Course: ___ female with metastatic NSCLC with brain mets s/p whole brain radiation, with diffuse bony metastases, here with new confusion and progressive weakness/fatigue in last few weeks and new shortness of breath. Found to have UTI, treated with IV antibiotics with improvement in mental status. However, given the poor functional status after her recent radiation therapy, patient was thought not to be a candidate for chemotherapy. Family meeting was had discussing the poor prognosis given her disease progression on Tarceva, and no further chemotherapy option. Family decided to transition her to home hospice. # Toxic metabolic encephalopathy: Thought to be multifactorial, with UTI, dehydration and brain metastases +/- radiation all contributing. Patient started on ceftriaxone for UTI with improvement in mental status per family. Patient's family denies that she has been taking large amounts of narcotics which could have contributed to her mental status changes. Neurology was consulted and EEG was done, which showed diffuse slowing consistent with toxic metabolic encephalopathy. MRI of brain and spine were ordered but patient was not able to tolerate the procedure. As family wanted to focus more on patient's comfort, repeat attempt for MRI was not made in setting of patient's prior agitation. # Urinary tract infection: does not have any history of resistant infections. She was treated with ceftriaxone 1 gm Q24hrs x7 days. Urine cultures showed klepsiella and e. coli that were sensitive to ceftriaxone. # Weakness/incontinence: patient with worsening weakness/fatigue, concerning for cord compression/issues initially, difficult to get good neuro exam with patient's language barrier and mental status. As patient's mental status improved, she began moving all of her extremities spontaneously in bed, though she was weaker in lower extremities consistent with family's report. Given patient's complaint of numbness in right lower chest area, MRI of spine was done which did not show cord compression. Physical therapy evaluated the patient and recommended discharge to rehab. However, as patient was being transitioned to hospice, she was discharged home with hospice following. # Chest pain: patient complained of chest pain on admission, likely from sternal mets. EKG unchanged, troponin negative x3. Patient was maintained on tylenol and morphine prn for pain. # Shortness of breath: patient had acute on chronic worsening of cough and symptomatic SOB at home. CTA chest shows worsening of disease, no PE or PNA. Pt does have chronic pleural effusion on imaging. Patient treated with prn nebs with some improvement. Thoracentesis was done on ___ with subjective improvement in breathing. Patient's O2 sat remained stable on RA. # Choking/Dysphagia: as patient's mental status cleared up, she started eating, however nursing noted that patient seemed to be choking on the thin liquid. Speech and swallow evaluated the patient and recommended soft/dysphagia diet with nectar thick liquid. However, prior to discharge, she was noted to have difficulty even with soft food and was further downgraded to ground diet. The risk of aspiration was discussed with family member and she was educated on different kind of foods that would be safer for the patient to eat. # Goals of care: family meeting had on ___ where her prognosis was discussed. Unfortunately, patient's tumor has progressed on Tarceva, and given her poor functional status at this time after radiation therapy, patient is not a candidate for chemotherapy. This was discussed with the family members and information about hospice was given. Family stated their focus on taking her home and making her comfortable. TRANSITIONAL ISSUES: [ ] Patient discharged home with home hospice, but further discussions regarding code status are needed. Medications on Admission: Amlodipne (2.5mg tablet) 1 tablet by mouth once a day for blood pressue Calcium carbonate-vitamin D3 (600mg) 1 tablet by mount twice a day as needed for bones. Carvedilol (6.25mg) 1 tablet by mount twice a day. Codeine-guaifenesin (100mg-10mg/5ml liquid) ___ by mouth every 4 hours as needed for cough. Hold for sedation, confusion. Dextran 70-hypromellose (artificial 30-drop tears drops) One drop 4 times a day. Erlotinib (Tarceva) 100 mg 1 table by mouth daily. Food supplemental, Lactose-free (Ensure) 1 can - 3 times a day. Hydrocodone-acetaminophen (Vicodin) 5mg-500mg tablet. take 2 tablets by mouth every 6 hours as needed for pain relieve. Lidocaine (Lidoderm) 5% (700mg/patch) Adhesive medicated patch. Apply in AM, remove in ___ once a day as needed for pain. Losartan 50mg tablet 1 tablet by mouth once a day for high blood pressure Methimazole 5mg 0.5 tablet by mouth daily. Omeprazole 20mg capsule, Delayed Release (E.C.) 1 capsule by mouth twice a day for heartburn and acid. Ondarsetron 4mg tablet, Rapid dissolved 1 tablet by mouth every 8 hours as need for nausea. Oxycodone 5mg tablet 1 or 2 tablets by mouth every 4 hours as needed. Pravastatin 20mg tablet 1 tablet by mouth at bedtime. Zonisamide 25mg capsule 1 capsule by mouth twice a day. Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. codeine-guaifenesin ___ mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for cough: instead of codeine-guaifenasin liquid. . Disp:*30 Tablet(s)* Refills:*0* 4. dextran 70-hypromellose Drops Sig: One (1) Ophthalmic four times a day: for dry eyes. 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. methimazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. 9. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. 10. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: ___ Tablet, Chewables PO four times a day as needed for stomach upset. Disp:*60 Tablet, Chewable(s)* Refills:*0* 11. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath, wheezing or cough. Disp:*60 nebs* Refills:*0* 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for fever or pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: toxic metabolic encephalopathy secondary to urinary tract infection, metastatic nonsmall cell lung cancer with metastases to the brain Secondary Diagnosis: ___ disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear ___ was a pleasure to take care of you at ___ ___. You were brought in because of worsening confusion and weakness. You were found to have a urinary tract infection and were treated with IV antibiotics. These CHANGES were made to your medications: STOP Calcium carbonate and vitamin D3 STOP Vicodin STOP Prilosec (omeprazole) STOP Pravastatin STOP Zonisamide START tums as needed for stomach upset START Duonebs (albuterol-ipratropium) every 6 hours as needed for wheezing, cough or shortness of breath START tylenol ___ mg every 6 hours as needed CHANGE codeine-guaifenasin liquid to tablet Hospice will also bring a medication kit for other symptom management and will teach you how to use it at home. Followup Instructions: ___

19994592-DS-13

DS

2134-04-09 00:00:00

2134-04-09 09:32:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with a past medical history of bipolar disorder, OSA, GERD, and anemia; presenting with confusion for 3 days. History is difficult to obtain due to patient confusion, language barrier with family (despite translator), and records scattered across multiple providers ___, new PCP and new psychiatrist). She was brought to the ED by her family for 3 days of confusion. Her husband says that she has been walking around the house "like a zombie", "not making any sense" when she speaks, not eating, bathing, or sleeping. Family also notes intermittent outbursts of arm raising and shaking that is nonsynchronized, nonrhythmic, and resembles a protracted startle response (which they demonstrated). Her husband believes her symptoms are the result of recent medication changes by a new psychiatrist she is seeing. At a recent PCP ___ visit on ___ she was noted to be alert and oriented with an essentially normal exam. She complained of 15 days of headache at that time. She was referred to a new psychiatrist, who the husband says she saw on ___ and who reportedly changed her medications. The husband believes her altered mental status is result of the medication changes but he does not know specifically what these are. He believes she may be taking too many of some of her medications. The OMR note on ___ noted she was taking lithium 600mg BID, but apparently this has been stopped at present (-- her husband did not bring the medication and her serum level is low.) In the ED a CT head revealed a left posterior fossa mass consistent with a meningioma, exerting mass-effect on the left cerebellum causing edema and minor distortion of the fourth ventricle. Neurosurgery was consulted and they did not think that this mass was related to her alterations in mental status, so neurology was consulted. Past Medical History: -Bipolar disorder -OSA -GERD -Anemia -Hyperlipidemia -Hepatic steatosis Social History: ___ Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: Admission Physical Exam: Vitals: T:98.8 P:99 BP:143/72 r:20 SaO2:100% General: Awake, frequently moving in bed. Inattentive and not cooperative with exam. HEENT: NC/AT, no scleral icterus noted. Neck: Supple. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR Abdomen: Obese, soft, NT/ND. Neurologic: -Mental Status: Alert, not oriented no self, place, situation; said "I don't know" in ___ these questions but replied yes to whether her name was ___. Profoundly inattentive, continuously moving in bed and unable to cooperate with exam. -Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. -Motor: Moved all extremities equally. -Sensory: Reacted to light touch in all extremities. -Coordination: Appeared able to grab bed rails with both hands without apparent ataxia. -Gait: Able to stand unassisted. Stable gait, short steps. Discharge Physical Exam: Vitals: Tm 37.2, HR 65-87, BP 75-175/46-155, RR ___, >97% RA General: Awake, lying in bed quietly, NAD HEENT: NC/AT, no scleral icterus noted. Neck: Supple. Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: Obese, soft, NT/ND. Neurologic: -Mental Status: Awake, alert, refuses to participate with exam; looks away to avoid eye contact -Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. -Motor: Moved all extremities equally antigravity -Sensory: Withdraws to light touch in all extremities. -Coordination: No truncal ataxia, no dysmetria reaching for objects Pertinent Results: ___ 05:15AM BLOOD WBC-8.8 RBC-4.44 Hgb-11.3 Hct-36.6 MCV-82 MCH-25.5* MCHC-30.9* RDW-18.8* RDWSD-56.3* Plt ___ ___ 05:48PM BLOOD Neuts-63.2 ___ Monos-9.9 Eos-0.8* Baso-0.5 Im ___ AbsNeut-8.24* AbsLymp-3.28 AbsMono-1.29* AbsEos-0.11 AbsBaso-0.07 ___ 08:23PM BLOOD ___ PTT-29.6 ___ ___ 05:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 ___ 06:35AM BLOOD ALT-19 AST-21 CK(CPK)-404* AlkPhos-67 TotBili-0.4 ___ 05:15AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 ___ 06:35AM BLOOD TSH-1.2 ___ 08:00PM BLOOD Lithium-0.2* ___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:08AM BLOOD Lactate-1.1 CXR: FINDINGS: There are low lung volumes.No definite focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac silhouette is mildly enlarged, likely accentuated by low lung volumes and AP technique. Mediastinal contours unremarkable. No pulmonary edema is seen. IMPRESSION: Low lung volumes without focal consolidation or pleural effusion seen. CT Head ___: FINDINGS: Abutting the superolateral left cerebellar hemisphere and the tentorium, there is a 3.2 x 2.6 x 2.8 cm dense lesion with adjacent vasogenic edema with resultant mass effect on the quadrigeminal plate cistern and fourth ventricle. No evidence of herniation currently. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: A dense mass abutting the tentorium and left cerebellar hemisphere with adjacent vasogenic edema and mass effect effacing the fourth ventricle and quadrigeminal plate cistern, most likely represents meningioma. No current herniation. Recommend MRI with intravenous contrast for further evaluation, if no contraindication. MRI Brain ___: FINDINGS: In the left posterior fossa, there is a round 3.2 x 2.9 x 3.0 cm dural-based mass inseparable from the left tentorium, abutting the superolateral aspect of the left cerebellar hemisphere, presumably meningioma. It is isointense to gray matter on T1 and T2 weighted imaging with homogeneous avid enhancement. There is regional T2 prolongation within the left cerebellar hemisphere consistent with vasogenic edema with and mild effacement of the fourth ventricle. No hydrocephalus. No evidence of hemorrhage or infarction. The left transverse sinus is hypoplastic. The left distal transverse sinus and sigmoid sinus do not enhance and may be compressed or occluded by the presumed meningioma. The left internal jugular vein traits postcontrast enhancement. The remainder of the dural venous sinuses are patent. IMPRESSION: Dural-based mass in the left posterior fossa, consistent with a meningioma. There is regional vasogenic edema with mild effacement of the fourth ventricle but no obstructing hydrocephalus. No definite enhancement of the distal left transverse sinus and sigmoid sinus which may be severely compressed with occlusion a possibility. There is reconstitution of contrast enhancement of the left internal jugular vein. Brief Hospital Course: Ms. ___ is a ___ woman with a history of bipolar disorder who presented with headache and increasing psychosis in the setting of medication non-compliance. Her exam was notable for limited speech output, paranoia and paratonia without clear focal neurologic deficits. CT demonstrated a left posterior fossa mass adjacent to the cerebellum with MRI confirming the diagnosis of meningioma (3.1 x2.6cm enhancing extra-axial mass abutting tentorium and left cerebellum), which per Neurosurgery required no acute surgical intervention and will be followed over time as an outpatient. She remained in a state of decompensated psychosis and Psychiatry recommended restarting her home Invega (paliperidone) 9mg daily, as she was likely non-compliant with this medication. She had notably last had this medication filled on ___ in quantity of 30 and there were still 20 pills left in bottle she brought with her to the hospital. EKG with QTc 473msec. She remained afebrile with stable vital signs throughout her admission and she is medically cleared for discharge. She will be discharged to ___ accepting MD ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. paliperidone 9 mg oral DAILY 2. Omeprazole 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. paliperidone 9 mg oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: meningioma, psychosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted due to concern for a mass in the brain (cerebellum) that was found to be a meningioma. No surgical intervention was required and you will be followed as an outpatient by Neurosurgery. You were seen by Psychiatry who recommended restarting your home paliparidone (Invega) and your medications will continued to be titrated at ___ ___. Best, Your ___ Neurology Team Followup Instructions: ___

19994730-DS-20

DS

2169-09-03 00:00:00

2169-09-10 10:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Dr ___ is a ___ yo man with stage IVB Hodgkin lymphoma s/p 6 cycles of chemotherapy with AVD (bleomycin held due to depressed DLCO at baseline) starting in ___ of this year. On ___ started the second cycle with the addition of bleomycin. He has tolerated the chemotherapy overall well, without significant side effects. Patient presenting with R sided chest wall pain wrapping around torso and right upper quadrant pain, that began earlier this week and is not improving. He has tried som heat pads, flexeril, percocet, and dexamethasone for pain without relief. He denies any N/V/D, constipation, worsening pain with food, fever, sweats, chills. He also complains of being tired. In the ER the patient received morphine for pain. He also had an episode of shaking chills and a temp of 100.8 which came down to 99 within the hour. ROS: otherwise negative Past Medical History: Past oncologic history: Hodgkin's Lymphoma diagnosed ___ after presenting with fatigue, night sweats and increased lymphadenopathy. Started on AVD (modified ABVD) on ___ . Past Medical History: -Left neck adenopathy s/p biopsy negative for malignancy in ___ -Sarcoidosis - diagnosed in ___ based on hilar lymphadenopathy and erythema nodosum. Treated with steroids with resolution of symptoms. In ___ in the setting of lymphadenopathy he had an ACE level of 114. -Pulmonary Embolism ___ -glucose intolerance Social History: ___ Family History: No family history of colon, lung, pancreatic, blood cancer. Physical Exam: PHYSICAL EXAM: VS 98.2, 150/87, 102, 18, 98% RA weight 227 GEN: AAOx3, NAD HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions NECK: supple, no LAD, no JVD ___: RRR, no m/r/g LUNGS: reg resp rate, breathing unlabored, no accessory muscle use, lungs clear to auscultation bilaterally ABD: soft, NABS , mild left upper quadrant tenderness without rebound or guarding Chest: mild R sided lower rib pain chest and back ext: 2+ pulses, no c/c/e Skin: no rashes neuro: CN ___ intact, strength ___ in UE and ___ bilat. LTSI in UE and ___. finger to nose intact, rapid alt. movements intact, heel to shin intact, gait normal, no pronator drift, no asterixis. DISCHARGE PHYSICAL EXAM: VS 98.5, 108/70, 85, 18, 98% RA GEN: AAOx3, NAD HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions NECK: supple, no LAD, no JVD ___: RRR, NS1S2, no m/r/g LUNGS: reg resp rate, breathing unlabored, no accessory muscle use, lungs clear to auscultation bilaterally ABD: soft, non-tender,normoactive bowel sounds, no masses, no HSM ext: 2+ pulses, no c/c/e Skin: crusted R T9 dermatomal herpetic rash, resolving neuro: CN ___ intact, strength ___ in UE and ___ bilat Pertinent Results: ADMISSION LABS: ___ 10:10AM WBC-4.3 RBC-3.15* HGB-10.3* HCT-30.5* MCV-97 MCH-32.7* MCHC-33.7 RDW-18.5* ___ 10:10AM NEUTS-87.1* LYMPHS-6.4* MONOS-3.8 EOS-1.8 BASOS-0.9 ___ 10:10AM PLT COUNT-162 ___ 10:10AM ___ PTT-29.9 ___ ___ 10:10AM GLUCOSE-242* UREA N-11 CREAT-0.8 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 ___ 10:10AM ALT(SGPT)-45* AST(SGOT)-24 ALK PHOS-163* TOT BILI-0.3 ___ 09:44AM LACTATE-2.5* ___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:00PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 10:10AM LIPASE-30 DISCHARGE LABS: ___ 07:50AM BLOOD WBC-4.0 RBC-2.98* Hgb-9.4* Hct-28.4* MCV-95 MCH-31.4 MCHC-33.0 RDW-17.7* Plt ___ ___ 07:50AM BLOOD Neuts-78.8* Lymphs-17.0* Monos-3.5 Eos-0.5 Baso-0.3 ___ 07:50AM BLOOD ___ PTT-43.8* ___ ___ 12:40PM BLOOD LMWH-PND ___ 07:50AM BLOOD Glucose-147* UreaN-14 Creat-0.8 Na-140 K-4.6 Cl-106 HCO3-24 AnGap-15 ___ 07:50AM BLOOD ALT-44* AST-25 LD(LDH)-219 AlkPhos-246* TotBili-0.3 ___ 07:30AM BLOOD GGT-409* ___ 07:50AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0 ___ 04:20AM BLOOD TSH-7.6* ___ 03:59AM BLOOD T4-8.9 RUQ U/S:Study Date of ___ IMPRESSION: 1. Gallbladder sludge without evidence of cholecystitis. 2. Splenomegaly. 3. Hyperechoic area in the left lobe of the liver is also seen on the CT from the same day. Differential includes old lymphomatous infiltration, area of greater fatty infiltration, or possibly an unusual appearance of a benign lesion such as an atypical hemangioma could be considered. There has been no definite recent change although the lesion is easier to visualize on this study. If further characterization is desired, then MR imaging may be useful. CXR Chest: Study Date of ___ IMPRESSION: Patchy new left mid and lower lung opacities, typical in morphology for atelectasis, although an infectious etiology is difficult to completely exclude based on the imaging. CT Chest and Abdomen Study Date of ___ IMPRESSION: 1. Chronic pulmonary embolism with no evidence of new acute pulmonary embolism. 2. Geographical distribution of a hypodense area in the left lobe of the kidney, also seen on the ultrasound of the same day. While the relative degree of ___ is more striking on today's exam, the etiology is uncertain. This was not avid on recent PET scan. Differential includes old lymphomatous infiltration with marked atrophy involving the left lobe or atrophy of other etiology; there may be relative fatty infiltration at the site and an unusual benign lesion such as a hemangioma could also be involved. 3. Overall, extensive mediastinal, retroperitoneal, celiac and pelvic lymphadenopathy appears to be stable to slightly decreased in size since the PET-CT from ___. 4. Splenomegaly. 5. No acute intra-abdominal or intrathoracic process to explain the patient's pain. ___ Radiology CHEST (PA & LAT) FINDINGS: Since the prior radiograph there are now small bilateral pleural effusions. Left retrocardiac opacity likely represents lower lobe pneumonia. There is no pneumothorax. The cardiomediastinal silhouette is similar in appearance to the prior radiograph. Bony structures are intact. IMPRESSION: 1. Interval development of bilateral pleural effusions. 2. Retrocardiac opacity likely represents left lower lobe pneumonia. ___ Radiology CHEST (PA & LAT) FINDINGS: PA and lateral chest radiographs are obtained. Heart is normal size and cardiomediastinal contours are unchanged. Lungs do not demonstrate significant changes compared to the prior radiograph. Opacification of the left base represents atelectasis or consolidation. Persistent small right pleural effusion with increased small left pleural effusion. No pneumothorax. IMPRESSION: 1. Persistent small pleural effusions bilaterally. 2. Left lower lobe atelectasis or consolidation. MICRO: ___ 4:19 pm Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 Negative for Herpes simplex by immunofluorescence. ___ 4:19 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final ___: POSITIVE FOR VARICELLA ZOSTER. Brief Hospital Course: # Paroxysmal Atrial Fibrillation: Patient has history of atrial fibrillation in setting of Hodgkin's lymphom diagnosis. He experienced intermittent atrial fibrillation starting ___ with rates up to 150's. He had numerous conversions into and out of afib: he was first converted to sinus rhythm with 5mg IV metoprolol, however went back into atrial fibrillation with rates in the 130's to 150's. He was converted a second time with IV diltiazem drip, but returned to ___ fibrillation after trying to transition to PO diltiazem. He was rate controlled on metoprolol 25mg Q6H, and self-converted to sinus rhythm overnight ___. With recommendations from cardiology, he was also started on sotalol 80mg BID for addtional rate control. His blood pressures were supported with IV fluid boluses, and he never require pressors. He had been on lovenox for PE in ___, and was increased from 75mg to 100mg BID to account for his weight. # Abdominal Pain: LUQ abdominal pain and rib pain. Laboratory values notable for mildly elevated alk phos, ALT and lactic acid (2.5). Per ___ records, his Alk Phos had been elevated in the past few months, likely secondary to his chemotherapy. RUQ ultrasound showed biliary sludge without any evidenc of cholecystitis. No acute processes seen on CXR. CT abdomen and chest notable for hypodense area in liver, chronic PE and stable LAD. ECG NSR without any evidence of ischemia. Patient spiked fever to 102.7 and was started on Unasyn and cultured. Antibiotics were subsequently discontinued due to low suspicion for infection. Etiology unclear, but no evidence of acute processes; may have been due to mild ileus from chemotherapy. # Zoster: Patient had right sided chest pain wrapping around torso during week prior to admission. He developed a herpetic rash in T9 dermatome during admission consistent with zoster. He was seen by dermatology who did a biopsy (positive for varicella zoster) and was started on IV acyclovir 1000mg q8hrs and put on precautions. The rash did not disseminate and crusted over prior to discharge. He was subsequently transitioned to PO acyclovir 800 mg PO 5x/day and will complete total 10 days. # Hodgkin's Lymphoma: Patient has stage IV Hodgkin's lymphoma. He is being treated by Dr. ___ with a modified ABVD. He finished his last infusion of chemotherapy on ___. He will continue prophylaxis with bactrim SS daily and complete course of acycovir for zoster. He will complete 7 days of neupogen treatment starting 24 hours after infusion and follow up with Dr. ___ in ___. Transitional Issues: -lovenox dosing and duration of treatment, to be discussed as outpatient with Dr. ___ up with Dr. ___ GGT, unknown etiology Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Allopurinol ___ mg PO DAILY 2. Enoxaparin Sodium 70 mg SC Q12H 3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 2. Enoxaparin Sodium 100 mg SC Q12H RX *enoxaparin 100 mg/mL inject 1 syringe subcutaneous every 12 hours Disp #*60 Syringe Refills:*2 3. Ondansetron 8 mg PO Q8H:PRN nausea 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*42 Tablet Refills:*0 6. Acyclovir 800 mg PO 5X/DAY RX *acyclovir 800 mg 1 tablet(s) by mouth five times a day Disp #*25 Tablet Refills:*0 7. Docusate Sodium 100 mg PO BID 8. Gabapentin 200 mg PO Q8H please hold for sedation RX *gabapentin 100 mg 2 capsule(s) by mouth every eight (8) hours Disp #*90 Capsule Refills:*0 RX *gabapentin 100 mg 2 capsule(s) by mouth every eight (8) hours Disp #*180 Tablet Refills:*2 9. Sotalol 80 mg PO BID please hold for HR < 60 RX *sotalol 80 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 10. Omeprazole 40 mg PO DAILY:PRN reflux 11. Dexamethasone 4 mg PO BID Duration: 2 Days RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 12. Filgrastim 480 mcg SC Q24H Duration: 7 Days take for 7 days after chemotherapy Discharge Disposition: Home Discharge Diagnosis: Primary: atrial fibrillation, abdominal pain, herpes zoster Secondary: Hodgkin's Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dr. ___, ___ was a pleasure taking care of you at ___ ___. You were admitted for abdominal pain of unclear etiology. You also developed atrial fibrillation during your admission which has converted back into sinus rhythm. On discharge you will need to follow up with Dr. ___ cardiology. Please call his office to make a follow up appointment in the next two weeks. You will also follow up with Dr. ___ as detailed below. New/Changed Medications: -Sotalol 80 mg PO BID -dexamethasone 4 mg PO BID for 2 days -enoxaparin 100 mg/mL subcutaneous injection every 12 hours -acyclovir 800 mg tab 5 times per day for 5 days (last day ___ ___ -gabapentin 100 mg, 2 tabs every 8 hours -neupogen 480 mcg/1.6mL one time daily for 7 days after chemo Followup Instructions: ___

19994772-DS-23

DS

2181-04-02 00:00:00

2181-04-02 15:08:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Keflex Attending: ___. Chief Complaint: Headache, nausea, and vomiting Major Surgical or Invasive Procedure: ___: Suture closure of open temporal lobe incision by neurosurgery ___: R craniectomy and wound revision History of Present Illness: This is a ___ year old female with a history of recurrent glioblastoma in the right frontal lobe who is s/p radiation, resection, and chemotherapy (see complete oncologic history below) presenting with headache, nausea, and vomiting. Her symptoms began around noon on day prior to admission; she called Dr. ___ who recommended she present to the emergency department. Her aunt drove her to the ED. She denied taking any medications at home to treat her symptoms. She reports fevers, chills, and photophobia associated with her symptoms but denies abdominal pain, diarrhea, neck stiffness. She does report a history of migraines and feels her symptoms are similar to prior migraines. She received morphine, zofran, and decadron in the ED and was transferred to the floor for further management of her symptoms. Review of systems otherwise negative for chest pain, chest pressure, shortness of breath, numbness, tingling, weakness, dysuria. Past Medical History: ___ with a history of recurrent glioblastoma in the right frontal lobe s/p(1) a subtotal resection by Dr. ___ on ___, and (2) received temozolomide chemo-irradiation from ___ to ___ to 6000 cGy, (3) resection of recurrent tumor by Dr. ___ on ___, (4) Portacath placement on ___, (5) started NovoTTF-100A on ___, and (6) started bevacizumab on ___. -hyperlipidemia Social History: ___ Family History: non-contributory Physical Exam: *Admission Physical* VS: temp 99.3, BP 133/76, HR 91, RR 20, 94% RA Gen: Caucasian female, somnolent but arousable HEENT: Anicteric Neck: mild pain along lateral neck musculature, but able to touch chin to chest Cardiac: Nl s1/s2 RRR no murmurs appreciable Pulm: lungs clear bilaterally Abd: soft and nontender with normoactive bowel sounds Ext: warm and well perfused Neuro: nonfocal - no neurologic deficits evident *Discharge Physical* A&O X3 R pupil slugish, PERRL CN II-XII intact Cardiac: Nl s1/s2 RRR no murmurs appreciable Pulm: lungs clear bilaterally Abd: soft and nontender with normoactive bowel sounds MAE and FC Sensation intact Incision healing well, there was no drainage noted. Pertinent Results: *Admission Labs* ___ 12:20AM BLOOD WBC-14.4*# RBC-3.85* Hgb-13.0 Hct-35.6* MCV-93 MCH-33.8* MCHC-36.5* RDW-12.8 Plt ___ ___ 12:20AM BLOOD Neuts-86.4* Lymphs-7.2* Monos-5.6 Eos-0.6 Baso-0.2 ___ 12:20AM BLOOD Glucose-140* UreaN-18 Creat-0.7 Na-140 K-3.7 Cl-106 HCO3-22 AnGap-16 ___ 12:20AM BLOOD ALT-19 AST-18 LD(LDH)-180 AlkPhos-85 TotBili-0.3 ___ 12:20AM BLOOD Lipase-32 ___ 05:52AM BLOOD Calcium-9.1 Phos-1.8*# Mg-1.9 ___ 12:37AM BLOOD Lactate-1.7 *CSF* ___ 11:22AM CEREBROSPINAL FLUID (CSF) ___ RBC-375* Polys-93 ___ ___ 11:22AM CEREBROSPINAL FLUID (CSF) TotProt-590* Glucose-1 LD(LDH)-57 ___ 11:23AM CEREBROSPINAL FLUID (CSF) WBC-7800 RBC-250* Polys-90 ___ Monos-8 Basos-1 ___ 03:43PM (CSF) BACTERIAL MENINGITIS ANTIGEN PANEL-PND ___ 11:48AM CEREBROSPINAL FLUID (CSF) Bacterial ID by PCR-PND *Urine* ___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 09:00PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 *Discharge Labs* XXXXXXXXXXXXXXXXXXXXXXXXXX *Microbiology* ___ Blood Culture: Negative ___ Blood Cultures: Pending ___ CSF Cryptococcal antigen: Negative ___ CSF Culture: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. No Growth on Fluid culture or fungal culture as of ___ Urine Culture: Negative ___ C diff amplification: Negative ___ Wound culture from temporal lobe drainage: Coag negative staph (rare) *Cytology* ___: CSF negative for malignant cells *Imaging* ___ CT Head w/o Contrast: Large region of encephalomalacia is seen involving most of the right frontal lobe and extends to the right lateral ventricle with ex vacuo dilatation. There is no hemorrhage, edema, shift of midline structures, or evidence of acute infarction. The basal cisterns are patent and gray-white matter differentiation is preserved. Post-surgical changes from prior right frontoparietal craniotomy are noted. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: 1. No acute hemorrhage or mass effect. 2. Large area of encephalomalacia in the right frontal lobe at the site of multiple prior resections. ___ MRI Head w/ and w/o contrast: There is a large resection cavity in the right frontal lobe without any nodular enhancement. The postoperative cavity appears to have minimally increased in size. There is a right frontal cranioplasty. No fluid collection is noted superficial or deep to the cranioplasty. There are no foci of restricted diffusion. There is a stable infiltrative signal abnormality along the margin of the operative cavity and extending into the corpus callosum on the left frontal lobe which could represent combination of post-treatment changes and infiltrative neoplasm. No evidence for acute ischemia or hydrocephalus is seen.There is mild meningeal enhancement, which could be postoperative in nature, but this should be correlated with CSF studies. Ventricles are unchanged in size and configuration. IMPRESSION: Postoperative changes in the right frontal lobe, but no definite evidence for infection noted. There is mild meningeal enhancement, which could be postoperative in nature, but this should be correlated with CSF studies. ___ CXR Portable: In comparison with study of ___, there are substantially lower lung volumes, which may account for much of the apparent increase in transverse diameter of the heart. No evidence of vascular congestion. There is some retrocardiac opacification medially. It is unclear how much of this could represent some volume loss or even consolidation in the lower lobe and how much could merely be a manifestation of low lung volumes and the supine portable technique. If clinically possible, lateral view would be extremely helpful. The right IJ catheter extends to about the level of the cavoatrial junction or possibly in the upper portion of the right atrium itself. ___ CXR PA/Lat: In comparison with study of ___, the patient has taken a much better inspiration. Again there is an area of increased opacification in the retrocardiac region with poor definition of the descending aorta. Although this could merely reflect atelectasis, the possibility of supervening pneumonia would have to be considered in the appropriate clinical setting. ___ MRI C-spine (patient did not tolerate, stopped early): Severely limited study due to motion artifact. Although there are no findings to suggest epidural abscess, the study must be considered nondiagnostic. ___: Non-Contrast Head CT Status post right frontal craniectomy and drainage catheter placement in a right frontal post-operative cystic collection with interval decrease in size of a fluid collection. ___: Non-Contrast Head CT Increased size of right frontal postoperative cystic fluid collection from the most recent prior head CT of ___ without significantly increased mass effect. Status post right frontal craniectomy with unchanged position of drainage catheter. ___ bilateral lower extremity doppler ultrasound IMPRESSION: No evidence of deep vein thrombosis in the either leg. Brief Hospital Course: ___ year old female with history of recurrent glioblastoma present with worsening headache, nausea, fevers and vomiting. #Bacterial Meningitis: Patient with worsening mental status overnight of admission. Complaining of severe neck pain on morning of ___ with difficulty moving without pain. Unable to cooperate for Kernig's and Brudzinski's signs. Spiking fevers to low 100s. LP performed ___ showing very high protein (590) and very low glucose (1). Gram stain showed 4+pmns and 1+ GPCs in clusters. ID was consulted for help with antibiotic coverage and etiology of symptoms and meningitis. Patient was started on vancomycin and meropenem for broad coverage. Vancomycin was adjusted over several days for goal trough level of ___. Patient continued to spike fevers during adjustment period as initial troughs were low. WBC count initially elevated but returned to normal on antibiotics. MRI head with and without contrast was performed ___ which did not show any evidence of intracranial abscess to explain ongoing fevers in spite of antibiotics. MRI of whole spine attempted ___ given ongoing fevers and concern for possible epidural abscess but patient did tolerate MRI which was non-diagnostic. Culture of CSF did not grow any organisms in spite of fact that patient was not on antibiotics prior to LP. Her mental status waxed and waned with periods of alertness and periods of extreme fatigue and difficulty arousing patient. Narcotic pain meds were held as these seemed to worsen her attention and alertness. Patient's fevers subsided on ___. Patient's parietal lobe incision from ___ was seen to be leaking on HD1 with fluctuance anterior to incision at level parietal bone. This was thought to be likely source of meningitis given communication of CSF with outside world. She was seen by neurosurgery who oversewed the wound where CSF leakage was occuring on ___. Her wound reopened with continued leakage on ___ and she was again seen by neurosurgery who recommended she lay on her left side (opposite the incision). Revision of surgery was initially held given recent Avastin and active meningitis. Given concern for ongoing fevers initially while on broad spectrum antibiotics, evaluation of other etiologies were performed. Patient was negative for C diff (had had diarrhea), had no clear pneumonia on CXR, and no evidence of malaria on thick and thin smear (given recent trip to ___). . #Anemia: Patient with baseline anemia w/ hct of 35. Acute hct drop to 30 on admission but stable during hospital course. No evidence of bleeding at site of LP. No other source of bleeding. Would benefit from follow-up of Hct as outpatient to make sure it is not continuing to trend down. . # History of recurrent glioblastoma: - s/p radiation, resection and chemotherapy, currently on bevicizumab. Last resection was on ___. Follow-up MRI in ___ showed multifocal residual tumor at the resection margins, including possible subpial involvement, superiorly, and subependymal involvement, dorsally. Patient was continued on keppra for seizure prophylaxis. Bevicizumab and TTF were held while inpatient. Neurosurgery was consulted as above for leakage from previous incision site over right parietal lobe. . # Hyperlipidemia: Patient was continued on home simvastatin. # Code Status - FULL Transitional Issues: [ ] Antibiotic course [ ] When to restart Avastin and ___ On ___, patient was transferred to the ___ and taken to the ___ for revision of incision and R craniectomy. There were no complications intraoperatively. A drain was placed in the R frontal cyst and skin was closed. Patient was extubated and transferred to the ICU for close monitoring. She is HOB>60 degrees and drain is leveled at 10cmH2O. Head CT was done and showed post-operative changes. The bone flap was sent to microbiology for culture. Gram staining was unable to be performed secondary to the size of the specimen. On ___, she remained neurologically stable. There was scant cyst drainage into the drain. ID was consulted and recommended continuing her antibiotics at the current regimen, Meropenum and Vancomycin for 3-weeks. Sh was also fit for a helmet. On ___ her vancomycin was increased to 1gram q8h per ID recommendations and she was started on salt tabs. Her vancomycin was subsequently changed back to 750mg q8hours later in the day. On ___ her vancomycin trough was 8.3 and he dose was increased to 1.5mg q12hours. Her drain was clamped. Her incision remained dry and her exam remained stable. On ___ PTT was elevated to 44, SQ heparin was decreased to BID dosing. Drain remained clamped. She was written for transferred to SDU. On ___ we discontinued her drain and transferred to the floor. On ___ she was stable. She was screened for rehab. Incision was clean and dry. On ___ the meropenem was discontinued, HCP updated. Sent urine and ordered LENIS for an axillary temp of 99.9. D/C'd ivf. LENIS were negative. Screened for SNF. On ___ she remained afebrile. Waiting for rehab placement On ___ she was refusing Salt tabs On ___ She accepted to take sodium tabs, NA continues to decrease. On ___ sutures were removed. Na remained within normal limits. On ___ Patient is being discharged to rehab in stable condition. Medications on Admission: CELECOXIB [CELEBREX] - Celebrex ___ mg capsule. 1 capsule(s) by mouth twice a day LEVETIRACETAM - levetiracetam 500 mg tablet. 1 tablet(s) by mouth twice a day OXYCODONE - oxycodone 5 mg tablet. one tablet(s) by mouth every 4 hours as needed for severe headaches - (Prescribed by Other Provider) RANITIDINE HCL [ZANTAC] - Zantac 150 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) SIMVASTATIN - simvastatin 10 mg tablet. one tablet(s) by mouth daily - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN - acetaminophen 325 mg tablet. one tablet(s) by mouth every 4 hours as needed for mild headache - (Prescribed by Other Provider) ASCORBIC ACID [VITAMIN C] - Dosage uncertain - (Prescribed by Other Provider) B COMPLEX VITAMINS [B COMPLEX] - Dosage uncertain - (Prescribed by Other Provider) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain - (Prescribed by Other Provider) DOCUSATE SODIUM [COL-RITE] - Col-Rite 100 mg capsule. 1 capsule(s) by mouth twice a day as needed for constipation - (Prescribed by Other Provider) MELATONIN - Dosage uncertain - (Prescribed by Other Provider) MULTIVITAMIN,TX-MINERALS [MULTI-VITAMIN HP/MINERALS] - Dosage uncertain - (Prescribed by Other Provider) OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. LeVETiracetam 500 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 5. Heparin 5000 UNIT SC BID 6. Heparin Flush (10 units/ml) 5 mL IV PRN line flush 7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port 8. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using REG Insulin 9. Megestrol Acetate 800 mg PO DAILY 10. Ondansetron 8 mg PO Q8H:PRN nausea 11. Sodium Chloride 2 gm PO TID 12. Famotidine 20 mg PO BID 13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 15. Glucose Gel 15 g PO PRN hypoglycemia protocol Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Bacterial meningitis Secondary: Glioblastoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your admission. You were admitted with nausea, vomiting, fevers and headaches. A lumbar puncture was performed which showed bacterial meningitis (an infection of the lining around your brain). You were treated with vancomycin and meropenem (antibiotics) and your fevers and thinking slowly improved. Your infection was thought to be due to an opening in the head incision from your previous surgery. You were seen by neurosurgery who sutured the wound closed to prevent further bacteria from getting in. Please take all of your medications as prescribed. Followup Instructions: ___

19994772-DS-24

DS

2181-05-01 00:00:00

2181-05-02 21:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Keflex Attending: ___. Chief Complaint: Aletered mental status and fever Major Surgical or Invasive Procedure: ___ Neurosurgery for craniectomy wound washout History of Present Illness: ___ is a ___ woman with past medical history of glioblastoma and resection x2, chemotherapy and radiation with recent admission from ___ for bacterial meningitis with right craniectomy and wound revision who presents from ___ with altered mental status and fever. Patient's brother, ___, states that since yesterday she has had a low grade fever and the nurse had reported her being less alert and attentive. Her brother states that she recovered back to baseline after the first two surgeries but has not since the third. She has been more lethargic though making some progress with rehab. She has had a decreased appetite but will eat when spoon-fed. Patient states she has a headache and chills but denies SOB, chest pain, abdominal pain, nausea, vomiting or diarrhea. In the ED, initial vital signs were: temperature 99.4 F, pulse 88, blood pressure 106/67, respiration 20 and oxygen saturation 99% in room air. She then spiked fever to 102.3 F. Dr. ___ ___ from neurology was consulted and requested stat lumbar puncture which was positive for protein 244, glucose 16, WBC 382 with 83% polys. UA large leukocytes, positive nitrites, >182 WBC and few bacteria. Patient was given 1 dose of vancomycin and ceftriaxone, Tylenol and ketorlac. Possible CSF leakage was noted out of right craniectomy incision so neurosurgery was called to evaluate the patient who then performed a bedside closure. Vital signs on transfer: Temperature 98.6 F, pulse 93, blood pressure 91/46, respiration 12 and oxygen saturation 98% in room air. On the floor, vital signs were: Temperature 98.7 F, blood pressure 116/83, respiration 16, O2 saturation 99% in room air. Patient denies headache, neck stiffness or nausea although there is a pool of vomit next to her. She is shivering and feels cold. She does not respond to most questioning. Review of sytems: (+) Per HPI (-) Denies nausea or abdominal pain. Past Medical History: PAST MEDICAL HISTORY: Recurrent glioblastoma in the right frontal lobe s/p a subtotal resection by Dr. ___ on ___, and (2) received temozolomide chemo-irradiation from ___ to ___ to 6000 cGy, (3) resection of recurrent tumor by Dr. ___ on ___, (4) Portacath placement on ___, (5) started NovoTTF-100A on ___, and (6) started bevacizumab on ___. -hyperlipidemia Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vital Signs: Temperature 98.7 F, pulse 98, blood pressure 116/83, respiration 16 and O2 saturation 99% in room air General: Alert to person and ___. Nods in affirmation to ___ ___. Shivering. HEENT: Right temporal incision scar with stitches in place mid-incision, no active drainage. Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Cardiovascular: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Right chest portacath. Abdomen: soft, diffusely tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Genitourinary: no foley Extremities: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurological Examination: Cranial nerves ___ grossly intact, moving four extremities spontaneously, not cooperative with motor exam or ___ assessment DISCHARGE PHYSICAL EXAMINATION: General: Very pleasant, tired appearing, slow to respond to questions HEENT: Right temporal incision scar with stitches in place mid-incision, no active drainage, wound clean and dry. Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Cardiovascular: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Right chest portacath. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Genitourinary: no foley Extremities: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurological Examination: Cranial nerves ___ grossly intact, moving four extremities spontaneously, strength ___ in upper extremities, 4+/5 in lower extremities bilaterally. Pertinent Results: ADMISSION LABS ___ 03:39PM BLOOD WBC-10.7 RBC-4.02* Hgb-13.1 Hct-36.8 MCV-92 MCH-32.5* MCHC-35.5* RDW-12.7 Plt ___ ___ 03:39PM BLOOD Neuts-84.7* Lymphs-8.9* Monos-5.8 Eos-0.3 Baso-0.4 ___ 05:35AM BLOOD Plt ___ ___ 10:07AM BLOOD ___ PTT-28.1 ___ ___ 03:39PM BLOOD Glucose-109* UreaN-9 Creat-0.6 Na-133 K-4.1 Cl-103 HCO3-19* AnGap-15 ___ 04:30AM BLOOD Calcium-10.3 Phos-3.8 Mg-2.0 DISCHARGE LABS: ___ 05:49AM BLOOD WBC-8.1 RBC-3.72* Hgb-12.3 Hct-34.8* MCV-94 MCH-33.2* MCHC-35.5* RDW-14.0 Plt ___ ___ 06:22AM BLOOD Neuts-83.8* Lymphs-9.7* Monos-5.9 Eos-0.4 Baso-0.3 ___ 05:49AM BLOOD Plt ___ ___ 05:49AM BLOOD Glucose-96 UreaN-14 Creat-0.4 Na-136 K-4.1 Cl-105 HCO3-24 AnGap-11 ___ 04:02AM BLOOD ALT-22 AST-13 AlkPhos-46 TotBili-0.4 ___ 05:49AM BLOOD Calcium-9.4 Phos-2.1* Mg-2.6 CSF STUDIES: ___ - WBC 268 RBC 0 Polys 88 Lymphs ___ Monos 6 Tprot 244 Gluc 16 Herpes simplex virus - negative MICROBIOLOGY: ___ 6:45 pm CSF;SPINAL FLUID TUBE 3. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. ___ BLOOD CULTURE: _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S IMAGING/STUDIES ___ MRI HEAD W/ and W/O CONTRAST Study somewhat limited by motion artifact, but there appears to be a mild decrease in the intensity of enhancement around the surgical site and within the occipital horns of the lateral ventricles. Slow diffusion material in the occipital horns appears unchanged. These findings are consistent with intraventricular infection. No new abnormalities are detected. ___ CT HEAD 1. New pneumocephalus layering within the large right frontal cyst, which is stable in size from the pre-operative exam. 2. New thin 5 mm fluid collection with an air-fluid level in the subcutaneous tissues along the craniectomy bed. 3. No evidence of acute hemorrhage. MRI of spine ___ 1. Somewhat motion limited study. 2. No evidence of epidural abscess discitis osteomyelitis in the cervical thoracic and lumbar region. 3. No evidence of cord compression or abnormal signal within the spinal cord. 4. Mild enhancement of the lumbar nerve roots consistent with patient's history of meningitis. 5. Areas of apparent increased signal within the lower lumbar spinal canal on post gadolinium sagittal T1 images are artifactual. Brief Hospital Course: ___ is a ___ woman with glioblastoma, status post resection x2, chemo, radiation, recent admission for bacterial meningitis, presents from rehabilitation with altered mental status and fever. She was found to have bacterial meningitis from direct inoculation, now s/p washout of wound on ___ by neurosurgery. 1. Bacterial Meningoencephalitis: Likely bacterial based on high protein, low glucose, neutrophil predominance on CSF sample. Likely source is outside communication via open craniectomy wound and patient continued to have clear leakage from wound. Underwent washout of wound by neurosurgery on ___. HSV negative, gram stain without organisms, CSF culture negative. Now has cognitive slowing, consistent with parenchymal involvement / encephalitis. Family meeting held ___ ___, aunt, brother, and husband outlined the poor prognosis and it was decided to transition the patient to hospice. - Continue empiric treatment with vancomycin ___ to ___ and meropenem ___ to ___ for 3 week course per ID (finish on ___. Covering for pseudomonas given that patient was living in a nursing home (avoided cephalosprins given Keflex allergy). - ID recommended follow-up in ___ weeks, but family declined. Phone number for ___ clinic is ___ - Please check weekly CBC with diff, chem7 and LFTs while on antibiotics. - Dr. ___ from neurosurgery is to remove sutures on ___, please do not change the dressing on the wound. If leaking or concerns about the wound please call ___ to confirm appointment with Dr. ___. 2. Bacteremia: Blood culture 1 out of 2 bottles on ___ grew gram(+) cocci in clusters, now speciated with coag negative staph, which is likely a contaminant, sensitive to vancomycin. All other blood cultures negative 3. UTI: UA suggestive of UTI but UCx never sent before antibiotics started. - Patient is being treated with meropenem already 4. Recurrent Glioblastoma/Goals of Care: She is status post radiation, resection and chemotherapy, was on bevicizumab. Last tumor resection was on ___, had wound revision and craniectomy on ___. Follow-up MRI in ___ showed multifocal residual tumor at the resection margins, including possible subpial involvement, superiorly, and subependymal involvement, dorsally. MRI on ___ with signs of infection but no new abnormalities. Goals of care discussion was held with patient's family on ___. Dr. ___ that the patient would likely eventually succumb to infection or blood clots. Given recurrent CNS infections, she will be unable to continue treatment for glioblastoma. The family stated that patient previously expressed a desire to go to an ___ facility at the end of life. The plan is to complete her course of antibiotics for her current infection, and eventually transfer to an ___ facility. -Continue Keppra for seizure prophylaxis -Continue dexamethasone 4mg q8h PO -Code status affirmed DNR/DNI status TRANSITIONAL ISSUES CODE: DNR/DNI EMERGENCY CONTACT: Aunt ___ (health care proxy) ___ - Neurosurgical wound to be managed by neurosurgery. Sutures should be removed in clinic on ___ - Please check CBC/diff, chem7, and LFTs weekly while on antibiotics - Patient would like to transition to inpatient hospice after completion of this course of antibiotics Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. LeVETiracetam 500 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 5. Insulin SC Sliding Scale using REG Insulin 6. Megestrol Acetate 800 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Sodium Chloride 2 gm PO TID 9. Famotidine 20 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. LeVETiracetam 500 mg PO BID 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN reflux 7. Dexamethasone 4 mg PO Q8H 8. Meropenem ___ mg IV Q8H 9. Omeprazole 40 mg PO DAILY 10. Vancomycin 1500 mg IV Q 12H 11. Famotidine 20 mg PO BID 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Meningoencephalitis Wound infection Secondary diagnoses: Glioblastoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Wear helmet when out of bed Discharge Instructions: Dear Ms ___, You were hospitalized for fevers and confusion, and were found to have meningoencephalitis, an infection of the fluid surrounding your brain, and of the brain tissue itself. Neurosurgery cleaned the wound during this hospitalization, and the sutures will be removed at the neurosurgery appointment on ___. You will complete a 3 week course of antibiotics for this infection. According to the wishes you and your family communicated to us, you will be transferring to a ___ facility with a focus on treating any symptoms of pain or discomfort. It was a pleasure being involved in your care, Your ___ Team Followup Instructions: ___

19994873-DS-16

DS

2160-03-09 00:00:00

2160-03-09 13:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: primidone Attending: ___ Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man s/p fall from standing. His wife was in the same room and heard him fall, but does not know if there was a associated syncope or seizure activity. OSH CT showed a small SAH and R clavulcular frx. He was transferred to ___ for further care. Past Medical History: PMH: hypercholesterolemia, HTN, afib, arthritis, adenocarcinoma lung, squamous cell face, left knee surgery, DM ___, CVA, Sick sinus syndrome, essential tremor, recurrent falls. PSH: Cholecystectomy, lung tumor removal Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Temp: 98.1 HR: 94 BP: 142/89 Resp: 16 O(2)Sat: 95 Normal Constitutional: Comfortable HEENT: small skin abrasion lateral to right eyebrow, no active bleeding, Extraocular muscles intact No C-spine tenderness Chest: Clear to auscultation, no chest wall tenderness Cardiovascular: Regular Rate and Rhythm Abdominal: Nontender, Soft GU/Flank: No costovertebral angle tenderness Extr/Back: Right clavicle swelling and tenderness, pain with ROM. Skin: Warm and dry Neuro: Speech fluent, moves all extremities except for right arm, answering questions and following commands appropriately, no focal neurological deficits Psych: Normal mentation, Normal mood ___: No petechiae Discharge Physical Exam: VS: 97.4 PO 138 / 82 102 18 96 Ra GENERAL: Elderly gentleman in NAD, daughter and wife at bedside HEENT: dried scabs on R side of forehead, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, poor dentition NECK: nontender supple neck, no LAD, no JVD HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose; lower legs both cool to touch PULSES: 2+ DP pulses bilaterally NEURO: CN ___ intact, strength ___ x ___xam limited by clavicle fracture SKIN: forehead lesions as above, cool ___ as above Pertinent Results: ADMISSION LABS: =============== ___ 05:28AM BLOOD WBC-5.2 RBC-3.95* Hgb-13.6* Hct-38.7* MCV-98 MCH-34.4* MCHC-35.1 RDW-12.2 RDWSD-44.3 Plt ___ ___ 04:29AM BLOOD WBC-7.0 RBC-4.06* Hgb-13.9 Hct-39.4* MCV-97 MCH-34.2* MCHC-35.3 RDW-12.3 RDWSD-43.9 Plt ___ ___ 04:29AM BLOOD ___ PTT-28.4 ___ ___ 05:28AM BLOOD Glucose-152* UreaN-20 Creat-0.8 Na-136 K-4.0 Cl-98 HCO3-30 AnGap-12 ___ 04:29AM BLOOD Glucose-111* UreaN-21* Creat-0.9 Na-139 K-3.5 Cl-100 HCO3-29 AnGap-14 ___ 04:29AM BLOOD cTropnT-<0.01 ___ 04:29AM BLOOD Calcium-8.7 Phos-3.4 DISCHARGE LABS: ============== ___ 05:04AM BLOOD WBC-6.2 RBC-3.88* Hgb-13.3* Hct-37.1* MCV-96 MCH-34.3* MCHC-35.8 RDW-12.1 RDWSD-42.1 Plt ___ ___ 05:04AM BLOOD Glucose-171* UreaN-13 Creat-0.8 Na-135 K-4.0 Cl-97 HCO3-28 AnGap-14 ___ 05:04AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 ___ 05:28AM BLOOD VitB12-552 MICRO: ===== Urine Culture: No Growth IMAGING/STUDIES: ================ ___ CXR: IMPRESSION: Increased heart size, mild pulmonary vascular congestion. Suggestion of pleural effusion. Basilar opacity, likely atelectasis, repeat lateral radiograph suggested. Acute or subacute fracture distal right clavicle. NCHCT ___: Acute subarachnoid hemorrhage involving the right hemisphere, the magnitude of which is mild. No midlines shift. Age-related atrophy and chronic white matter ischemic changes, no evidence of additional acute intracranial abnormality. CT C-spine ___: Marked degenerative disease, no definite fracture, soft tissues unremarkable. XR R shoulder ___: Distal right clavicular fracture. No dislocation or shoulder or humerus fracture. Brief Hospital Course: ___ HTN, DM, Afib (not on AC), hx ___ presenting s/p fall c/b SAH and clavicular fracture, initially admitted to ___ and subsequently transferred to medicine for fall/?syncope workup. ACUTE ISSUES ============ # SAH/R clavicular fracture: Pt initially presented to ___ where CT imaging showed small right new acute subdural hemorrhage. Xray imaging showed new acute right clavicle fracture. He was transferred to ___ for neurosurgical evaluation. Neurosurgery was consulted and recommended no intervention, frequent neurologic monitoring, and maintain systolic blood pressure less than 160. Initially admitted to surgery service. No neurosurgical intervention needed as SAH small and stable. R clavicular fracture nonoperative. Sling provided as needed for comfort. No need for keppra prophylaxis per neurosurgery. Pt was on q4h neuro checks. He exhibited no neurologic deficits, and did not require additional medication for blood pressure control. ___ was consulted and recommended discharge to rehab. # Fall/syncope workup: Patient transferred to medicine service for further workup of recent falls. Orthostatics positive. Pt maintained on telemetry without arrhythmias noted (besides his baseline Afib). TTE was ordered, but patient and family wished to be discharged to rehab prior to the completion of this study. This can be completed as an outpatient. No further falls/syncope. B12 normal and infectious workup negative (negative blood/urine cultures, CXR). Continued home florinef (which was started for orthostatic hypotension). # Afib: Pt not anticoagulated in setting of recent falls (was previously on Eliquis, stopped in ___ due to falls). Maintained good rate control on home meds and did not require any further intervention. # Urinary retention: Patient retained urine during hospitalization, requiring foley catheter. Tamsulosin started. UA with neg nit/leuks, 3 RBCs, 1 WBC. Foley catheter able to be removed and patient voided without issue before discharge. CHRONIC ISSUES ============== # Hx ___: Continued home AED. According to outpatient neurologist and family, pt's possible seizures are typically characterized by aphasia and confusion. No concerning neuro changes while in-house. #Afib: Pt was previously on eliquis, but this was stopped I/s/o frequent falls. Continued home propranolol (this is prescribed for essential tremor but may be contributing to rate control). HR was well controlled. #HTN, HLD: continue home propranolol and simvastatin #DM: ISS while in house # Goals of care: Palliative care consulted per patient's family request for more information about hospice. We confirmed pt's DNR/DNI status, and filled out a MOLST with him before discharge. TRANSITIONAL ISSUES: [] Consider obtaining TTE as an outpatient for further workup of falls. [] Pt noted to have incidental thrombocytopenia while admitted. Platelets 121 on discharge. HCV negative. He had no evidence of active bleeding other than provoked SAH as above. Consider ongoing monitoring of platelets as an outpatient. [] Clavicle fracture: pt should avoid lifting with R arm, but ROM exercises as tolerated are fine #Code Status: DNR/DNI (confirmed with patient and family) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 20 mg PO QPM 2. Propranolol 10 mg PO DAILY 3. Valproic Acid ___ mg PO Q8H 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Nexium 40 mg Other DAILY 6. 70/30 20 Units Breakfast 70/30 10 Units Bedtime Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Docusate Sodium 100 mg PO BID 5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 6. Glucose Gel 15 g PO PRN hypoglycemia protocol 7. Heparin 5000 UNIT SC BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Senna 8.6 mg PO BID:PRN constipation 10. Tamsulosin 0.4 mg PO QHS 11. TraMADol 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hours Disp #*16 Tablet Refills:*0 12. 70/30 20 Units Breakfast 70/30 10 Units Bedtime 13. Fludrocortisone Acetate 0.1 mg PO DAILY 14. Nexium 40 mg Other DAILY 15. Propranolol 10 mg PO DAILY 16. Simvastatin 20 mg PO QPM 17. Valproic Acid ___ mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Subarachnoid hemorrhage R Clavicular fracture Fall Secondary diagnoses: Hypertension Diabetes Atrial fibrillation 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: Dr. ___, You were admitted to the Acute Care Trauma Surgery Service at ___ after a fall that caused a small bleed in your head and a right clavicle fracture. You were seen and evaluated by the neurosurgery team for your head bleed and no intervention was needed. Your clavicle fracture is stable and will continue to heal without surgical intervention. Please continue to avoid using your right arm for activity but range of motion exercises as tolerated are okay. Wear your sling for comfort as needed. The medical team was contacted to further evaluate for underlying causes of your falls. You chose not to stay for an echocardiogram of your heart. This can be done as an outpatient. Thank you for allowing us to participate in your care. Sincerely, Your ___ Team Followup Instructions: ___

19995012-DS-13

DS

2161-02-16 00:00:00

2161-02-16 14:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Attending: ___ Chief Complaint: SOB Major Surgical or Invasive Procedure: Diagnostic coronary angiogram Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is.free of significant disease. * Left Anterior Descending The LAD has mid 40% stenosis. * Circumflex The Circumflex has origin 40% stenosis. The ___ Marginal has origin 50% stenosis. * Right Coronary Artery The RCA is very difficult to engage. Non-selective angiography shows mid ___ stenosis. The Right PDA is a small vessel and the distal RCA is possibly occluded before a small RPL branch. Impressions: 1. Moderate 3 vessel CAD with possible branch occlusion of distal RCA. There are no good targets for PCI or surgery. Recommendations 1. Medical therapy, History of Present Illness: This patient is a ___ year old female who complains of headache following a fall at a casino three days ago, injuring the left side of her face. She has poor recall of the circumstances and since has had left sided headaches and facial pain. She reports three weeks of dyspnea and non-productive cough for which she saw her PCP one week ago. Past Medical History: diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: ___ Family History: Family history of arthritis Physical Exam: On Admission: PHYSICAL EXAMINATION Temp: 98.9 HR: 72 BP: 153/69 Resp: 16 O(2)Sat: 99 Normal Constitutional: Comfortable HEENT: abrasion over her left zygoma, Pupils equal, round and reactive to light, Extraocular muscles intact diffuse C-spine tenderness Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Psych: Normal mentation ___: No petechiae ECG Heart Rate: 70 Rhythm: Sinus Ischemia: None ECG Axis: Normal Intervals: Normal Comparison to prior results: Same At Discharge: VS: T 98 HR 70 RR 18 BP 138/78 97% RA tele: SR 70-90's General: no c/o discomfort currently, asking why her BP was so high post procedure and her severe headache cause HEENT: no JVP appreciated. supple, thick neck, no masses CHEST: CTAB CV: RRR no m/r/g ABD: Soft, obese, NT, +BS Skin: Warm and dry, R radial access site with gauze and Tegaderm c/d/I, no erythema or excess warmth Neuro: Grossly N/V/I, moving all 4 extremities, thoughts linear, crosses hemispheres, answering questions appropriately Pertinent Results: LABS ON ADMISSION: ___ 09:30AM BLOOD WBC-6.3 RBC-3.96 Hgb-11.9 Hct-36.9 MCV-93 MCH-30.1 MCHC-32.2 RDW-13.2 RDWSD-45.1 Plt ___ ___ 09:30AM BLOOD Neuts-59.3 ___ Monos-8.1 Eos-2.2 Baso-1.0 Im ___ AbsNeut-3.71 AbsLymp-1.79 AbsMono-0.51 AbsEos-0.14 AbsBaso-0.06 ___ 09:30AM BLOOD ___ PTT-34.3 ___ ___ 09:30AM BLOOD Glucose-169* UreaN-10 Creat-0.7 Na-139 K-3.6 Cl-100 HCO3-23 AnGap-20 ___ 09:30AM BLOOD cTropnT-<0.01 ___ 04:30PM BLOOD cTropnT-<0.01 ___ 09:30AM BLOOD proBNP-111 ___ 09:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.6 LABS AT DISCHARGE: ___ 06:00AM BLOOD WBC-10.6* RBC-3.78* Hgb-11.9 Hct-35.1 MCV-93 MCH-31.5 MCHC-33.9 RDW-13.5 RDWSD-46.5* Plt ___ ___ 06:00AM BLOOD ___ PTT-33.3 ___ ___ 06:00AM BLOOD Glucose-209* UreaN-12 Creat-0.8 Na-136 K-4.4 Cl-98 HCO3-19* AnGap-23* ___ 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7 CATHETERIZATIN REPORT ___: Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is.free of significant disease. * Left Anterior Descending The LAD has mid 40% stenosis. * Circumflex The Circumflex has orign 40% stenosis. The ___ Marginal has oirigin 50% stenosis. * Right Coronary Artery The RCA is very difficult to engage. Non-selective angiography shows mid ___ stenosis. The Right PDA is a small vessel and the distal RCA is possibly occluded before a small RPL branch. Impressions: 1. Moderate 3 vessel CAD with possible branch occlusion of distal RCA. There are no good targets for PCI or surgery. Recommendations 1. Medical therapy, CARDIAC PERFUSION STUDY ___: SUMMARY FROM THE EXERCISE LAB: For pharmacologic stress dipyridamole was infused intravenously for approximately 4 minutes at a dose of 0.142 milligram/kilogram/min. 1 to 2 minutes after the cessation of infusion, the stress dose of the radiotracer was injected. She had no anginal symptoms or ischemic ECG changes. TECHNIQUE: ISOTOPE DATA: (___) 31.9 mCi Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM admin) Dipyridamole; Following intravenous infusion of the pharmacologic agent, Tc-99m sestamibi was administered intravenously. Stress images were obtained approximately 30 minutes following tracer injection. Resting perfusion images were obtained on a subsequent day with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. FINDINGS: The image quality is adequate but limited due to soft tissue and breast attenuation. Left ventricular cavity size is normal. Rest and stress perfusion images reveal a reversible, mild reduction in photon counts involving the entire inferior wall. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 57% with an EDV of 77 ml. IMPRESSION: 1. Reversible, medium sized, mild perfusion defect involving the RCA territory. 2. Normal left ventricular cavity size and systolic function. CT HEAD w/o CONTRAST ___: COMPARISON: CT head without contrast ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. Small mucous retention cyst is noted in the right anterior ethmoid sinus. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. CT C-SPINE w/o CONTRAST ___: FINDINGS: Alignment is normal. No fractures are identified. There is no prevertebral soft tissue swelling. Degenerative changes notable for disc bulges and thickening of the ligamentum flavum. Disc protrusion at C2-3 and C3-4 effaces the ventral CSF and may contact the ventral aspect of the cord. Thyroid is small but grossly unremarkable. Lung apices are notable for a 3 mm right apical nodule (3:70), unchanged from prior. IMPRESSION: No acute fracture or malalignment of the cervical spine. A 3 mm right apical pulmonary nodule unchanged since prior ___. RECOMMENDATION(S): If patient has risk factors such as smoking or malignancy, ___ year followup suggested for followup of a 3 mm right apical pulmonary nodule. Otherwise no additional imaging necessary. CT SINUS ___: FINDINGS: There is no facial bone fracture. Pterygoid plates are intact. There is no mandibular fracture and the temporomandibular joints are anatomically aligned. The orbits are intact. The globes and extra-ocular muscles are unremarkable. There is no orbital hematoma. Included paranasal sinuses are clear besides a mucous retention cyst in the right maxillary sinus. Included extracranial soft tissues are unremarkable. IMPRESSION: No fracture. CXR PA & LATERAL ___: FINDINGS: Slightly lower lung volumes on the current exam. Lungs remain clear without consolidation, effusion, or edema. Cardiomediastinal silhouette is stable. Atherosclerotic calcifications seen at the aortic arch. No acute osseous abnormalities, hypertrophic changes again noted in the spine. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: The patient presented to the ED complaining of a headache, SOB and facial pain following a fall at a casino several days earlier. She reports no significant headaches in the past and when quizzed regarding her blood pressure control states she checks her pressure at home and it typically runs in the 120's systolic. She was subsequently transferred to the ___ for further observation until she underwent numerous studies include a pharmacological stress test indicating a mild perfusion defect. It was suspected given her history that she could have coronary artery disease. She underwent catheterization on ___ and had three vessel moderate disease not obstructive or amenable to PCI or surgery and to continue/enhance medical management, particularly in light of her other co-morbidities including obesity and diabetes. She was expected to discharge home following the catheterization but reported a severe headache and had a high blood pressure running to 230/97. She was subsequently triggered and had vomiting. She was given Zofran, Hydralazine and persistently hypertensive. A nitro drip was started and she was given Ativan to help with her anxiety and her nausea, which subsequently resolved. She was started on Atorvastatin and Metoprolol. Her blood pressure normalized by the early morning hours on ___ and her nitro drip was discontinued. At the time of discharge, her blood pressure was ranging in the 130's systolic. She had no further headache, was tolerating her diet and voiding without difficulty. She was counseled regarding lifestyle changes, management of blood pressure and close follow up with her physicians. Her headache was felt to be multi-factorial, including her NPO status until her late day catheterization, and her high blood pressures, which likely exist at home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Sucralfate 1 gm PO QID 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. GlipiZIDE 5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Metoprolol Tartrate 25 mg PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Losartan Potassium 100 mg PO DAILY 8. Sucralfate 1 gm PO QID Discharge Disposition: Home Discharge Diagnosis: NEW: Abnormal stress test: Cardiac Cath: multivessel moderate disease, no obstructive CAD w/o good targets for PCI or surgery - manage medically PRIOR: DM Type 2 Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). VS: T 98 HR 70 RR 18 BP 134/65 97% RA tele: SR 70-90's LABS: Na2+ 136; K+ 4.4; Cl- 98; HCO3 19; BUN 12; Cr 0.8; Ca2+ 9.1; P 3.8; Mg2+ 1.7 PHYSICAL EXAM: Gen: ___ yr old woman in NAD. Seen post-procedure. She is alert and oriented and resting comfortably with no CP, SOB, palpitations or dizziness Neck: No JVD appreciated Lungs: CTAB, no wheezing or rhonchi Heart: S1S2 regular, no MRG Abd: soft, obese, non-tender, BS + PV: right radial site is soft with no bleeding or hematoma. gauze and Tegaderm c/d/I. Good CSM to wrist. Pedal pulses palpable. No clubbing, cyanosis or edema Neuro: Alert and oriented x 3. No focal deficits or asymmetries noted. A/P: ___ from ED after + pharm stress showing a 'reversible, medium sized, mild perfusion defect involving the RCA territory'. Initially presented with left sided headache s/p fall at a casino on ___ with ongoing sharp left-sided headaches and facial pain. Her head CT was negative. At that time, she complained of dyspnea with exertion, prompting cardiac workup. EKG: NSR @ 70, NA/NI, no ischemia or ectopy, Trop- negative x2. She underwent a coronary angiogram, which showed moderate 3 vessel CAD #. CAD -start ASA 81 -start Atorvastatin (escripted to her pharmacy) -start Metoprolol 25 mg bid (escripted to her pharmacy) -follow up with Dr. ___ in ___ wks #. DM A1C 7.3% -cont Glipizide -heart healthy carb consistent diet #. Hypertension -cont Losartan -Added Metoprolol #. Disp -DC home Discharge Instructions: You were admitted overnight to our cardiac direct access unit for monitoring due to your symptoms of shortness of breath and abnormal stress test. You had an elevated blood pressures that required some additional medication. We also imaged your head which was negative for any bleeding or stroke. You had a cardiac catheterization which showed that you had some blockages in 3 of your heart arteries. Because of these blockages, you were started on a low dose Aspirin, Atorvastatin and Metoprolol. You will follow up with Dr. ___ in ___ weeks. Activity restrictions and care of our wrist site will be included in your discharge instructions. Please follow up with your PCP within the next ___ weeks for continued outpatient management. Followup Instructions: ___

19995012-DS-14

DS

2161-05-01 00:00:00

2161-05-02 13:27:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ incisional hernia repair with underlay mesh, lipoma excision History of Present Illness: Ms. ___ is a ___ year old female with history of NIDDM, CAD (cath ___ and PDA occlusion not amenable to revascularization), hyperlipidemia presents with abdominal pain and acute onset diarrhea starting at 7pm last evening. She denies nausea or vomiting. She has never experienced similar episodes; however, she continues to pass flatus and have bowel movements. She continues to have pain but has been alleviated with medication. The pain is constant in her abdomen and has not remitted. Past Medical History: diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: ___ Family History: Family history of arthritis Physical Exam: Admission Physical Exam: Vitals: 97.8 63 179/78 18 100%RA GEN: AOx3, NAD, obese HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, tender over paramedian incision +guarding, no rebound, unable to reduce as the exam is limited by pain, 2 separate hernias appreciated on exam. Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 97.6, 147/73, 60, 20, 95% RA Gen: A&O x3 CV: HRR Pulm: CTAB Abd: soft, NT/ND. Midline incision w/ staples, OTA Ext: No edema Pertinent Results: ___ 12:25AM BLOOD WBC-11.1* RBC-3.88* Hgb-11.3 Hct-35.4 MCV-91 MCH-29.1 MCHC-31.9* RDW-13.1 RDWSD-43.2 Plt ___ ___ 10:46AM BLOOD WBC-9.6 RBC-3.64* Hgb-10.7* Hct-33.6* MCV-92 MCH-29.4 MCHC-31.8* RDW-13.1 RDWSD-44.3 Plt ___ ___ 10:00PM BLOOD WBC-12.8* RBC-3.71* Hgb-11.1* Hct-34.2 MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-44.6 Plt ___ ___ 05:16AM BLOOD WBC-13.3* RBC-3.60* Hgb-10.8* Hct-33.5* MCV-93 MCH-30.0 MCHC-32.2 RDW-13.4 RDWSD-45.4 Plt ___ ___ 05:40AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.5* Hct-30.0* MCV-94 MCH-29.6 MCHC-31.7* RDW-13.2 RDWSD-45.5 Plt ___ ___ 06:15AM BLOOD WBC-8.7 RBC-2.97* Hgb-8.9* Hct-27.9* MCV-94 MCH-30.0 MCHC-31.9* RDW-13.2 RDWSD-45.9 Plt ___ ___ 05:30AM BLOOD WBC-7.6 RBC-2.99* Hgb-8.9* Hct-27.9* MCV-93 MCH-29.8 MCHC-31.9* RDW-13.1 RDWSD-44.5 Plt ___ ___ 05:30AM BLOOD Glucose-147* UreaN-7 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-27 AnGap-14 ___ 06:15AM BLOOD Glucose-140* UreaN-6 Creat-0.7 Na-140 K-3.4 Cl-102 HCO3-24 AnGap-17 ___ 05:40AM BLOOD Glucose-143* UreaN-7 Creat-0.8 Na-138 K-3.3 Cl-100 HCO3-25 AnGap-16 ___ 05:16AM BLOOD Glucose-155* UreaN-12 Creat-1.0 Na-144 K-4.0 Cl-106 HCO3-24 AnGap-18 ___ 10:00PM BLOOD Glucose-214* UreaN-15 Creat-1.0 Na-139 K-3.2* Cl-103 HCO3-21* AnGap-18 ___ 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7 ___ 06:15AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8 ___ 05:40AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.4* CT A/P: 1. Re-demonstrated are 2 midline, ventral abdominal wall hernias-the hernia located more cranially contains a small segment of the nonobstructed transverse colon, while the hernia located caudally contains a small portion of a small bowel loop. There is trace fluid within the hernial sac containing the small bowel however no transition point or other evidence to suggest bowel obstruction noted. There has been prior mesh repair of the ventral abdominal wall and the mesh is located inferior to the latter hernial sac. 2. Mild hepatic steatosis, extensive sigmoid diverticulosis, severe atherosclerotic calcification of the abdominal aorta and its branches with focal narrowing (up to 50%) at the origin of the celiac artery are additional incidental findings. Brief Hospital Course: Ms. ___ is a ___ year old female who presented to the Emergency Department on ___ with abdominal pain. The patient was evaluated by the Acute Care Surgery Service and a CT scan of abdomen and pelvis was obtained. These images revealed an incarcerated hernia. Given these findings, the patient was taken to the operating room for repair. There were no adverse events in the operating room; please see the operative note for details. She was extubated, taken to the PACU until stable, then transferred to the surgical floor for observation. The patient was alert and oriented throughout hospitalization; pain was initially managed with IV Tylenol and Dilaudid and then transitioned to oral Tylenol and Tramadol once tolerating a diet. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. She remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toileting, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient was initially kept NPO. On POD1 diet was advanced to clears with good tolerability. On POD2 the patient tolerated a regular diet. Patient's intake and output were closely monitored She has a midline incision to her abdomen with staples that are clean, dry and intact (will be removed at follow up appointment with Dr. ___. Her bowel function returned and began to pass gas and have bowel movements. The patient's fever curves were closely watched for signs of infection, of which there were none. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. The patient was seen and evaluated by physical therapy who recommended discharge to home with continued home physical therapy. 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: AMMONIUM LACTATE - ammonium lactate 12 % topical cream. apply to dry skin on feet but not between toes twice a day ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 unit capsule. 1 capsule(s) by mouth 1 week for 40 weeks get repeat level when this is completed - (Not Taking as Prescribed) FLUTICASONE - fluticasone 50 mcg/actuation nasal spray,suspension. 2 sprays(s) each nostril daily as needed for congestion or post nasal drip for 2 weeks GLIPIZIDE - glipizide 5 mg tablet. One tablet(s) by mouth daily HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply pea size to affected area every day after bathing for 14 days, then as needed for itching ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg tablet,extended release 24 hr. 1 tablet(s) by mouth daily LEVOTHYROXINE - levothyroxine 150 mcg tablet. 1 tablet(s) by mouth daily This is an INCREASED dose LOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth once a day METOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 1 tablet(s) by mouth twice a day PENCICLOVIR [DENAVIR] - Denavir 1 % topical cream. apply to lips every 2 hours until cold sores resolve - (Not Taking as Prescribed: discontinued) SUCRALFATE - sucralfate 1 gram tablet. 1 tablet(s) by mouth tid before meals and hs tell her to take about 30min before meals. STOP THE PANTAPROZOLE Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by mouth once a day - (Not Taking as Prescribed) BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra Test strips. Use as directed for blood sugar monitoring twice a day and as needed. Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) BLOOD-GLUCOSE METER [ONETOUCH ULTRA2] - OneTouch Ultra2 kit. Use as directed for blood sugar monitoring twice a day and as needed Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) CAMPHOR-MENTHOL [ANTI-ITCH (MENTHOL/CAMPHOR)] - Anti-Itch (menthol/camphor) 0.5 %-0.5 % lotion. apply to affected areas as needed as needed for itch disp qs for 30 days - (Pt denies taking) (Not Taking as Prescribed: discontinued) CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg tablet. 1 tablet(s) by mouth daily LANCETS [ONETOUCH ULTRASOFT LANCETS] - OneTouch UltraSoft Lancets. Use as directed for blood sugar monitoring twice a day and as needed Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. TraMADol ___ mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. GlipiZIDE 5 mg PO DAILY 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 100 mg PO DAILY 12. Metoprolol Tartrate 25 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ventral hernia, lipoma of the abdominal wall 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 ___ on ___ with abdominal pain. You were evaluated by the Acute Care Surgery Service and after a CT scan was done, we found a piece of your bowel was entrapped in your stomach lining. We took you to the operating room and repaired this. You tolerated the procedure well and are now being 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. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. It was a pleasure being part of your care! Followup Instructions: ___

19995127-DS-11

DS

2138-03-11 00:00:00

2138-03-11 15:07:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Atorvastatin Attending: ___. Chief Complaint: depression, anorexia, with cough Major Surgical or Invasive Procedure: biopsy of lung mass (left upper and left lower lobes), via bronchoscopy History of Present Illness: PCP: ___ MD CC: ___ mood, decreased appetite, found to have new chest mass HISTORY OF PRESENT ILLNESS: This is an ___ yom with PMH of hypertension, hyperlipidemia, and hyperthyroidism status post RAI ablation on ___ who presents with worsening fatigue and insominia over ___ weeks. He says that his appetite had generally been good but this morning reported poor appetite and became suddenly tearful. He has also had decreasing interest in his activities over this time. He denies hallucinations, suicidal ideation, or homicidal ideations. Ultimately given his progressing symptoms, he went to the emergency department. The patient has no psychiatric history. While in the ED, pt had a CT head given concern for AMS, which showed no acute intracranial process but chronic microvascular ischemic changes with global atrophy. He also had CXR done which showed 6.2 x 5 cm mass projecting to the superior segment of the left lower lobe, concerning for malignancy particularly with calcified pleural plaques. CT chest was obtained which confirmed 8.5 cm left upper and lower lobe mass, infiltrating the mediastinum with loss of fat planes with the, esophagus, and occluding a short segment of the left lower lobe pulmonary artery with distal reconstitution. Psych saw the patient who felt he did not meet ___ criteria. He was admited to medicine given finding of new mass and for medical clearance prior to ___ bed search. They recommended starting mirtazapine for sleep/depression. REVIEW OF SYSTEMS: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Left common iliac anneurysm hyperthyroidism status post RAI ablation on ___ Social History: ___ Family History: FAMILY HISTORY: -Thyroid issues in his cousins -Lung cancer in his sister. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.3 129/56 83 16 955 ra GENERAL: well appearing HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, JVP normal LUNGS: CTA bilat, no wheezes or crackles HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all extremities PSYCH: Affect appropriate, speech fluent, denying SI/HI DISCHARGE PE:98.1 119/77 83 20 97%RA GENERAL: NAD, HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, JVP normal LUNGS:some ronchi HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all extremities PSYCH: Affect appropriate, speech fluent, Pertinent Results: ADMISSION LABS ___ 02:07PM BLOOD WBC-7.7 RBC-5.32 Hgb-14.0 Hct-44.4 MCV-84 MCH-26.3* MCHC-31.6 RDW-14.5 Plt ___ ___ 02:07PM BLOOD Glucose-109* UreaN-21* Creat-1.1 Na-135 K-5.3* Cl-97 HCO3-30 AnGap-13 ___ 08:11AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1 ___ 02:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING CXR ___ A mass is present in the superior segment of the left lower lobe and therefore malignancy must be considered. Elsewhere, the left lung appears clear. There is no effusion. Calcified pleural plaque is present in the right mid zone. The right lung appears clear. Some tracheal displacement to the right is present at the thoracic inlet probably due to thyroid, but lymph nodes should also be considered. IMPRESSION: Left lung mass. CT should be performed. CT chest ___. 8.5 cm (in longest dimension) left upper and lower lobe mass traverses the major fissure, infiltrates the mediastinum with loss of fat planes with the esophagus, and occludes a short segment of the left lower lobe pulmonary artery with distal reconstitution. Mild narrowing of the left upper and lower lobe airways without lobar collapse. Mild surrounding septal thickening could reflect postobstructive changes or lymphangitic tumor spread. Esophageal compression and thickening from the mass, correlate for history of dysphagia. 2. Pleural plaques with subpleural reticulations consistent with asbestosis from prior exposure as well as moderate emphysema. 3. Heterogeneous enlarged left thyroid gland as before status post recent radioactive iodine therapy. 4. Unchanged left adrenal nodularity. While the nodules were of indeterminate density on prior non-contrast abdominal CT examinations, stability in size since ___ suggests benignity. 5. Mild heterogeneity in the T3 vertebral body is nonspecific and can be correlated with bone scan if indicated. Preliminary findings were discussed with Dr. ___ by Dr. ___ at 2215 on ___ by phone. Final Report HISTORY: Mass on chest radiograph. TECHNIQUE: CT images were obtained through the chest after the uneventful intravenous administration of 75 cc of Omnipaque contrast media. Multiplanar reformations were prepared. COMPARISON: ___, CT abdomen ___ FINDINGS: The left thyroid lobe remains heterogeneous and enlarged as on previous studies in this patient status post recent radioactive iodine therapy on ___ (2:2). The aorta and major branches are patent and normal in caliber with mild atherosclerotic calcifications. The heart and pericardium are unremarkable without pericardial effusion. The previously described anterior mediastinal lesion concerning for thymoma has resolved. An 8.5 x 6.8 x 6.0 cm mass (602b:49 and 2:30) traverses the left major fissure involving superior segment of the left lower lobe as well as the inferior aspect of the apicoposterior segment of the left upper lobe. The mass exerts marked local mass effect resulting in segmental occlusion of the left lower lobe pulmonary artery with distal reconstitution (2:32 and 601b:32), mild attenutation of the left upper lobe airways and moderate compression of the left lower lobe bronchus without lobar collapse. Mild septal thickening and ground glass opacity along the lateral and inferior aspect of the lesion could reflect lymphangitic spread of tumor, mild atelectasis or postobstructive changes. The lesion drapes along 180 degrees of the descending thoracic aortic circumference with somewhat blurred fat planes (2:26) and extends along the medial aspect of the posterior pleura at the site of a calcified pleural plaque without accompanying pleural effusion. A confluent soft tissue projection extends from the lesion into the mediastinum measuring 3.7 x 4.2 cm (2:24) with anterior and rightward displacement of the carina and esophagus and mild attenuation of the left mainstem bronchus. The esophagus appears compressed with circumferential esophageal mural thickening noted slightly more distally (2:27). Multiple subcentimeter right upper paratracheal lymph nodes are notable in number (2:14). Moderate predominantly centrilobular emphysema is unchanged. Bilateral calcified pleural plaques and a predominantly basilar subpleural interstitial abnormality is consistent with the previous diagnosis of asbestosis. The trachea and right-sided airways appear patent to the segmental level. A right major fissural 5 mm nodule is unchanged (4:104). Although this study is not tailored for subdiaphragmatic evaluation the imaged upper abdomen reveals unchanged nodularity in the lateral limb of the left adrenal gland measuring 9 mm and body of the left adrenal gland measuring 12 mm (2:61 and 58), which is stable. OSSEOUS STRUCTURES: No definite lytic or blastic bony lesion is seen to suggest malignancy with mild heterogeneity in the T3 vertebral body of uncertain significance. IMPRESSION: 1. 8.5 cm left upper and lower lobe mass traverses the major fissure, infiltrates the mediastinum with loss of fat planes with the esophagus, and occludes a short segment of the left lower lobe pulmonary artery with distal reconstitution. Mild narrowing of the left upper and lower lobe airways without lobar collapse. Mild surrounding septal thickening could reflect postobstructive changes or lymphangitic tumor spread. 2. Esophageal compression and thickening from the mass, correlate for history of dysphagia. 3. Pleural plaques with subpleural reticulation consistent with asbestosis from prior exposure. 4. Moderate emphysema. 5. Heterogeneous enlarged left thyroid gland as before status post recent radioactive iodine therapy. 6. Unchanged left adrenal nodularity. While the nodules were of indeterminate density on prior non-contrast abdominal CT examinations, stability in size since ___ suggests benignity. 7. Mild heterogeneity in the T3 vertebral body is nonspecific and can be correlated with bone scan if indicated. Preliminary findings were discussed with Dr. ___ by Dr. ___ at 2215 on ___ by phone. CT head FINDINGS: There is no acute intracranial hemorrhage, mass effect, edema or Preliminary Reportmajor vascular territorial infarct. The ventricles and sulci are mildly Preliminary Reportprominent, compatible with age-related global atrophy. There are Preliminary Reportmoderate-to-significant periventricular and subcortical white matter Preliminary Reporthypodensities, nonspecific, but most likely representing chronic microvascular Preliminary Reportischemic changes. The gray-white matter differentiation is preserved. Preliminary ReportThere is no acute skull fracture. There is scattered ethmoidal mucosal Preliminary Reportthickening. The remaining visualized paranasal sinuses and mastoid air cells Preliminary Reportare clear. Preliminary ReportIMPRESSION: Preliminary Report1. No acute intracranial process. No intracranial hemorrhage. Preliminary Report2. Chronic microvascular ischemic changes with global atrophy. Brief Hospital Course: ___ year old man with known hypertension, hyperthyroidism (s/p RAI ablation in ___, presents with worsening symptoms of depression, insomnia, weight loss now found to have large, likely malignant lung mass. # New lung mass: The patient was found to have a lung mass on imaging on admission, and further history is notable for cough, as well as poor appetite which could be attributable to his lung mass in addition to suspected depression. Of note, he has a history of asbestos exposure, as used to work in a ___ and was a smoker from the age of ___. On imaging, the lesion appeared suspicious for malignancy with evidence of compression of surrounding structures and mention of adjacent lymph nodes. He denies hemoptysis, no difficulty swallowing, and denies a productive cough. CT head showed no suspicious lesions. Interventional pulmonary was consulted for biopsy which was performed on ___ and patient will follow up with the interdisciplinary lung clinic in the next 2 weeks. He was made NPO the night before biopsy and there were no complications of the procedure. Head MRI and PET scan ordered while here as outpatient, and we discussed with Dr ___ the suspected diagnosis. # Depression: The patient reported recent difficulty sleeping consistent with insomnia, poor appetite, decreased interest, and tearfulness consistent with depression. Psych saw the patient in the ED and recommended mirtazapine 15mg qhs for his symptoms. He will follow-up with his internist for ongoing discussion of his depression and to assist in determining what his further needs might be. # Hyperthyroidism s/p RAI ablation: TSH <0.02 FreeT4 1.5, currently has subclinical hyperthyroidism. We continued his recent propranolol 10mg po daily. We understand that he has endocrinology f/u in ___. # HTN: We continued his home enalapril 10mg daily # HL: We continued his home pravastatin 40mg daily # BPH: Continued home tamsulosin 0.4mg daily. Continued home finasteride 5mg daily TRANSITIONAL ISSUES #f/u head MRI (ordered as outpatient) #f/u PET (ordered as outpatient) #f/u endobronchial biopsy and EBUS TBNA reports. #lung mass: will f/u with lung clinic as per interventional pulmonology -will need PET and brain MRI at some point after biopsy to continue with staging #patient will call to make an appointment with Dr ___ psychiatry, psychiatry requests that PCP prescribe ___ from now till his appointment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 10 mg PO DAILY hold for sbp<100 2. Finasteride 5 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. Hydrochlorothiazide 25 mg PO DAILY hold for sbp<100 5. Pravastatin 80 mg PO DAILY 6. Propranolol 10 mg PO BID hold for sbp<100, hr <60 7. Tamsulosin 0.4 mg PO HS 8. Aspirin 325 mg PO PRN headache 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Enalapril Maleate 10 mg PO DAILY hold for sbp<100 2. Finasteride 5 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY hold for sbp<100 4. Multivitamins 1 TAB PO DAILY 5. Pravastatin 80 mg PO DAILY 6. Propranolol 10 mg PO BID hold for sbp<100, hr <60 7. Tamsulosin 0.4 mg PO HS 8. Aspirin 325 mg PO PRN headache 9. Fluticasone Propionate NASAL 1 SPRY NU BID 10. Mirtazapine 15 mg PO HS RX *mirtazapine 15 mg 1 tablet(s) by mouth take at night before bed Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: primary: lung mass, depression secondary: hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, It was a true pleasure caring for you here at the ___. You came to the hospital because you had weight loss and you werent feeling right. While you were here we had psychiatrists see you and they felt that you likely have depression. On imaging a mass was seen in your lung. We had the specialists biopsy the lung. You will follow up with the lung clinic when you go home. They will call you but if you don't hear from them by ___ you can all them at ___. You will have imaging done (see below) this week to see if there is any cancer anywhere else. Also while you were here you were seen by psychiatry for depression. You need to call them (see below) to make an appointment. Followup Instructions: ___

19995127-DS-13

DS

2138-05-19 00:00:00

2138-05-20 13:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Atorvastatin Attending: ___. Chief Complaint: Near syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year-old retired ___ with a history of pAF, formerly HTN, and recent diagnosis of SCLC (___) who recently finished his third cycle of carboplatin-etoposide and pegfilgrastim on ___ who presents with the chief complaint of near-syncope. Mr. ___ has never had near syncope or hypotension previously, and in fact has had hypertension in the past. On ___, be felt lightheaded after standing and fell on his right flank. There was no LOC, palpitations, chest pain, or headstrike. He received carboplatin 330mg (___), etoposide 150mg IV ___, ___ In the MICU his BPs were ___ and received 3 L of NS in successive boluses with response of his blood pressure to relative normotension to ___. Of note, he has been serially tested for orthostatic vital signs and has been markedly orthostatic each time. PCP had planned to start midodrine, fludcrocortisone for his hypotension, and this regimen was started in the MICU with response of blood pressure. Initially there was concern for pneumonia based on his CT, but on final read his findings were unchanged and likely due to his underlying malignancy. He has been afebrile, and infecious work-up has been negative. Antibiotics were given initially empirically, but have been discontinued. Past Medical History: - Formerly hypertension (likely underlying physiolgoy has changed and will no longer be hypertensive) - Hyperlipidemia - Left common iliac anneurysm - Hyperthyroidism status post RAI ablation on ___ - BPH PAST ONCOLOGIC HISTORY: - ___: presented with symptoms of insomnia, depression, was noted to have an abnormal CXR and subsequent CT chest showed an 8.1 cm mass in the left upper and left lower lobe which infiltrated the mediastinum and caused compression on the esophagus. - ___: bronchoscopy and biopsy proved to be small cell carcinoma which was positive for TTF-1, CD56 and synaptophysin and negative for p63, LCA and chromogranin. - ___: PET showed no other sites of metastatic disease. - ___: Brain MRI with 3-mm enhancing focus in the left cerebellar hemisphere concerning for metastasis - ___: Cycle 1 Carboplatin AUC 5/Etoposide 100 mg/m2 - ___: admission for cough, malaise, admission complicated by febrile neutropenia and thrombocytopenia, and new-onset atrial fibrillation - ___: Cycle 2 Carboplatin AUC 3.75/Etoposide 75 mg/m2 (25% dose reduction in both drugs) - ___: Chest CT with improvement in mediastinal mass; MRI with improvement in cerebellar lesion - ___: Cycle 3 of carboplatin/etoposide - ___: Admission for profound orthostatic intolerance, started on midodrine, fludricortisone. Also pancytopenic and neutropenic, with slow recovery in cell counts. Social History: ___ Family History: - Thyroid issues in his cousins - Lung cancer in his sister. - Daughter with metastatic breast cancer - No history of heart disease Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T 98.6 HR 79-105, BP 88/42-124/49, RR 13, SaO2 98% on RA Wgt (current): 81.1 kg (admission): 78 kg General: Cachectic-appearing man in no apparent distress sitting in chair with wife at side. HEENT: EOMI, MMM Neck: No JVD Lungs: CTAB CV: RRR currently, no m/r/g. PMI nondisplaced. Back: Scattered nevi on back but no ecchymosis of R flank seen. No tenderness to palpation of beck. Abdomen: Soft, nontender, nondistended. Ext: Nonedeamtous, WWP. Skin: No rashes appreciated Neuro: Intact strength and sensation in lower and upper extremities. CN II-XII grossly intact. No obvious ataxia. Orthostatics (___) Standing: BP 64/palp HR 130 Orthostatics (___) Standing: BP 88/54 HR 119 Orthostatics (___) Supine: BP 96/54 HR 74 Sitting: BP 104/50 HR 81 Standing: 104/52 HR 101 DISCHARGE PHYSICAL EXAM Vitals: T 98.5 BP 106/62 HR 106 RR 12 SaO2 98% on RA General: Cachectic-appearing man in no apparent distress sitting in bed. HEENT: EOMI, MMM Neck: Jugular veins flat. Lungs: CTAB CV: RRR currently, no m/r/g. PMI nondisplaced. Abdomen: Soft, nontender, nondistended. GU: Foreskin slightly edematous. Slightly erythematous folds in between foreskin and glans with smegma and suggestion of mycosis. Ext: Nonedeamtous, WWP. Neuro: A&Ox3. Moving all four extremities spontaneously, follows commands. Pertinent Results: ___ 11:00AM BLOOD WBC-63.1*# RBC-3.86* Hgb-10.2* Hct-32.1* MCV-83 MCH-26.4* MCHC-31.8 RDW-18.5* Plt ___ ___ 07:30PM BLOOD WBC-45.6* RBC-3.48* Hgb-9.3* Hct-29.1* MCV-83 MCH-26.7* MCHC-32.0 RDW-19.0* Plt ___ ___ 04:45AM BLOOD WBC-33.7* RBC-3.40* Hgb-9.0* Hct-27.7* MCV-82 MCH-26.6* MCHC-32.6 RDW-19.2* Plt ___ ___ 03:19AM BLOOD WBC-19.2* RBC-3.70* Hgb-9.7* Hct-30.5* MCV-82 MCH-26.2* MCHC-31.9 RDW-19.0* Plt ___ ___ 08:00AM BLOOD WBC-1.2*# RBC-3.48* Hgb-9.1* Hct-29.8* MCV-86 MCH-26.3* MCHC-30.7* RDW-18.9* Plt ___ ___ 07:35AM BLOOD WBC-1.0* RBC-3.36* Hgb-8.8* Hct-27.7* MCV-82 MCH-26.3* MCHC-32.0 RDW-18.8* Plt ___ ___ 06:10AM BLOOD WBC-1.0* RBC-3.02* Hgb-8.0* Hct-24.6* MCV-82 MCH-26.6* MCHC-32.6 RDW-18.8* Plt ___ ___ 07:10AM BLOOD WBC-0.8* RBC-3.20* Hgb-8.5* Hct-26.1* MCV-82 MCH-26.7* MCHC-32.7 RDW-18.8* Plt Ct-81* ___ 06:30AM BLOOD WBC-2.0*# RBC-2.91* Hgb-7.6* Hct-24.4* MCV-84 MCH-26.1* MCHC-31.1 RDW-18.7* Plt Ct-59* ___ 11:00AM BLOOD Glucose-141* UreaN-22* Creat-0.9 Na-136 K-4.1 Cl-98 HCO3-25 AnGap-17 ___ 03:19AM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-137 K-4.2 Cl-100 HCO3-29 AnGap-12 ___ 06:10AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-138 K-3.6 Cl-101 HCO3-29 AnGap-12 ___ 06:30AM BLOOD Glucose-82 UreaN-11 Creat-0.7 Na-139 K-3.6 Cl-101 HCO3-31 AnGap-11 ___ 08:00AM BLOOD TSH-3.4 ___ 06:10AM BLOOD Cortsol-13.0 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-3.9*# (58% PMNs) RBC-3.02* Hgb-8.2* Hct-24.8* MCV-82 MCH-27.0 MCHC-33.0 RDW-19.1* Plt Ct-44* CT CHEST WITH INTRAVENOUS CONTRAST (___): Heterogeneous enlargement of the left thyroid gland is stable compared to prior examination. Aside from known tumor, remaining mediastinal lymph nodes are subcentimeter and appear unchanged compared to prior examination. No supraclavicular or axillary lymphadenopathy is identified. The heart size is normal, and there is no pericardial effusion. Thoracic aorta is non-aneurysmal and patent. Known small cell lung carcinoma within the posterior segment of the left upper lobe and within the superior segment of the left lower lobe is similar to recent prior examination from 11 days prior. Inferior portion measures 26 x 31 mm as compared to 23 x 25 mm previously. Superior portion measures 44 x 27 mm as compared to 48 x 27 mm previously (2A:54). The superior segment left lower lobe bronchus continues to contain tumor, however, is not fully occluded, unchanged. Tumoral invasion and thrombus within the left lower lobe pulmonary artery appears unchanged (2A:60). The remainder of the pulmonary arterial tree is widely patent without sign of superimposed acute pulmonary embolism. No distal propagation of tumoral thrombus is evident. Irregular opacities within the posterior right upper lobe (2A:46 and 54) are stable compared to prior examination, are are likely infectious or inflammatory in etiology. Previously described sub-3-mm pulmonary nodules are not well characterized on this examination likely due to differences in technique. No new suspicious pulmonary nodule or mass is identified. Diffuse emphysema is unchanged. Numerous calcified pleural plaques are unchanged and consistent with asbestosis. There is mild basilar atelectasis. CT ABDOMEN WITH INTRAVENOUS CONTRAST: Focal irregular arterial enhancement within the hepatic dome is not seen on delayed phase imaging and likely reflects a perfusional abnormality. No suspicious hepatic lesion is identified. Hepatic veins and portal venous system are grossly patent. No intra- or extra-hepatic biliary ductal dilatation is identified. Tiny hypodense foci within the gallbladder may reflect nitrogen-containing stones. The gallbladder is otherwise unremarkable. The spleen, pancreas, and right adrenal gland are normal. An 11 mm indeterminate left adrenal nodule is stable dating back to ___, likely a small adenoma. The kidneys enhance symmetrically without suspicious focal lesion or hydronephrosis. Subcentimeter hypodensities within the left kidney remain too small to characterize, though likely small cysts. No perinephric fluid collection or hydronephrosis is evident. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. The stomach and small bowel loops are normal in caliber and configuration without evidence of obstruction or inflammation. The appendix is visualized and is normal. No abdominal free fluid or free air is evident. The abdominal aorta and branch vessels are non-aneurysmal and patent. Redemonstrated is aneurysmal dilatation of the left common iliac artery measuring 4.2 x 4.5 cm. Thrombosis of >75% of the left common iliac aneurysm is stable. Distal flow is preserved to the left external iliac, internal iliac, and common femoral artery. CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum and colon are normal in caliber and configuration without evidence of obstruction or inflammation. A Foley catheter and a small amount of air are seen within the urinary bladder. Prostatic enlargement is unchanged from prior. A hypodense lesion within the anterior aspect of the prostate gland is stable and likely represents a small cyst (2B:185). There is no pelvic free fluid. No pathologically enlarged pelvic or inguinal lymph nodes are identified. BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is identified. Heterogeneity of the sacrum is unchanged compared to ___, findings consistent with a benign process. No bone destructive lesion is identified. IMPRESSION: 1. Stable small cell lung carcinoma within the left upper and lower lobes with invasion into the mediastinum. Ongoing tumoral invasion into the left lower lobe bronchus and left lower lobe pulmonary artery. Findings are unchanged compared to recent prior examination from ___. 2. No superimposed acute pulmonary embolism 3. Ground-glass nodules within the right upper lung persist, though are likely infectious/inflammatory in etiology. Attention on followup is recommended. Additional millimeteric pulmonary nodules not seen likely due to technical differences. 5. Stones in an otherwise normal gallbladder. 6. Stable 11-mm left adrenal lesion, likely an adenoma. 7. Stable 4.5-cm partially thrombosed left common iliac aneurysm 8. Stable prostatic enlargement with an anterior prostatic cyst. 9. Stable heterogeneous enlargement of the left lobe of the thyroid gland which can be characterized by ultrasound if it has not been done previously. Brief Hospital Course: #) ORTHOSTATIC INTOLERANCE: The new-onset of orthostatic hypotension, given the temporal relationship to his chemotherapy and underlying malignancy make these the most likely culprits. * Chemotherapy-induced autonomic neuropathy: his carboplatin regimen is well known to cause peripheral sensory neuropathy, and has been described to cause autonomic neuropathy. However, he developes appropriate tachycardic response to orthostasis, arguing against dysautonomia. Etoposide is not known to cause neuropathy, and mainly manifets with GI upset. * Paraneoplastic syndrome: Commonly seen in lung cancers (particularly small cell), these tumors secrete ___ antibody can cause autonomic neuropathy (23% of cases). However, this is usually associated with cerebellar degeneration, which he does not demonstrate since he has no ataxia, dysmetria, or nystagmus. INTERVENTIONS: Mr. ___ was started on midodrine, fludricortisone, and salt tablets with modest response in blood pressure. He was unable to tolerate salt tabs (had emesis), so these were discontinued. His tamsulosin was held due to possible contribution of orthostasis, and he experienced some worsening of his urinary retention, but was still able to void without significant difficulty. He subsequently was able to maintain BP 88/50 when standing and without lightheadedness, which was a large improvement from his 64/palp orthostatic readings immediately after being called out of the ICU. On the day prior to discharge, his standing vitals were BP 104/52 with HR 101 which he maintained for two minutes without lightheadedness. #) LEUKOCYTOSIS -> PANCYTOPENIA: Initially with leukocytosis on admission, likely due to pegfilgrastim therapy, with WBC 60K. His antibiotics were discontinued and was afebrile and without systemic signs of infection. His cell lines declined and became profoundly neutropenic, but never manifested a fever. After speaking to his outpatient oncology providers, no further pegfilgrastim was indicated in the short term. #) ATRIAL FIBRILLATION, PAROXYSMAL: Sinus rhythm while here. Family decided not to pursue anticoagulation given limited prognosis. They had been told he likely had ___ months to live and perhaps ___ months with chemothearpy. Thus, they decided against anticoagulation despite his CHADS2 score of 2. #) BALANITIS: Patient noted to have swollen glans penis and mycotic-appearing foreskin, so he was given fluconazole x 1. TRANSITIONAL ISSUES =================== ** Patient is thrombocytopenic (platelets = 44,000 on discharge). Please monitor closely for signs of bleeding, or headache (which could represent intracranial hemorrhage since he has known brain metastasis). [ ] Please check a CBC in 3 days and fax results to his heme/onc physicians: Dr. ___ at fax number ___. Dr. ___ phone # is ___. - At night: Patient should be in bed, supine with HOB ~20 degrees with compression stockings OFF. - During the day: Patient should be OOB to chair as much as possible with compression stockings ON. - He should be continued on midodrine, fludricortisone, and monitored for chest pain, palpitations, as well as supine hypertension. - Be VERY careful with changes in position since he has become profoundly orthostatic with rapid changes in position. Until he becomes more stable he should NOT be stood with assist until he receives his AM midodrine. [ ] Please continue to up-titrate his fludricortisone with increases of 0.1mg per week with a maximum dose of 1.0 mg. This should be titrated to increase his blood pressure, targeting specifically his BP while standing to be above > 90/60 and/or without symptoms of hypoperfusion (lightheadedness, dizziness, etc.) [ ] Please monitor for worsening signs of urinary retention. We stopped his tamsulosin while in ___ since we thought it could be contributing to his orthostatic hypotension, but we anticipated that it may worsen urinary retention. Pt. was seen and examined on ___. Agree with resident evaluation and plan as above. - ___, MD signed electronically. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Finasteride 5 mg PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. Mirtazapine 50 mg PO HS 6. Pravastatin 80 mg PO DAILY 7. Prochlorperazine 10 mg PO Q6H:PRN nausea 8. Senna 2 TAB PO BID 9. Tamsulosin 0.4 mg PO HS 10. traZODONE 50 mg PO HS 11. Nystatin Oral Suspension 5 mL PO TID 12. Polyethylene Glycol 17 g PO DAILY 13. Aspirin 81 mg PO DAILY 14. Hydrochlorothiazide 50 mg PO DAILY 15. Levothyroxine Sodium 25 mcg PO DAILY 16. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Finasteride 5 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Nystatin Oral Suspension 5 mL PO TID 9. Polyethylene Glycol 17 g PO DAILY 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Senna 1 TAB PO BID 12. Fludrocortisone Acetate 0.2 mg PO DAILY 13. Midodrine 10 mg PO TID 14. traZODONE 25 mg PO HS:PRN Insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Orthostatic intolerance Small cell lung carcinoma Pancytopenia (including neutropenia), chemotherapy-related bone marrow suppression. Atrial fibrillation, paroxysmal 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 ___ ___. You were admitted for dizziness and were found to have a condition called orthostatic hypotension. This means that your blood pressure falls dramatically when you stand up. We think this may be related to your chemotherapy regimen. We started you on some medicines to increase your blood pressure which helped you stay without lightheadness when you stand. Followup Instructions: ___

19995258-DS-2

DS

2130-06-15 00:00:00

2130-06-15 15:58:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: anastrozole / Augmentin / barocat / Latex, Natural Rubber Attending: ___. Chief Complaint: complicated diverticulitis Major Surgical or Invasive Procedure: ___: exploratory laparotomy, complicated sigmoid colectomy, ileocecectomy, and total abdominal hysterectomy and bilateral salpingo-oopherectomy with diverting loop ileostomy History of Present Illness: ___ hx of sigmoid diverticulitis in ___, breast ca presents with over 1wk of LLQ abdominal pain, N/V and imaging consistent with large bowel obstruction and a focal thickening of sigmoid colon concerning for a diverticular stricture vs malignant obstruction. Colorectal surgery is consulted for a surgical evaluation. Patient reports she has had an uncomplicated sigmoid diverticulitis ___ where she was admitted to ___ medicine service for about 2 days and resolved with antibiotics. She subsequently underwent a colonoscopy at the time that showed diverticulosis and no other abnormalities. She has been feeling well until about 4 weeks ago, had a similar LLQ abdominal pain and was seen by her PCP and underwent ___ CT ___ scan which showed a focal thickening in the sigmoid colon and a proximal obstruction. She was sent home with 5 days of Cipro/Flagyl and feeling better however started having recurrent crampy LLQ abdominal pain, nausea, vomiting and ostipation. She presented to ___ ED where she underwent a CT A/P w/IV contrast which showed a worsened large bowel obstruction at a focal thickening of the sigmoid colon. She was transferred to ___ ED for further management. Upon transfer, patient had normal vitals, labs only notable for elevated lipase at 587. She currently endorses stable LLQ pain, no nausea, last passed flatus yesterday, last BM 2 days ago. She denies any fevers, chills, night sweats, weight loss or bloody stools Past Medical History: sigmoid diverticulitis ___ HTN, HL Mitral valve prolapse. Autoimmune disorder of unclear etiology, manifesting as neutrophilic dermatosis, diagnosed in ___ for which she is under the care of Dr. ___ and ___ recently Dr. ___. Social History: ___ Family History: The patient's mother developed breast cancer at age ___. Her father had lymphoma at age ___. She underwent BRCA1-2 testing drawn on ___ at ___, which was negative. She is of ___ ethnic background. Physical Exam: afebrile, vital signs stable General: well appearing, NAD HEENT: normocephalic, atraumatic, no scleral icterus Resp: breathing comfortably on room air CV: regular rate and rhythm on monitor Abdomen: soft, NT, ND, incision clean, dry, intact Brief Hospital Course: Mrs. ___ presented to the emergency department with abdominal pain and imaging consistent with complicated diverticulitis with a malignant vs inflammatory stricture on ___. She underwent a sigmoidosocopy on ___ which showed a 3 cm stricture that decompressed with rectal tube in the proximal sigmoid colon. NGT was placed and the patient was kept NPO. The decision was made to take her to the operating room on ___ for Sigmoid colectomy, ileocecectomy, TAH/BSO, and diverting loop ileostomy. The procedure was complicated by intraoperative blood loss of 1.2L. She remained hemodynamically unstable with pressor requirement in the immediate post operative period, thus she was transferred to the surgical ICU for further management. Neuro: Pain was initially controlled with dilaudid PCA until the patient had return of bowel function. At this point the patient was transitioned to PO pain meds. CV: The patient was hemodynamically unstable after the OR with persistent tachycardia and hypotension requiring pressors, likely secondary to post operative systemic inflammatory response. She was resuscitated with chrystalloid and colloid, and her lactate normalized by the end of post op day 1. She no longer required pressors to maintain her pressure by the end of post operative day one, and her tachycardia resolved by post operative day 2. Pulm: She was extubated in the PACU after her operation. She had a persistent oxygen requirement until post operative day 3 when she was able to be weaned off of oxygen. She was transferred to the floor on post operative day 3. GI: Diet was advanced in a stepwise fashion until the patient was tolerating a regular diet without difficulty. GU: foley was removed on POD 2, patient voided appropriately without issue. ID: Due to presumed intra-abdominal contamination from the visualized abscesses, she was started on a 7 day course of antibiotics. When she was tolerating a regular diet, she was transitioned to PO antibiotics. Previna vac was used over her wound until post operative day 5. It was removed on the day of discharge. Heme: No major issues. On POD 5, the patient was discharged to home. At discharge, the patient was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. The patient will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [x] Abscess [ ] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying discharge. [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Start: ___, First Dose: Next Routine Administration Time 2. Lisinopril 10 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 80 mg ___ tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 4. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL ___aily Disp #*25 Syringe Refills:*0 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*6 Tablet Refills:*0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*45 Tablet Refills:*0 7. Psyllium Wafer ___ WAF PO BID RX *psyllium [Metamucil] 1.7 g ___ wafer(s) by mouth twice a day Disp #*100 Wafer Refills:*0 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Medical Assist Device: Commode please provide patient with commode upon discharge Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: recurrent diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ were admitted to the hospital after an exploratory laparotomy, complicated sigmoid colectomy, ileocecectomy, and total abdominal hysterectomy and bilateral salpingo-oopherectomy with diverting loop ileostomy. ___ have recovered from this procedure well and ___ are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. ___ will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact ___ regarding these results they will contact ___ before this time. ___ have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. ___ may return home to finish your recovery. Please monitor your bowel function closely. ___ may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that ___ have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but ___ should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if ___ notice that ___ are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If ___ are taking narcotic pain medications there is a risk that ___ will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If ___ have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. ___ have an ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. ___ have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if ___ develop a fever. Please call the office if ___ develop these symptoms or go to the emergency room if the symptoms are severe. ___ may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. ___ may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. ___ will be prescribed a small amount of the pain medication oxycodone. Please take this medication exactly as prescribed. ___ may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___

19995478-DS-21

DS

2128-07-02 00:00:00

2128-07-02 19:23:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Pneumococcal Vaccine Attending: ___. Chief Complaint: s/p MVC with intrusion into driver's side Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p MVC restr driver with intrusion, L comminuted clavicle Fx, small R abdominal hematoma extending to L iliacus with ? bone fragment vs small extrav by R iliac crest, L5 R TP Fx Past Medical History: PMH: chron MRSA, A fib, ?CKD, pulmonary infection PSH: hx RLL resection Social History: ___ Family History: Noncontributory Physical Exam: Exam at discharge: Vitals: 98.0F, HR 60, RR 18, SpO2 97% RA, BP 148/74 Gen app: sitting upright in bedside chair, appears comfortable, NAD HEENT: EOMI, PERRL. There is erythema of the left eye but no drainage or pain. Vision grossly intact. Oral mucosa pink and moist. Neck: trachea midline CV: RRR, no m/r/g Lungs: CTA Abd: bowel sounds present. Soft, NT. Extrem: warm, well-perfused Neuro: CN II-XII intact. Sensation intact and symmetric throughout. Strength ___ in all muscle groups, except for LUE, which was unable to be tested ___ presence of sling. Gait intact. Skin: large ecchymosis at left upper chest and over the left shoulder. Pertinent Results: On admission: ___ 10:44AM BLOOD WBC-9.0 RBC-4.32* Hgb-13.8 Hct-42.9 MCV-99* MCH-31.9 MCHC-32.2 RDW-12.6 RDWSD-46.0 Plt ___ ___ 10:44AM BLOOD ___ PTT-37.3* ___ ___ 10:44AM BLOOD UreaN-19 ___ 05:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1 On day of discharge: ___ 03:20PM BLOOD Hct-37.6* ___ 05:00AM BLOOD WBC-8.9 RBC-3.69* Hgb-11.9* Hct-36.8* MCV-100* MCH-32.2* MCHC-32.3 RDW-12.7 RDWSD-46.6* Plt ___ Brief Hospital Course: Pt brought to ___ via EMS after ___ where pt was the driver of a car that was T-boned with intrusion into the driver's side. Found to have L comminuted and displaced clavicular fx, L5 right transverse process fx, and R abdominal wall hematoma. On CT abdomen/pelvis, there was a small hyperdense area in the R low abdomen that was felt to represent either a bone fragment or possible extravasation of IV contrast. Given that pt was on Eliquis, the pt was admitted for observation. His hematocrits were trended and initially dropped from 42.9 on arrival to 36.8. Subsequent labs demonstrated stable hemocrit with last value prior to discharge 37.6. He was seen and evaluated by the orthopedic service for his clavicle fracture. They recommended sling for the L arm and follow up in their clinic in 2 weeks. His pain was well controlled with Tylenol alone. He was doing well and was discharged to home. He was instructed to stop his Eliquis until he sees his cardiologist. Medications on Admission: Eliquis Bactrim Discharge Medications: Bactrim Discharge Disposition: Home Discharge Diagnosis: 1. s/p motor vehicle collision 2. Displaced comminuted left clavicle fx 3. Right abdominal wall hematoma 4. L5 right transverse process fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital after a car accident. You were found to have a broken left collarbone, a broken piece of bone in your low back, and a blood collection in your right abdomen. You were monitored overnight to ensure there was no evidence of continued bleeding. Your blood counts decreased initially but were stable on repeat lab work. You were discharged to home in stable condition. You should not restart your Eliquis unless told to do so by your cardiologist. You should keep your left arm in the sling until told otherwise by the orthopedic surgeons at your follow up appointment. You may take Tylenol for the pain. You should take no more than 3,000mg of Tylenol per day. Followup Instructions: ___

19995593-DS-17

DS

2110-11-20 00:00:00

2110-11-23 09:03:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Lipitor Attending: ___ Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ left handed man with a past medical history of HTN, PAD, CAD, CHF, MCI and multiple prior TIA with recent Right CEA who presents following 3 events of transient left leg weakness. Neurology is consulted due to concern for TIAs. History is gathered primarily from his wife, who is present at bedside. The reported history begins in ___. perhaps on the ___, Mr. ___ was walking in the park and had sudden onset of gait change. She reports it as a fenestrating and side stepping, unsteady gait due to an acute onset of left leg weakness. He took approximately 12 steps, before falling and EMS was called. By the time they arrived approximately 5 minutes later, he was already back at baseline. He was evaluated at the hospital and underwent CT imaging before being discharged home. Approximately 6 days later, while at a friends house, he had another similar episode. He was walking up the stairs and suddenly had onset of left leg weakness. He left leg collapsed and he fell, with subsequent Left cheek and eye eccymosis. He was evaluated at the hospital. The next day, he had a somewhat different episode. While attempting to get out of the car to go into a restaurant, he found to could not get up out of the car. It is not entirely clear if it was due to left leg weakness. This weakness lasted 20 minutes and then spontaneously resolved. He was admitted to the hospital and reportedly found to have b/l carotid stenosis (R 70%, left 50%). He underwent an outpatient Right CEA on ___, without complication. He was without further episodes until approximately a month later. He is here in Mass visiting his newly born grand child. On ___, while attempting to get out of a boat, he had onset of the left leg weakness and could not stand. It lasted 15 min and then resolved. Then, on ___, he had another episode of left leg weakness, lasting ___ minutes. Finally, om the day of his presentation, at 320pm, he once again had onset of left leg weakness. He was unable to get out of the car. It lasted approximately 25 minutes and then resolved. It was for this, he presented to our ED. He was unable to coordinate his leg. With all of his episodes, there were no associated sensory change. No known weakness of any other extremities. There were no preceding auras, sensory changes, or unusual sensations. The events always happened suddenly and resolved suddenly. No warning symptoms When he presented to our ED, a code stroke was called. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies other focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - Congestive heart failure - B/L Carotid stenosis- s/p CEA on right. - PAD with Claudication - COPD - OSA on CPAP - CAD- s/p CABG and Stents - HTN - Atrial Fibrillation - Mild Cognitive Impairment Social History: ___ Family History: - Mother ___ from stroke at ___. brother with ___. family hx of cad. Physical Exam: ADMISSION EXAM Vitals: T= 98.3 HR 75 BP 142/75 RR 18 Satting 97% RA General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: WWP. ___ stockings in place. Neurologic: -Mental Status: Alert, oriented x 2 (Thinks it is the ___. History is entirely related by his significant other, but he is able to clarify points when directly asked. 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 from NIHSS. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, able to name ___ backward without difficulty. Pt. was able to register 3 objects and recall ___ at 5 minutes. The pt. had very limited knowledge of current events ("there is something going on in the ___, but there is always something going on in the ___ ___". There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI with endgaze nystagmus b/l. Normal saccades. V: Facial sensation intact to light touch, pinprick in all distributions VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline, and deviates side to side w/o difficulty. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 R ___ ___ ___ 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 1 R 2 2 2 3 1 - Plantar response was upgoing on left, equiv on right. - Crossed Adductors are present. -Sensory: No deficits to light touch, pinprick, cold sensation. States he cannot feel vibration at all at the great toes, but feels it at the ankles. No extinction to DSS. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. DISCHARGE EXAM: R hand with 6cm x 7cm hematoma at site of prior IV. Neuro exam unchanged. Pertinent Results: ADMISSION LABS: ___ WBC-5.8 RBC-3.13* Hgb-9.0* Hct-29.2* MCV-93 RDW-17.2* Plt ___ Neuts-73.6* Lymphs-16.0* Monos-6.9 Eos-1.9 Baso-0.2 NRBC-0.3* Im ___ AbsNeut-4.24 AbsLymp-0.92* AbsMono-0.40 AbsEos-0.11 AbsBaso-0.01 ___ PTT-38.6* ___ Glucose-95 UreaN-38* Creat-1.2 Na-141 K-4.7 Cl-105 HCO3-27 AnGap-14 Calcium-9.1 Phos-3.3 Mg-2.2 ALT-38 AST-72* AlkPhos-219* TotBili-0.8 Albumin-3.6 ___ 07:04AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9 UA: bland urine/serum tox: Negative STROKE RISK FACTORS: Cholest-146 Triglyc-86 HDL-34 CHOL/HD-4.3 LDLcalc-95 %HbA1c-5.2 eAG-103 IMAGING: CXR ___ Heart size and mediastinum are mildly enlarged. The patient is after median sternotomy and CABG. Lung volumes are preserved. Mild interstitial changes are noted bilaterally, potentially representing chronic changes but mild interstitial edema is a possibility. No definitive focal consolidations to suggest infectious process demonstrated. No pleural effusion or pneumothorax. CT Head ___ There is no evidence of acute major vascular territorial infarction, hemorrhage, edema, or mass. Bilateral periventricular and subcortical white matter hypodensities are nonspecific but may be the sequela of chronic small vessel ischemic changes. Prominence of the ventricles and sulci are compatible with age related involutional changes. Atherosclerotic calcifications are noted within the bilateral carotid siphons. No osseous abnormalities seen. There is mild mucosal thickening within the bilateral maxillary and ethmoid sinuses. Sphenoid sinuses are clear. Mastoid air cells and middle ear canals are clear. The orbits are unremarkable. CTA Head/Neck ___. No evidence of aneurysm or vascular malformation 2. Atherosclerotic irregularity and narrowing of the left distal intracranial vertebral artery and basilar artery. 3. Patient is status post right carotid endarterectomy with expected postsurgical changes including a patulous vessel and small dissections at the proximal and distal anastomoses. 4. Calcification of the left carotid bifurcation with resulting 35-40% narrowing of the proximal left internal carotid artery. 5. Enlarged pulmonary artery compatible with pulmonary arterial hypertension. RECOMMENDATION(S): Interlobular septal thickening, mosaic attenuation, and mildly enlarged mediastinal and hilar lymph nodes are noted in the included lung fields which could be seen in the setting of pulmonary edema. Clinical correlation is recommended. MRI Head ___ There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is periventricular and subcortical white matter hyperintensity on the FLAIR images suggesting chronic small vessel ischemia. There appears to be at least three small holes (suggestive of small chronic infarcts) in the right distal ACA territory. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. The visualized portion of the vascular flow foids are preserved. IMPRESSION: 1. Findings suggesting chronic small vessel ischemia, in particular involving the right distal ACA territory Otherwise normal study with no evidence of hemorrhage or infarction Brief Hospital Course: Mr. ___ is an ___ left handed man with a past medical history of atrial fibrillation on dabigatran, HTN, PAD, CAD on plavix, CHF, mild cognitive impairment and multiple prior TIAs with recent right CEA who presented following three stereotyped episodes of left leg weakness without sensory change or other symptoms. On examination, the strength of his left leg was full. CTA demonstrated an occlusion vs flow-limiting stenosis in the right ACA. MRI demonstrated no acute infarct but there was evidence of small vessel stroke and at least three very small chronic infarcts in the right ACA territory. His symptoms were thought to represent symptomatic hypoperfusion of the mesial right frontal lobe due to the stenosis of the right ACA. He was started on dipyrimadole 75 mg BID as a vasodilator which he tolerated well. This was done as a attempt and trial to see if one could get the distal ACA to be more dilated and potentially overcome the intrinsic narrowing or stenosis within this vessel In addition, we continued with all of his other medications. He was able to ambulate without becoming symptomatic. He was seen by physical and occupational therapy who cleared him for home. His dabigatran and plavix were continued. He was also advised that in case that these episodes happened again, she should lower himself to the ground, lie flat on the ground and try to elevate his legs in order to increase cerebral perfusion pressure. He was noted to be hypertensive to the 170s during his hospitalization on his home medications so his losartan dose was increased to 75 mg daily. = = = = = = ================================================================ 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 = 95) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Dabigatran Etexilate 150 mg PO BID 3. Metoprolol Tartrate 50 mg PO BID 4. Sertraline 75 mg PO DAILY 5. Tamsulosin 0.4 mg PO BID 6. Furosemide 60 mg PO DAILY 7. Losartan Potassium 50 mg PO DAILY 8. Potassium Chloride 20 mEq PO BID Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Dabigatran Etexilate 150 mg PO BID 3. Furosemide 60 mg PO DAILY 4. Losartan Potassium 75 mg PO DAILY RX *losartan 25 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*3 5. Metoprolol Tartrate 50 mg PO BID 6. Potassium Chloride 20 mEq PO BID Hold for K > 7. Sertraline 75 mg PO DAILY 8. Tamsulosin 0.4 mg PO BID 9. Dipyridamole 75 mg PO BID RX *dipyridamole 75 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: right ACA stenosis hypertension congestive heart failure Multiple prior strokes Extensive small vessel disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came into the hospital because you were having symptoms of left leg weakness. We looked at the blood vessels in your brain and saw that there was a narrowing in the blood vessel that goes to the area that controls your leg. We believe that the episodes of weakness in your leg are because blood is not flowing as well to this area of your brain. For this reason we have started a medication to open up the blood vessels in your brain. If your symptoms come back you should sit down or lie flat with your feet up. When you are getting up to a standing position, please do not go immediately from lying down to standing as your blood pressure can drop when this happens and provoke symptoms. You should also exercise this leg to improve the representation of your leg muscles in the brain as this will help to protect the function of the leg. We spoke with the Neurosurgeons about your case. At this time we would like to try medical therapy first because the risks of medical therapy are lower than those of surgical intervention. If this therapy does not work we can reassess. We have made the following changes to your medications: - Started dipyrimadole to improve the blood flow to your brain - Increased your losartan to 75 mg daily You should take your other medications as prescribed. Here you had some bleeding where you were stuck with a needle! This bleeding was not dangerous. However you should be aware that because of the medications you are taking (pradaxa and plavix) you are at risk of bleeding. If you have any fall, particularly if you hit your head, you should come to the emergency department for evaluation in case you are having any bleeding in the head. If you cut yourself please apply pressure and elevate the cut area as much as possible to help the bleeding stop. If you have blood in your stool, black sticky stool, or vomit blood you should seek medical attention immediately. You are here visiting from ___. We will provide the information regarding your hospitalization to your primary care physician and neurologist in ___. It has been a pleasure taking care of you. - The ___ Deaconess ___ team Followup Instructions: ___

19995595-DS-14

DS

2126-11-12 00:00:00

2126-11-12 18:27:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: heparin Attending: ___. Chief Complaint: Abdominal aortic aneurysm rupture with hemodynamic instability Major Surgical or Invasive Procedure: ___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR WASHOUT OF HEMATOMA ___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT ___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN History of Present Illness: HPI: Mr. ___ is a ___, former smoker, with PVD s/p aortobifemoral bypass (___ ___ vs ___ per wife), who presented to the OSH with sudden onset abdominal pain this morning. He underwent a CTA which showed a disrupted proximal anastomosis of the aorto-femoral graft with rupture. Additionally he has a right groin pseudoaneurysm between the right limb of the aort-bifemoral graft with the native artery which appears contained. He was therefore transferred to ___ for further management. On Medflight, he became hypotensive with worsening abdominal distention and was given a total of 4u pRBC and ___ FFP. He was taken directly to the OR for definitive treatment. Past Medical History: PMH: afib, stroke (no neuro deficits ___, PVD, HTN PSH: - aortobifemoral bypass ___ vs ___ - >___nd endovascular procedures including left iliac artery stent, fem-fem bypass, ultimately resulting in R BKA Social History: ___ Family History: FH: unknown Physical Exam: Physical Exam: ON ARRIVAL Vitals: HR 112 BP 135/110 GEN: in acute distress, conversant CV: tachycardic PULM: no respiratory distreess ABD: tense, distended abdomen, tender to palpation Ext: No ___ edema, ___ warm and well perfused Pulses: R: p/d/BKA L: p/d/d/d ON DISCHARGE *************** Pertinent Results: ___ 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4* MCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt ___ ___ 05:37AM BLOOD ___ PTT-33.4 ___ ___ 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138 K-5.0 Cl-97 HCO3-27 AnGap-14 ___ 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2 ___ 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255 Brief Hospital Course: Mr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who presented to the OSH with sudden onset of abdominal pain with CTA confirming p/w ruptured ___ anastomosis. He was transfused 4u rPBC 2uFFP in medflight with worsening hypotension. He was taken immediately to the OR where he underwent infrarenal ___ aortic cuff x4 w open abdomen (see op note for further details). He was transferred to the ICU in critical condition. He was started on fondaparinux prophylaxis due to his history of HIT. His respiratory status was tenuous and he frequently desatted and required increasing FiO2 while he remained intubated. Pulmonology was consulted and he was started on Lasix. During this initial post-op period his antibiotic coverage was adjusted as appropriate and he was started on tube feeds. He had a TTE that showed a PFO, but cardiology did not feel that any intervention was necessary at this time. He returned to the OR on POD4 for an abdominal washout, lysis of adhesions, and abthera placement. Following his second trip to the OR he had continued PRN Lasix requirements in the ICU. Two days following this he became febrile and his R IJ line had evidence of pus when it was removed, so a L IJ was placed. His fevers continued and he was taken back to the OR again for another washout and at this time his abdomen was closed. After this third trip to the OR he was persistently hypertensive and required nicardipine for BP control. In the following days the ICU team attempted to wean him from the vent but it was not well tolerated. He also went into Afib and was started on metoprolol. He continued to be febrile so a CTA of his torso was obtained, but it showed no obvious source of infection that would explain his fevers. On POD12 from his original operation he was extubated, but developed respiratory distress and needed to be reintubated. The following day he continued to be febrile so ID was consulted. The following day he went into Afib with RVR again and was started on a dilt drip. He had an echo for unexplained hypotension which didn't show a cardiac cause, but revealed a thrombus in his IJ. At this time he was also transitioned to bivalirudin for a short period before being restarted on fondaparinux. On POD16 from his original operation he was successfully extubated and his oxygen requirements were subsequently weaned down. His mental status then became one of his chief issues, as he would only occasionally follow commands and would not communicate in any meaningful manner. His fevers subsided and on POD18 he was transferred to the VICU. While on the floor in the VICU his blood pressure and mental status were his main issues. Vascular medicine provided assistance with his anti-hypertensive regimen, which needed to be adjusted multiple times for adequate control. Neurology was consulted for his altered mental status, which they attributed to delirium secondary to an extended ICU stay. Additionally, ACS was consulted for placement of a PEG tube as he would likely need long term feeding access due to his mental status. Ultimately, his family opted not to go through with the PEG so that they could avoid reintubation, so his feedings were continued with the Dobhoff. Neurology attributed his mental status to delirium related to his prolonged ICU stay, so delirium precautions were put in place. His mental status began to improve and he became more conversant and oriented as time progressed. Vascular medicine continued to be involved in his care and he was diuresed as necessary. On hospital day ___ he had a brief run of afib that was seen on telemetry, but had no further issues with afib afterwards. On hospital day ___ he was hemodynamically stable and his mental status continued to improve so he was determined to be fit for discharge. His discharge was ultimately delayed due to difficulties with finding rehab placement, but by hospital day 27 case management had found a rehab facility and he was transferred there with plans to follow up with vascular surgery clinic for re-imaging of his abdomen. Medications on Admission: Lisinopril Lovastatin Gabapentin Prilosec Warfarin Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry eyes 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 6. Captopril 37.5 mg PO TID RX *captopril 25 mg 1.5 tablet(s) by mouth three times a day Disp #*135 Tablet Refills:*0 7. CARVedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Fondaparinux 7.5 mg SC DAILY RX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe Refills:*0 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 12. Metoclopramide 10 mg PO Q6H 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 14. QUEtiapine Fumarate 12.5 mg PO QHS agitation 15. Senna 8.6 mg PO BID 16. Divalproex (DELayed Release) 500 mg PO BID 17. Gabapentin 800 mg PO TID 18. Lovastatin 40 mg oral DAILY 19. Memantine 10 mg PO DAILY ___ 20. Memantine 5 mg PO DAILY AM 21. Omeprazole 20 mg PO DAILY 22. Warfarin 2 mg PO 5X/WEEK (___) 23. Warfarin 4 mg PO 2X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Abdominal Aortic Aneurysm Rupture Peripheral Vascular Disease Anemia secondary to rupture requiring transfusion Oliguria Pleural effusions with pulmonary edema requiring diuresis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___- It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after transfer from an outside institution for ruptured abdominal aortic aneurysm. You underwent emergent repair which required placement of a graft in you aorta. You also required an incision made into your abdomen to release the blood that collected after the rupture. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm Repair Discharge Instructions PLEASE NOTE: After endovascular aortic repair (EVAR), it is very important to have regular appointments (every ___ months) for the rest of your life. These appointments will include a CT (“CAT”) scan and/or ultrasound of your graft. If you miss an appointment, please call to reschedule. WHAT TO EXPECT: •Bruising, tenderness, and a sensation of fullness at the groin puncture sites (or incisions) is normal and will go away in one-two weeks CARE OF THE GROIN PUNCTURE SITES: •It is normal to have mild swelling, a small bruise, or small amounts of drainage at the groin puncture sites. In two weeks, you may feel a small, painless, pea sized knot at the puncture sites. This too is normal. Male patients may notice some swelling in the scrotum. The swelling will get better over one-two weeks. •Look at the area daily to see if there are any changes. Be sure to report signs of infection. These include: increasing redness; worsening pain; new or increasing drainage, or drainage that is white, yellow, or green; or fever of 101.5 or more. (If you have taken aspirin, Tylenol, or other fever reducing medicine, wait at least ___ hours after taking it before you check your temperature in order to get an accurate reading.) FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •If you have sudden, severe bleeding or swelling at either of the groin puncture sites: -Lie down, keep leg straight and apply (or have someone apply) firm pressure to area for ___ minutes with a gauze pad or clean cloth. -Once bleeding has stopped, call your surgeon to report what happened. -If bleeding does not stop, call ___ for transfer to closest Emergency Room. •You may shower 48 hours after surgery. Let the soapy water run over the puncture sites, then rinse and pat dry. Do not rub these sites and do not apply cream, lotion, ointment or powder. •Wear loose-fitting pants and clothing as this will be less irritating to the groin puncture sites. MEDICATIONS •Take aspirin daily. Aspirin helps prevent blood clots that could form in your repaired artery. •It is very important that you never stop taking aspirin or other blood thinning medicines-even for a short while- unless the surgeon who repaired your aneurysm tells you it is okay to stop. Do not stop taking them, even if another doctor or nurse tells you to, without getting an okay from the surgeon who first prescribed them. •You will be given prescriptions for any new medication started during your hospital stay. •Before you go home, your nurse ___ give you information about new medication and will review all the medications you should take at home. Be sure to ask any questions you may have. If something you normally take or may take is not on the list you receive from the nurse, please ask if it is okay to take it. PAIN MANAGEMENT •Most patients do not have much pain following placement of the stent alone. You had an abdominal incision in addition to this, so recovery may take longer. Your puncture sites may be a little sore. This will improve daily. If it is getting worse, please let us know. •You will be given instructions about taking pain medicine if you need it. ACTIVITY •You must limit activity to protect the puncture sites in your groin. For ONE WEEK: -Do not drive -Do not swim, take a tub bath or go in a Jacuzzi or hot tub -Do not lift, push, pull or carry anything heavier than five pounds -Do not do any exercise or activity that causes you to hold your breath or bear down with your abdominal muscles. -Do not resume sexual activity •Discuss with your surgeon when you may return to other regular activities, including work. If needed, we will give you a letter for your workplace. •It is normal to feel weak and tired. This can last six-eight weeks, but should get better day by day. You may want to have help around the house during this time. ___ push yourself too hard during your recovery. Rest when you feel tired. Gradually return to normal activities over the next month. •We encourage you to walk regularly. Walking, especially outdoors in good weather is the best exercise for circulation. Walk short distances at first, even in the house, then do a little more each day. •It is okay to climb stairs. You may need to climb them slowly and pause after every few steps. BOWEL AND BLADDER FUNCTION •You should be able to pass urine without difficulty. Call you doctor if you have any problems urinating, such as burning, pain, bleeding, going too often, or having trouble urinating or starting the flow of urine. Call if you have a decrease in the amount of urine. •You may experience some constipation after surgery because of pain medicine and changes in activity. Increasing fluids and fiber in your diet and staying active can help. To relief constipation, you may talk a mild laxative. Please take to your pharmacist for advice about what to take. SMOKING •If you smoke, it is very important that you STOP. Research shows smoking makes vascular disease worse. This could increase the chance of a blockage in your new graft. Talk to your primary care physician about ways to quit smoking. Followup Instructions: ___

19996783-DS-16

DS

2188-04-24 00:00:00

2188-04-24 15:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea, abdominal discomfort Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o M with PMhx of HTN, NIDDM, pituitary macroadenoma and recently diagnosed pancreatic mass causing biliary obstruction s/p recent ERCP with stent who returns after discharge with nausea, abd discomfort and inability to tolerate much po. Pt reports feeling much better after ERCP with stent and felt return of appetite. He went home and ate well initially. However, he soon developed abd discomfort and intractable nausea. He tried simethicone without any relief and was unable to sleep because of symptoms. He returned to the ED and was found to have mild dehydration, acute on chronic hyponatremia and persistent LFT abnormalities. He was able to have a BM in the ED which provided some relief. He has not eaten much all day and feels some improvement in symptoms. Denies any nausea currently and abd discomfort has improved. He is concerned about how to manage symptoms at home and feels his stomach may be blocked up. Denies any CP, SOB, cough, LH, HA, congestion, dysuria, hematuria, rash or abd pain currently. He has not noticed and worsening in ___ edema and is wearing TEDs currently. Past Medical History: NIDDM HTN Recently Dx with large pancreatic mass causing biliary obstruction now s/p ERCP with stent, final path pending though prelim + adenocarcinoma Social History: ___ Family History: none relevant to current presentation Physical Exam: PE: ___ Temp: 98.3 PO BP: 133/75 L Lying HR: 91 RR: 18 O2 sat: 100% O2 delivery: Ra GEN: pleasant elderly Asian male in NAD HEENT: MMM CV: RRR RESP: CTAB no w/r ABD: distended, mild TTP over RUQ but no rebound, BS present GU: no foley EXTR: thin, trace ankle edema bilaterally, TEDS in place NEURO: alert, appropriate, oriented x 3 Pertinent Results: ___ 07:20AM BLOOD WBC-9.1 RBC-3.19* Hgb-8.3* Hct-26.0* MCV-82 MCH-26.0 MCHC-31.9* RDW-16.1* RDWSD-47.8* Plt ___ ___ 07:15AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.0* Hct-23.8* MCV-78* MCH-26.3 MCHC-33.6 RDW-15.7* RDWSD-43.9 Plt ___ ___ 08:55AM BLOOD WBC-9.6 RBC-3.59* Hgb-9.5* Hct-28.0* MCV-78* MCH-26.5 MCHC-33.9 RDW-15.7* RDWSD-43.5 Plt ___ ___ 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* MCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt ___ ___ 08:55AM BLOOD Neuts-84.4* Lymphs-7.4* Monos-6.4 Eos-0.8* Baso-0.2 Im ___ AbsNeut-8.11* AbsLymp-0.71* AbsMono-0.62 AbsEos-0.08 AbsBaso-0.02 ___ 07:20AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-130* K-3.8 Cl-91* HCO3-24 AnGap-15 ___ 07:15AM BLOOD Glucose-158* UreaN-13 Creat-0.6 Na-131* K-3.7 Cl-95* HCO3-24 AnGap-12 ___ 10:25PM BLOOD Glucose-260* UreaN-15 Creat-0.8 Na-129* K-3.8 Cl-92* HCO3-24 AnGap-13 ___ 10:20AM BLOOD Glucose-208* UreaN-17 Creat-0.9 Na-126* K-5.0 Cl-92* HCO3-20* AnGap-14 ___ 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* K-3.9 Cl-93* HCO3-21* AnGap-17 ___ 07:20AM BLOOD ALT-43* AST-29 AlkPhos-217* TotBili-2.0* ___ 07:15AM BLOOD ALT-47* AST-31 AlkPhos-235* TotBili-2.1* ___ 10:20AM BLOOD ALT-59* AST-57* AlkPhos-286* TotBili-2.5* ___ 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* TotBili-3.0* ___ 10:20AM BLOOD Lipase-61* KUB: IMPRESSION: Nonspecific bowel gas pattern. Stomach is mildly dilated. No evidence of small-bowel obstruction. Gas and stool filling the large bowel loops Brief Hospital Course: ___ y/o M with NIDDM, HTN and recently diagnosed pancreatic cancer causing biliary obstruction s/p ERCP with stent who returns with nausea and decreased ability to tolerate po. #possible functional duodenal/gastric outlet obstruction #Pancreatic adenocarcinoma #Nausea/abd discomfort: mass invasion of duodenum may be causing functional gastric outlet obstruction. Pt's symptoms improved with decreased PO intake, after ERCP, and after BM, gas may be contributing. Pt tolerated better PO during admission. D/w Pt importance of nutrition and taking what he is able to tolerate and to supplement with ensure or boost if needed. Nutrition consulted. Discussed attempting a liquid diet if he is unable to tolerate solid food. Discussed symptom control with ___, simethicone, bowel regimen. Discussed case with oncology and ERCP teams. Plan for outpt onc f/u (as already arranged ___ and per ERCP team, no significant intestinal stricture noted on ERCP to intervene upon at this time. #Hyponatremia/SIADH: clinically euvolemic now and Na improved on repeat labs likely because pt was taking decreased PO. Na stable during admission without IVF or fluid restriction. #anemia-no clear evidence of bleeding. Trend/monitor. Outpt f/u. #NIDDM: Restarted home oral agents on DC. If PO intake over the long run becomes an issue, he may need to DC some of these agents. #Pituitary Macroadenoma: outpt f/u Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 2. Polyethylene Glycol 17 g PO BID 3. Senna 17.2 mg PO BID 4. Simethicone 40-80 mg PO QID:PRN stomach upset 5. Simvastatin 10 mg PO QPM 6. glimepiride 4 mg oral DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS Discharge Medications: 1. Docusate Sodium 100 mg PO BID you may purchase over the counter RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg ___ tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. glimepiride 4 mg oral DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS 7. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gm powder(s) by mouth daily Refills:*0 8. Senna 17.2 mg PO BID RX *sennosides [Senna-Gen] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 9. Simethicone 40-80 mg PO QID:PRN stomach upset 10. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: pancreatic cancer nausea constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for evaluation and treatment of abdominal pain/bloating and nausea and decreased ability to eat and drink likely secondary to your pancreatic cancer and also some constipation. For this, you were evaluated by the nutritionist and we discussed using supplements such as boost or ensure if you are unable to eat and drink well. Please try to eat and drink as you are able. You may need to have a liquid or a softer diet if you feel unable to eat and drink well. You will meet with the cancer doctors this week to discuss the next steps in your treatment. Followup Instructions: ___

19996783-DS-17

DS

2188-05-19 00:00:00

2188-05-20 07:45:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Pain, SOB Major Surgical or Invasive Procedure: EGD with duodenal stenting ___ History of Present Illness: Mr. ___ is an ___ year-old gentleman with hypertension, hyperlipidemia, T2DM and recently diagnosed pancreatic ductal adenonocarcinoma with biliary/duodenal involvement who presents with nausea, vomiting, chest pain and shortness of breath. Per ED report he presented to ED complaining of shortness of breath and chest discomfort since the morning of ___ via son as interpreter. He also had intermittent diarrhea and nausea. ED initial vitals were 97.1 106 114/63 18 99% RA Prior to transfer vitals were 97.7 103 113/56 16 100% RA Exam in the ED showed : "Gen: Comfortable, appears chronically ill but in no acute distress. HEENT: NC/AT. EOMI. Neck: No swelling. Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Soft, NT, ND. Ext: No edema, cyanosis, or clubbing. Skin: No rash, skin pale Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. " ED work-up significant for: -CBC: WBC: 5.2. HGB: 8.3*. Plt Count: 206. Neuts%: 90*. -Chemistry: Na: 125*. K: 4.0 . Cl: 86*. CO2: 13* . BUN: 21*. Creat: 1.0. Ca: 8.0*. Mg: 1.2*. PO4: 3.3. -Lactate:4.4-> 1.9 -Coags: INR: 2.1*. PTT: 31.6. -UA: WBC 4, Gluc 300, Ket 40, UA -EKG read as "sinus, ischemia:non-specific" -TnT: 0.02 -CT Torso: "1. Small, subsegmental right lower lobe pulmonary embolus. No evidence of right heart strain or definite pulmonary infarction. 2. ___ and ground-glass opacities most conspicuous at left lung base and lingula, appear similar to ___ and are likely infectious or inflammatory. 3. No significant interval change in the large hypoenhancing mass arising from the head of the pancreas. Peripancreatic adenopathy is overall minimally increased. The mass invades the second and third portion of the duodenum resulting in upstream obstruction which appears progressed in comparison to the prior examination. There has been interval CBD stent placement with decompression of the intrahepatic biliary tree and expected pneumobilia, however there is extensive soft tissue at the inferior ostium of the stent and partial or pending obstruction can't be excluded. The mass again obliterates the main portal vein, but the aorta and encases the SMA. 4. 8 mm right middle lobe pulmonary nodule, unchanged from ___. 5. Multiple bilateral old rib fractures are noted." -CT head: No acute intracranial hemorrhage -___: negative ED management significant for: -Medications: MgSO4 2g iv, CTX 1g, Levofloxacin 750mg iv, enoxaparin 60mg sc x1 Patient had bed assignment 15:56, accepted by HMED. First documented vital signs at 1823. Patient transferred from HMED to this writer at 20:00, signout out as stable. When asked about his symptoms patient reports having had an episode of nausea, diarrhea and malaise on ___ that subsided. On the morning of ___ he woke up with nausea, chest pain and shortness of breath. He tried to eat but could not as he vomited. He also reports having 2 episodes of loose stool. He felt unwell and had prominent malaise and was brought in to ED by son. Here he continues to feel unwell, no longer has shortness of breath or chest discomfort. He feels much better than in the morning. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, cough, hemoptysis, chest pain, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: 1. Cardiac Risk Factors -Hypertension -Hyperlipidemia -DM2 2. Cardiac History -None 3. Other PMH -Stage III/IV pancreatic adenocarcinoma -Pituitary macroadenoma complicated by ___ Social History: ___ Family History: No known family history of malignancy. His mother lived to ___ years. His father died at a young age of unknown causes. He had 4 brothers and 3 sisters most of whom lived to their ___. He has 2 sons without health concerns. Physical Exam: ADMISSION PHYSICAL ================= VS: T:97.9, BP: 109/58, HR: 97, RR: 17, O2: 100% RA GENERAL: Chronically ill appearing, NAD HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM NECK: Supple. No appreciable JVD. CARDIAC: RRR, +S1/2, no murmurs, rubs, gallops LUNGS: CTAB ABDOMEN: Soft, NTND, +BS EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees SKIN: no rashes PULSES: symmetric distal pulses DISCHARGE PHYSICAL ================= VS: ___ 0511 Temp: 97.8 PO BP: 90/54 R Lying HR: 114 RR: 16 GENERAL: Chronically ill appearing, cachectic, NAD HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM NECK: Supple. No appreciable JVD CARDIAC: sinus tachycardia, +S1/2, no murmurs, rubs, gallops LUNGS: CTAB ABDOMEN: Distended. Epigastric TTP throughout. No rebound or guarding EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees SKIN: no rashes PULSES: symmetric distal pulses Pertinent Results: ADMISSION LABS ============= ___ 05:25AM BLOOD WBC-5.2 RBC-3.26* Hgb-8.3* Hct-25.3* MCV-78* MCH-25.5* MCHC-32.8 RDW-15.3 RDWSD-42.7 Plt ___ ___ 05:25AM BLOOD Neuts-90* Bands-3 Lymphs-7* Monos-0 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-4.84 AbsLymp-0.36* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 05:25AM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-3+* Polychr-NORMAL Burr-1+* ___ 05:25AM BLOOD ___ PTT-31.6 ___ ___ 05:25AM BLOOD Glucose-297* UreaN-21* Creat-1.0 Na-125* K-4.0 Cl-86* HCO3-13* AnGap-26* ___ 05:25AM BLOOD CK(CPK)-58 ___ 05:25AM BLOOD CK-MB-5 ___ 05:25AM BLOOD cTropnT-0.02* ___ 09:56PM BLOOD CK-MB-40* MB Indx-13.6* cTropnT-1.37* ___ 05:25AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.2* ___ 05:31AM BLOOD Lactate-4.4* Na-122* K-3.8 ___ 08:09AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:09AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-300* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 08:09AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-<1 ___ 08:09AM URINE CastHy-35* ___ 08:09AM URINE Mucous-RARE* ___ 08:09AM URINE Hours-RANDOM Na-80 ___ 08:09AM URINE Osmolal-405 PERTINENT RESULTS ================ ___ 05:28AM BLOOD ___ ___ 04:46AM BLOOD ___ 05:28AM BLOOD Ret Aut-0.4 Abs Ret-0.01* ___ 03:56AM BLOOD CK-MB-24* MB Indx-11.8* cTropnT-1.92* ___ 05:28AM BLOOD calTIBC-101* VitB12-324 Hapto-347* Ferritn-695* TRF-78* ___ 11:30AM BLOOD ___ pO2-165* pCO2-20* pH-7.34* calTCO2-11* Base XS--12 Comment-GREEN TOP ___ 08:52AM BLOOD Lactate-1.9 ___ 11:30AM BLOOD Lactate-7.6* ___ 07:30PM BLOOD Lactate-1.8 ___ 12:18PM BLOOD Lactate-2.3* ___ 09:12PM BLOOD Lactate-1.4 ___ 12:04PM BLOOD Lactate-2.2* MICRO ===== ___ 11:18 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:13 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:45 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ (___) @12:26 (___). __________________________________________________________ ___ 5:25 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. STUDIES ======= CXR PA and LAT ___ An infrahilar opacity best seen on lateral view is unchanged from ___. In the appropriate clinical setting this may represent pneumonia, although this could represent atelectasis given low volumes. CTA Chest, CT Abdomen ___. Small, subsegmental right lower lobe pulmonary embolus. No evidence of right heart strain or definite pulmonary infarction. 2. ___ and ground-glass opacities most conspicuous at left lung base and lingula, appear similar to ___ and are likely infectious or inflammatory. 3. No significant interval change in the large hypoenhancing mass arising from the head of the pancreas. Peripancreatic adenopathy is overall minimally increased. The mass invades the second and third portion of the duodenum resulting in upstream obstruction which appears progressed in comparison to the prior examination. There has been interval CBD stent placement with decompression of the intrahepatic biliary tree and expected pneumobilia, however there is extensive soft tissue at the inferior ostium of the stent and partial or impending obstruction can't be excluded. The mass again obliterates the main portal vein, abuts the aorta and encases the SMA. 4. 8 mm right middle lobe pulmonary nodule, unchanged from ___. 5. Multiple bilateral old rib fractures are noted. CT Head w/o Contrast ___. No acute intracranial process. 2. Paranasal sinus retention cysts, similar to previous study. ___ ___ No evidence of deep venous thrombosis in the lower extremities. TTE ___ The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is mild regional left ventricular systolic dysfunction with near-akinesis of the distal ___ of the left ventricle (distal LAD territory; see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 40%. No thrombus or mass is seen in the left ventricle. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Adequate image quality. Mild regional left ventricular systolic dysfunction most consistent with coronary artery disease (LAD distribution). Mild mitral regurgitation. CXR ___ Patchy retrocardiac opacity, potentially atelectasis with infection or aspiration not excluded in the correct clinical setting. Marked distension of the stomach. Abdomen Xray ___ Massive distention of the stomach for which nasogastric tube decompression is recommended. No evidence for small or large bowel obstruction. Abdomen Xray ___ NG tube in the stomach loops back into the still esophagus. Improvement of the gastric distension. Abdomen Xray ___ Massive distention of the stomach similar in appearance to study of ___ with duodenal air-fluid levels compatible with gastric outlet obstruction. CXR ___ Extensive dilatation of the stomach is re-demonstrated with the stomach bubble approaching 27 x 19 cm. NG tube tip is projecting over the stomach bubble left basal consolidation is most likely representing atelectasis. Right PICC line tip is at the cavoatrial junction no appreciable pleural effusion demonstrated. CXR ___ (NG Placement) Extensive dilatation of the stomach is re-demonstrated with the stomach bubble approaching 27 x 19 cm. NG tube tip is projecting over the stomach bubble left basal consolidation is most likely representing atelectasis. Right PICC line tip is at the cavoatrial junction no appreciable pleural effusion demonstrated. EGD ___ Large gastric ulcer. Malignant duodenal sweep ulcer. Duodenal stricture s/p placement of uncovered duodenal stent. DISCHARGE LABS ============= ___ 06:26AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.7* Hct-32.5* MCV-89 MCH-29.2 MCHC-32.9 RDW-21.2* RDWSD-59.5* Plt ___ ___ 06:26AM BLOOD Glucose-186* UreaN-32* Creat-1.6* Na-137 K-5.1 Cl-107 HCO3-17* AnGap-13 ___ 06:26AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old male with PMHx of stage III/IV pancreatic adenocarcinoma, DM2, Hyponatremia, SIADH who presented with a 1-day history of chest pain and shortness of breath found to have anterior missed STEMI s/p medical management (high risk for PCI, missed window, no symptoms), hospital course complicated by GI bleed in the setting of anticoagulation with heparin and known active malignancy with gastric and duodenal ulcerations, now s/p 5U PRBC with improved hemodynamics, evidence of gastric obstruction likely ___ malignancy s/p palliative duodenal stent discharged to hospice care. ACUTE ISSUES: ============ #GOC Mr. ___ presented with known advanced pancreatic cancer on palliative chemotherapy, complicated by symptomatic gastric outlet obstruction. Patient was also noted to have a GI bleed in the setting of anticoagulation for STEMI and small subsegmental PE. Several goals of care discussions were held with the patient's son and the patient was made DNR/DNI based on these conversations. Goals of care discussions included patient's primary oncologist as well as the inpatient palliative care team. He was screened for hospice eligibility and is now being discharged to hospice care. #Melena #Acute Blood Loss Anemia Hospital course complicated by GI bleed requiring 5U PRBC total. The patient had a GI bleed was secondary to known necrotic gastric and duodenal malignant ulcerations. Patient's anticoagulation as well as antiplatelet therapy (started for medical management of STEMI) were held in the setting of an active GI bleed. Gastroenterology was consulted and placed a palliative uncovered duodenal stent via EGD for symptomatic relief of gastric outlet obstruction. #Bilious emesis #Gastric outlet obstruction The ___ hospital course was complicated by gastric obstruction in setting of known pancreatic malignancy invading duodenum and KUB revealed severely distended stomach without evidence of small or large bowel obstruction. Patient underwent EGD with palliative duodenal stenting with marked improvement in symptoms. An NG tube was also placed prior to stenting and was removed once stent was placed. ___ Patient was noted to have ___ on presentation. This was thought to be likely in the setting of hypotension and decreased PO intake secondary to gastric obstruction. He was managed supportively. His creatinine initially improved with fluids however had a repeat ___ likely in the setting of hypotension with Cr 1.6 at discharge. #STEMI The patient presented with 1 day history of chest pain and was initially admitted to oncology service but was transferred to CCU after EKG showing STE in V2-V3 and troponin elevation at 1.02. Onset of symptoms occurred ___ hours prior to presentation and given complex comorbidities and complete resolution of symptoms, cardiac cath was deferred and medical management was pursued. A TTE showing mild regional LV systolic dysfunction in LAD distribution with EF 40%. The patient was initially started on heparin drip and on dual anti platelet therapy but these were deferred in the setting of GI bleed. Metoprolol and lisinopril were not started due to hypotension and significant GI bleed per above. # Small Subsegmental Pulmonary Embolus On admission, there was evidence of small sub-subsegmental PE on CTA chest. He was started on anticoagulation for STEMI that would also cover small segmental PE, however given active GI bleed, continuation of anticoagulation was deferred. # Hyponatremia # ___ Patient presented with known history of hyponatremia thought to be SIADH in the setting of a macroadenoma in the pituitary. Sodium was trended daily and improved with IVF and PO intake # Possible LLL Pneumonia, CAP Patient was initially started on a 5 day course of ceftriaxone and briefly broadened to vancomycin and cefepime. However given lack of fevers, leukocytosis, clinical signs of pneumonia, the patient's antibiotics were stopped and he was closely monitored. # H. pylori Infection The patient was continued on metronidazole QID, tetracycline QID, omeprazole, bismuth x 2 weeks (___) # Pancreatic Adenocarcinoma, Stage III-IV # Functional Gastric Outlet Obstruction Recently diagnosed with stage III-IV pancreatic adenocarcinoma (7.5cm) obliterating SMV and encasing SMA on cycle 1 of palliative gemcitabine (first/last dose ___. CT torso ___ again with large hypodense mass in pancreatic head invading second and third portions of the duodenum. Possible or impending obstruction of CBD stent also noted. Patient underwent palliative duodenal stenting. CHRONIC ISSUES: =============== # Type 2 Diabetes Mellitus Patient had known history of type 2 diabetes. He was on a regimen of metformin and glimepiride at home. These oral hypoglycemics were held in the inpatient setting and the patient was started on insulin sliding scale. # Pituitary Macroadenoma 14mm non-enhancing lesion in anterior right pituitary noted on MRI ___. Thought to possibly be cystic. Further management not within goals of care. TRANSITIONAL ISSUES =================== []Pain control: Recommend titration of pain control to make patient comfortable []Nausea/Vomiting: Recommend use of anti-emetics/benzodiazepines to aggressively control symptoms # CODE: DNR/DNI, MOLST in chart # CONTACT/HCP: ___ (son, lives with him) ___ ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Bismuth Subsalicylate 15 mL PO QID 3. Simethicone 120 mg PO QID:PRN gas 4. MetroNIDAZOLE 250 mg PO QID 5. Omeprazole 20 mg PO DAILY 6. glimepiride 4 mg oral DAILY 7. Tetracycline 500 mg PO QID 8. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. GlipiZIDE XL 2.5 mg PO DAILY 2. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Moderate 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild 4. Sucralfate 1 gm PO QID 5. Bismuth Subsalicylate 15 mL PO QID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Simethicone 120 mg PO QID:PRN gas Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses ================= Acute blood loss anemia Upper GI bleed Gastric outlet obstruction Thrombocytopenia Leukocytosis Acute Kidney Injury STEMI Pulmonary embolus, small sub-submental Hyponatremia SIADH Left lower lobe pneumonia, community-acquired Secondary Diagnoses =================== Pancreatic adenocarcinoma, stage III–IV H pylori infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you in the hospital! Why was I admitted? You were admitted to the hospital because had a heart attack What happened while I was admitted? -You had a heart attack and were given blood thinning medications -You had a stent placed in your stomach to help with nausea and vomiting -You were given blood back because you were bleeding What should I do after I leave the hospital? -Spend time with your family and loved ones We wish you the very best! Your ___ Care Team Followup Instructions: ___

19996902-DS-9

DS

2156-09-25 00:00:00

2156-09-28 20:56:00

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: Left lower quadrant pain Major Surgical or Invasive Procedure: CT guided drainage ___ History of Present Illness: ___ G1P0010 with T1DM, p/w 2 wks of n/v/loose stools, RUQ pain, and LLQ progressive crampy pain. No f/c at all. Was in her usual state of health prior to 2 wks ago. Nausea came first, does not seem to be assoc w/pain, which was mild at first and felt like usual ovulatory/premenstrual cramp, but only on left. GI sxs peaked ___ wks ago, and today all sxs feel much improved. However, seen by PCP ___ and +chlamydia cervical culture, did not fill doxy Rx due to access issues. Monogamous with partner who is out of state for work right now. Outpt PUS today showed concern for ___, so sent in for eval. Outpt RUQ US showed ?___. Of note, ran out of Lantus so only took 18u of her usual 32u today. Also no Humalog, decreased PO so did not cover crackers. ROS: No dysuria but feels some incomplete void, though voiding normal amounts. No dyspnea/CP. No back pain, no weight or appetite changes, no night sweats. Has occ constipation and diarrhea, chronically. Past Medical History: GYN Hx: - LMP ___ - menses q month regular, x5-6 days nl flow - severe dysmenorrhea -> ibuprofen - no dyspareunia, postcoital or intermenstrual bleeding - occ yeast infxns treated with monistat - no other hx STI/PID or abnl Pap, last Pap ___ neg OB Hx: - G1 TAb 12 wks in ___, office MVA not well-tolerated, followed by same-day D&E for rPOC MED Hx: - asthma, off symbicort, no hosp/intub - T1DM dx ___ ago, NPDR, reg eye exams, sees ___ - depression previously seeing psychotherapist SURG Hx: - necrobiosis lipoidica excision from shin (___) - LSC CCY (___) - MVA -> D&E (___) Social History: ___ Family History: no known GYN or colorectal malignancies Physical Exam: On admission: 98.4 74 134/87 16 100RA NAD NARD RRR, CTAB No CVAT Abd soft ND, mild TTP and fullness in LLQ, no R/G Ext NT NE SSE no cervicitis or discharge, nl mucosa BME mild focal CMT, RV ut, adn masses/ttp not appreciated On discharge: AF VSS NAD RRR CTAB Abd soft, mildly TTP LLQ, no r/g GU no VB Ext no TTP, no edema Pertinent Results: CBC ___ 06:05PM BLOOD WBC-11.5* RBC-3.82* Hgb-11.3* Hct-34.6* MCV-91 MCH-29.6 MCHC-32.8 RDW-13.2 Plt ___ ___ 06:00AM BLOOD WBC-10.6 RBC-3.82* Hgb-11.4* Hct-34.5* MCV-90 MCH-29.8 MCHC-32.9 RDW-13.5 Plt ___ ___ 06:03AM BLOOD WBC-8.4 RBC-3.84* Hgb-10.8* Hct-34.9* MCV-91 MCH-28.0 MCHC-30.9* RDW-13.4 Plt ___ ___ 06:05AM BLOOD WBC-8.4 RBC-3.91* Hgb-11.2* Hct-35.1* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.1 Plt ___ Chem ___ 06:05PM BLOOD Glucose-340* UreaN-9 Creat-0.6 Na-135 K-4.6 Cl-97 HCO3-28 AnGap-15 ___ 06:00AM BLOOD Glucose-195* UreaN-6 Creat-0.4 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-13 ___ 06:05AM BLOOD Glucose-143* UreaN-10 Creat-0.6 Na-135 K-4.2 Cl-99 HCO3-29 AnGap-11 ___ 06:00AM BLOOD %HbA1c-10.5* eAG-255* LFTs ___ 06:05PM BLOOD ALT-61* AST-58* AlkPhos-138* TotBili-0.3 ___ 06:00AM BLOOD ALT-68* AST-63* AlkPhos-127* ___ 06:03AM BLOOD ALT-80* AST-63* LD(LDH)-265* AlkPhos-125* TotBili-0.2 ___ 06:05AM BLOOD ALT-85* AST-66* ___ 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE ___ 06:00AM BLOOD HCV Ab-NEGATIVE ___ 06:00AM BLOOD HCG-<5 ___ 08:55AM BLOOD HIV Ab-NEGATIVE Fluid analysis PELVIC FLUID COLLECTION. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. IMAGING Abd U/S, ___: FINDINGS: The liver demonstrates diffusely hypoechoic appearance with mild prominence of the portal triads consistent with "starry sky" appearance. There is no evidence of focal liver lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is resected. The pancreas is within normal limits. The right kidney measures 10.3 cm and left kidney measures 11.6 cm. There is a mild central hydronephrosis in the left kidney. There is no evidence of stones or masses bilaterally. The spleen measures 9.4 cm. Aorta and IVC unremarkable. IMPRESSION: 1. Hypoechoic appearance of the liver with prominent portal triads, which is known as "starry sky" appearance. Ffurther correlation is recommended with liver function tests. 2. Mild left mild hydronephrosis. PUS, ___ FINDINGS: The uterus is measuring 7.7 x 2.4 x 5.8 cm. The endometrium is 5 mm and homogeneous in appearance. The right ovary is enlarged and located to the right posterior to the uterus. Arizing and medial to the right ovary a cystic lesion with multiple septations and a low-level echoes is seen measuring 7 x 4.1 x 7 cm. There is most probably representing a hemorrhagic cyst. The left adnexa located above the left iliac vessels and lateral to the sigmoid colon. The overall ___ of the left adnexa is 8.5 x 5.5 x 7.2 cm and contains multiple septations, some of the with vascularity. Prominent vascularity of adjacent sigmoid is also seen. There is no free fluid in the pelvis. IMPRESSION: 1. There is a cyst with hemorrhagic contents is in the right ovary with measurements as above. Due to large size follow up is recommended in 6 weeks. 2. Complex adnexal mass on the left adjacent to the sigmoid colon with secondary inflammation. Due to known hstory of current chlamydia infection, findings are consistent with tubo-ovarian abscess. CT pel, ___: FINDINGS: The small and large bowel are unobstructed. There is colonic wall thickening adjacent to the left adnexal abscess. There is diffuse mesenteric and omental edema, likely related to pelvic inflammation. In the region of the left adnexa there is a 3.1 x 3.2 x 5.2, cm fluid collection with thick enhancing rim which is indistinguishable from the left ovary. Medial to this there is a thin-walled fluid collection measuring 3.5 x 3.3cm. In the pelvic cul-de-sac, there is a 3.3 x 5.5 x 6.1 cm rim enhancing fluid collection consistent with abscess. Normal appearance of the right adnexa. No significant osseous or vascular abnormalities. There is a prominent left internal iliac node which is likely reactive to pelvic inflammation. IMPRESSION: 1. Pelvic cul-de-sac abscess would likely be accessible with CT guidance. The left adnexal presumed abscess which is indseparable from the ovary also likely amenable to CT-guided drainage. 2. The midline fluid collection without a thick rim may represent a noninfected cystic structure and would be very difficult to access with CT or ultrasound guidance. 3. Diffuse mesenteric and omental edema likely related to pelvic inflammation. Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service from the ED for LLQ pain and findings of left adnexal mass with multiple septations on PUS in the setting of untreated chlamydia, raising the concern for ___. She was also found to have some RUQ pain and elevated liver enzymes in the ED. # LLQ ___: Upon admission, the patient had mild LLQ tenderness and CMT. She had a mild leukocytosis and was afebrile. Given her untreated chlamydia and findings on U/S, she was presumed to have ___ and was admitted for IV antibiotics and pain control. She remained NPO/IVF on HD1 in the event that the adnexal collection was amenable to drainage. IV gentamicin and clindamycin were started empirically. Other possible diagnoses including adnexal torsion, malignancy, ectopic pregnancy, diverticulitis/pelvic abscess were considered and evaluated for. Additional imaging with CT abd/pel was performed and demonstrated three areas within the pelvis concerning for pelvic abscesses. It was felt that the pelvic cul-de-sac and left ovarian fluid collections were amenable to CT-guided drainage; the third more midline fluid collection was more consistent with non-infected cystic structure and was also felt to be difficult to access for drainage. On ___, the patient underwent CT-guided drainage of the pelvic cul-de-sac abscess and a drain was left in place. The left adnexal collection could not be drained or aspirated. Additional attempts to drain the left adnexal collection were not made. The drain was left in place and continued to have minimal output; the drain was discontinued on ___ prior to discharge. Fluid cultures were obtained at the time of drainage, and prior to discharge, the gram stain was negative and the culture demonstrated no growth. On day of discharge (___), the patient remained afebrile with minimal abdominal tenderness. She was transitioned to po doxycycline for a 2 week course of antibiotics. She had outpatient follow-up scheduled at time of discharge. # Transaminitis: At time of presentation, the patient complained of mild RUQ tenderness and labs were obtained in the ED which demonstrated a mild transaminitis. A RUQ U/S was significant for a "starry sky" appearance, but was otherwise unremarkable. The differential at time of admission included a reactionary response to capsular inflammation (eg ___, acute hepatitis or hepatic congestion. Hepatitis serologies and HIV were negative. Liver enzymes were trended and remained stable. Given that the patient developed no signs of liver function compromise, it was felt that her transaminitis was likely secondary to capsular inflammation relating to her PID. # T1DM: On admission, the patient's FSBG was poorly controlled; she reported a home regimen of Lantus 32u qAM and HISS with a correction of 1:25 and ___ 1:9. A HbA1c was 10.5, which was consistent with her outpatient values. A ___ consult was obtained on ___ in order to optimize her insulin regimen, but while NPO on day of admission, her insulin regiment was initially Lantus 18u with HISS. After being seen by ___, the patient was recommended to receive her full dose of Lantus even while NPO given her poorly controlled FSBG. On ___, her Lantus was eventually increased to 36u given persistently elevated FSBG. She was discharged home on this regimen plus the recommendation to change her ___ to 1:8. Upon discharge, she was instructed to follow-up with ___. On ___, the patient was discharged home on oral antibiotics, specifically doxycycline for a 2 week course. She had an outpatient appointment scheduled prior to discharge. Medications on Admission: Lantus, humalog, ASA 81mg, albuterol Discharge Medications: 1. Lantus 36 Units Breakfast Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus] 100 unit/mL ___aily before breakfast Disp #*1 Vial Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PID ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with pelvic inflammatory disease (PID) with a tubo-ovarian abscess (___). This is likely a result of Chlamydia. You were treated with IV antibiotics and the ___ was drained under CT guidance. You should continue your antibiotics. You received a script for Chlamydia for your partner and he should take this to prevent re-infection for you. Followup Instructions: ___

19997367-DS-21

DS

2127-05-12 00:00:00

2127-05-12 20:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox / Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide / Minocycline / Cleocin / Percocet / vancomycin Attending: ___. Chief Complaint: Hemoptysis and melanotic stools Major Surgical or Invasive Procedure: EGD with MAC Anesthesia History of Present Illness: Ms. ___ is a ___ with a PMHx of AML (sp T-cell depleted allogenic BMT in ___, CKD, lymphoproliferative disorder, hypogammaglobulinemia, ___ PEA arrest cb anoxic brain injury (___), severe MR ___ MVR), hemochromatosis (cb cirrhosis and encephalopathy), recurrent pleural effusions, and varices sp GIB, recently admitted for endocarditis/septic shock, who presented with hemoptysis and melanotic stools. She was at ___ following her recent admission for endocarditis and septic shock, while on PCN. She began noticing some dyspnea on exertion when working there with ___. She also noted that her legs and feet were more swollen ___ dependent edema and she was started on Lasix. At rehab, she was sitting at dinner on ___ and coughed after she took a bite. Following the cough, blood gushed from her mouth. She could not quantify the amount of blood, but noted that it covered the entire anterior aspect of her shirt. Blood also flowed from her nose continuously. Pressure was applied with a towel until the ambulance arrived and bleeding had stopped on arrival in the ED. She denied any recent trauma, cough, congestion, sore throat, or bleeding conditions. Also, of note, she has had ___ dark stools at rehab. She denied constipation, diarrhea, abdominal pain, and dysuria. In the ED, initial VS were: T 100, P ___, BP 104/83 (SBP 90-104), R 20 O2 Sat 100% on 5L. She had a small amount of dark red stool in ED. Her HCT dropped from 32 to 25. Brown stool, guiaic positive. Labs were also remarkable for WBC 13.8. She received 2U PRBC with increase of HCT to 32.4. CXR showed R pleural effusion and increased R atelectasis (she has had recurrent pleural effusions that are tapped as treatment). There was also a new perihilar parenchymal opacity (cw PNA or aspiration). She received pantoprazole, azithro and CTX. On arrival to the floor, she was hemodynamically stable. She had a recurrence of the bleeding from the right nares in the evening of ___. She also noted some pain in her feet from dependent edema. Past Medical History: - Severe mitral stenosis (area < 1.0cm2) s/p MVR ___/b AMS, recurrent pleural effusions, pneumonia, septic shock with bacteremia, and GI bleed due to varices - Presumed diastolic dysfunction - PEA arrest in ___. Husband resuscitated her. Found to be in complete heart block s/p pace maker placement. Anoxic brain damage with short term memory loss. - Left breast cancer status post mastectomy with radiation therapy in ___ and ___. - AML - in CCR, s/p Cy/TBI conditioning and allogeneic T-cell depleted allogeneic bone marrow transplant from sister in ___. - BMT complicated by lymphoproliferative disorder status post tonsillectomy and Rituxan in ___, ITP s/p Rituxan in ___ without recurrence, and hypogammaglobulinemia requiring monthly IVIG. - Basal cell carcinoma with excision in ___. - Iron overload diagnosed by liver biopsy in ___ and undergoing periodic phlebotomy - cirrhosis due to hemachromatosis c/b varices, UGI bleed, hepatic encephalopathy - obstrucitve airway disease per PFTs - recurrent pleural effusions s/p pleurX catheter (___), last thoracentesis ___ (800cc drained) Social History: ___ Family History: Breast cancer in mother and sister. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: T: 97.6 BP: 105/53 P: 90 R: 19 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur LUSB, no rubs/gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, trace PE in ___ b/l, no clubbing or cyanosis Neuro: CN II-XII intact, strength ___ in UE and ___ b/l DISCHARGE PHYSICAL EXAM ======================= Vitals: Tm: 98.7 BP: 80-90s/40-50s, P: 60s R: ___, O2: 99% (2L). General: Alert, oriented, no acute distress HEENT: Sclera anicteric, no blood in nares or oropharynx, MMM Neck: supple, JVP not elevated, no LAD Lungs: Tachypnic, rales in right base ___ way up, clear to auscultation otherwise, no wheezes or rhonchi CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur LUSB, no rubs/gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, trace PE in ___ b/l, no clubbing or cyanosis Neuro: CN II-XII intact, strength ___ in UE and ___ b/l Pertinent Results: ADMISSION LABS ============== ___ 12:05AM BLOOD WBC-13.8* RBC-2.87* Hgb-7.5* Hct-24.9* MCV-87 MCH-26.1* MCHC-30.1* RDW-18.8* Plt ___ ___ 12:05AM BLOOD Neuts-89.9* Lymphs-4.3* Monos-5.3 Eos-0.3 Baso-0.2 ___ 09:05AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL Burr-OCCASIONAL Tear Dr-NORMAL ___ 12:05AM BLOOD ___ PTT-33.4 ___ ___ 12:05AM BLOOD Glucose-175* UreaN-26* Creat-1.0 Na-136 K-3.5 Cl-94* HCO3-31 AnGap-15 ___ 12:05AM BLOOD ALT-17 AST-26 AlkPhos-353* TotBili-0.5 ___ 12:05AM BLOOD Albumin-3.2* ___ 11:15PM BLOOD Type-MIX pO2-52* pCO2-39 pH-7.48* calTCO2-30 Base XS-5 Comment-GREEN TOP ___ 11:15PM BLOOD freeCa-1.13 NOTABLE LABS ============ ___ 05:17AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7 ___ 09:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 09:30PM URINE RBC-4* WBC-22* Bacteri-NONE Yeast-NONE Epi-1 ___ 07:40PM BLOOD Vanco-32.8* ___ 05:59AM BLOOD Vanco-34.5* ___ 06:00AM BLOOD Vanco-29.1* DISCHARGE LABS ============== ___ 06:00AM BLOOD WBC-7.2 RBC-3.33* Hgb-9.3* Hct-30.8* MCV-93 MCH-28.1 MCHC-30.3* RDW-19.3* Plt ___ ___ 06:00AM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-138 K-3.5 Cl-104 HCO3-26 AnGap-12 ___ 06:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9 MICRO ===== ___ 8:54 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. Blood cultures pending. IMAGING ======= CXR ___ As compared to the previous radiograph, there is a slight increase in extent of a pre-existing right pleural effusion. The areas of atelectasis on the right are also increasing. On the left, and new perihilar parenchymal opacity has occurred that could represent pneumonia or aspiration. Normal size of the cardiac silhouette. Unchanged left pectoral pacemaker and right Port-A-Cath. CXR ___ As compared to the previous radiograph, the lung volumes have minimally decreased, causing an apparent increase in radiodensity at the right lung base. However, there is no new focal parenchymal opacity and no progression of the pre-existing changes. No pulmonary edema. Borderline size of the cardiac silhouette. Unchanged alignment of the sternal wires. CT chest with contrast ___ 1. Multifocal dependently distributed peribronchiolar consolidations, several of which have a rounded configuration, but none of which demonstrate cavitation. Observed findings favor multifocal aspiration/aspiration pneumonia, but septic emboli are also possible given history of endocarditis. 2. Decrease in extent of multiloculated right pleural effusion compared to ___, but very minimal increase in small left effusion. Small pericardial effusion. 3. Similar mediastinal lymphadenopathy compared to ___, but slight increase in right hilar lymphadenopathy. 4. Basilar predominant septal thickening, most likely due to hydrostatic edema. EGD ___ 2 cords of small, grade I-II varices were seen in the distal esophagus. Snakeskin appearance of the mucosa was noted in the stomach body. These findings are compatible with moderate portal hypertensive gastropathy. A few small angioectasias which were bleeding were seen in the duodenal bulb. An Argon-Plasma Coagulator was applied for hemostasis successfully. CXR ___ Interval increase in size of moderate right and small left pleural effusions, with bibasilar atelectasis. Brief Hospital Course: ASSESSMENT AND PLAN: Ms. ___ is a ___ with a PMHx of AML (sp T-cell depleted allogenic BMT in ___, CKD, lymphoproliferative disorder, hypogammaglobulinemia, ___ PEA arrest cb anoxic brain injury (___), severe MR ___ MVR), hemochromatosis (cb cirrhosis and encephalopathy), recurrent pleural effusions, and varices sp GIB, recently admitted for endocarditis/septic shock, who presented with hemoptysis and melanotic stools. ACUTE ISSUES ============ # Hemoptysis/melanotic stools: On initial presentation, the patient reported coughing up blood as well as blood draining from the nose. In the ED, it was noticed that she had melanotic stools and she recollected that her stools had a similar appearance for ___ days prior. The differential included recurrent variceal bleed (variceal bleed with banding ___ ___, cavitating pneumonia ___ seeding from S. bovis bacteremia and/or recurrent pleural effusion c/b empyema, or septic emboli. She was placed on a PPI and octreotide drip for a possible recurrent GI bleed. She was also started on propranolol, which could only be given with SBP > 90 (her SBPs run low, 80s-100s, on midodrine 10mg TID). Stools were guaiac positive and stool cultures were negative for Shigella, salmonella, campylobacter. Interventional pulmonology was consulted. Bedside ultrasound and CT chest with contrast did not show much interval change in pleural effusions compared to previous and there was no evidence of PE or septic emboli. Hepatoology was also consulted and EGD was performed. EGD demonstrated two bleeding varices in the distal esophagus and angioectasias in the proximal duodenum, and treatment with thermal probe was completed. At discharge, her stools were less frequent, more formed, and lighter in color. She will be continued on pantoprazole 40mg BID and propranolol 20mg TID with the holding parameter of SBP <90. # S. bovis bacteremia/endocarditis: With recent hospitalization at the end ___ for S. bovis bacteremia and shortness of breath with exertion, her coverage was broadened from penicillin, initially to ceftraiaxone and azithromycin, and then vancomycin and zosyn to protect against HCAP after ID consultation. Her vancomycin was originally 1g q12h, but trough was supratherapeutic and her dose was changed to 1g q24h on ___. Her dose was held on ___ and ___ to allow the vancomycin trough to enter a therapeutic range. Her zosyn was originally 4.5g q6h, but was also converted to 2.25g q6h on ___. She has received zosyn without interruption. At discharge, her vancomycin trough should be repeated, both vancomycin and zosyn should be continued through ___. # VRE UTI: Final urine cultures grew VRE > ___ colonies, but the pt remained asymptomatic. For this reason, there was no clinical indication to start antibiotics, but the patient should continue to be monitored for symptoms. # Recurrent pleural effusions: The patient has had ongoing shortness of breath, especially with exertion. She has had recurrent pleural effusions drained in the past, and prior effusions have been complicated in that they have grown S. bovis and resulted in empyema requiring 2 chest tubes removed on ___. Repeat CXR demonstrated worsening effusion. However, interventional pulmonology performed a bedside ultrasound, which did not show effusions large enough to drain. Chest CT with contrast showed small, loculated effusions. She was monitored with serial CXR. At discharge, her shortness of breath had not worsened, though she should have close follow-up to ensure drainage at the appropriate time. # Cirrhosis ___ hemochromatosis c/b encephalopathy: The patient has a longstanding hx of cirrhosis secondary to hemochromatosis complicated by encephalopathy. She has not had SBP, recent MELD score of 10. Because of her cirrhosis, she has a chronically elevated AST and alk phos. No evidence of ascites. Hepatology was consulted, and PPI BID and propranolol were initiated. She will be continued on pantoprazole 40mg BID and propranolol 20mg TID with the holding parameter of SBP <90. While lactulose and rifaxamin were initially held due to diarrhea and nausea, these medications were restarted at discharge and should be titrated to ___ bowel movements daily. CHRONIC ISSUES ============== # AML: Pt is s/p transplant (___) c/b lymphoproliferative disorder, ITP, and hypogammaglobulinemia, currently on monthly IVIG. Contact was made with her outpatient oncologist, Dr. ___ she received IVIG treatment as an inpatient on ___. Her acyclovir was continued in-house and at discharge. # CHF and hx of MVR: The patient has a hx of severe mitral regurgitation, s/p MVR. Most recent TTE/TEE demonstrated preserved EF. # CKD: Patient's baseline has been 1.2-1.7 over the past year. Through her course in the hospital, she has had no interval worsening of her CKD, with Cr ranging from 0.8-1.1. TRANSITIONAL ISSUES =================== # Pt should continue on pantoprazole 40mg PO daily and propranolol 20mg PO TID. # Pt should continue IV abx of vancomycin 1g IV q24h and zosyn 2.25g q6h through ___. Repeat vancomycin level to ensure therapeutic range. # Pt should follow-up regarding variceal GI bleed at the ___ ___ with an appointment on ___. # Pt was started on pantoprazole 40mg BID and propranolol 20mg TID. Propranolol should be held if pt SBP < 90. # Monitor for UTI symptoms, as patient's final urine culture grew out VRE. # Follow up on final blood cultures # Pt noted to have R hilar LAD and bronchial wall thickening on CT from this admission, consider follow-up imaging if indicated # Emergency contact: ___ Relationship: husband Phone number: ___ Cell phone: ___ # Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. FoLIC Acid 1 mg PO DAILY 3. Midodrine 10 mg PO TID 4. Pantoprazole 40 mg PO Q24H 5. Sucralfate 1 gm PO QID 6. Acetaminophen 500 mg PO Q6H:PRN pain 7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Gabapentin 100 mg PO HS 11. Baclofen 5 mg PO BID 12. Spironolactone 25 mg PO DAILY 13. Rifaximin 550 mg PO BID 14. Phosphorus 500 mg PO DAILY 15. Ondansetron ___ mg PO Q8H:PRN nausea 16. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN hemorrhoids 17. Furosemide 20 mg PO DAILY 18. Potassium Chloride 20 mEq PO BID 19. Aspirin EC 81 mg PO DAILY 20. Penicillin G Potassium 3 Million Units IV Q4H 21. Lactulose 30 mL PO DAILY 22. Lorazepam 0.25 mg PO BID:PRN anxiety 23. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 24. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Acyclovir 400 mg PO Q8H 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 4. FoLIC Acid 1 mg PO DAILY 5. Lactulose 30 mL PO DAILY 6. Midodrine 10 mg PO TID 7. Rifaximin 550 mg PO BID 8. Sucralfate 1 gm PO QID 9. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN indigestion 10. Pantoprazole 40 mg PO Q24H 11. Phosphorus 500 mg PO DAILY 12. Potassium Chloride 20 mEq PO BID 13. Spironolactone 25 mg PO DAILY 14. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID 15. Piperacillin-Tazobactam 4.5 g IV Q6H 16. Propranolol 20 mg PO TID 17. Vancomycin 1000 mg IV Q 12H 18. Multivitamins W/minerals 1 TAB PO DAILY 19. Ondansetron ___ mg PO Q8H:PRN nausea 20. Gabapentin 100 mg PO HS 21. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN hemorrhoids 22. Aspirin EC 81 mg PO DAILY 23. Baclofen 5 mg PO BID 24. Furosemide 20 mg PO DAILY 25. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 26. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 27. Lorazepam 0.25 mg PO BID:PRN anxiety Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= 1. Variceal bleed SECONDARY DIAGNOSES =================== 1. S. bovis bacteremia 2. Recurrent pleural effusions 3. Acute myeloid leukemia 4. Diastolic congestive heart failure 5. Chronic kidney disease 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 ___, ___ was a pleasure taking care of you during your stay at ___. You were recently admitted because of an episode of coughing up blood and dark stools. In determining the source of this bleeding, imaging and endoscopy was performed. CT scan of the lungs did not show any bleeding site and pleural effusions were not large enough to tap. An endoscopy revealed bleeding varices, which were treated with a thermal laser. You were also treated for a GI bleed with octreotide, propranolol, and pantoprazole to decrease bleeding from the GI tract. At discharge, you have been scheduled for follow-up at the ___. Because you will have 5 more days of IV antibiotic therapy, you have also been scheduled to follow-up with infectious disease physicians. Sincerely, Your ___ care team Followup Instructions: ___

19997367-DS-22

DS

2127-05-27 00:00:00

2127-05-27 19:58:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox / Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide / Minocycline / Cleocin / Percocet / vancomycin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with PMH significant for recent admission for endocarditis (pulmonic valve), dCHF, cirrhosis c/b variceal bleed, and AML ___ BMT who presented to ___ for dyspnea. Patient developed throat and chest tightness, associated with shortness of breath. She was reportedly very anxious with labored breathing. EMS was activated. She was given albuterol nebs, SL nitro, ASA 325mg, vicodine, and ativan with some relief of symptoms. She was placed on O2 for comfort. In the ED, initial vitals were: T97.6 P72 BP90/50 RR14 98% 2L. Labs were notable for WBC 6.8, H/H 8.5/28.9, K 5.0, Cr 1.0. EKG showed paced rhythm with RBBB. CXR showed stable bilateral pleural effusions. The patient was given lasix 20mg IV, unknown response. Vitals prior to transfer were: P70 BP107/73 RR18. Upon arrival to the floor, patient reports progressive worsening of dyspnea on exertion. She notes orthopnea, has used ___ pillows over past few months, weight gain, and increased peripheral edema. She reports recurrent pleural effusions secondary to her heart. The pleural effusions are drained intermittently for symptoms. Last drainage was 3 months ago. She does not like taking lasix or spironolactone as she already makes several trips to the bathroom due to lactulose. No recent fever, chills, cough, chest pain, palpitations, abdominal pain, hematochezia, melena, or dysuria. On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, and syncope or presyncope. Past Medical History: - Severe mitral stenosis (area < 1.0cm2) ___ MVR ___/b AMS, recurrent pleural effusions, pneumonia, septic shock with bacteremia, and GI bleed due to varices - Presumed diastolic dysfunction - PEA arrest in ___. Husband resuscitated her. Found to be in complete heart block ___ pace maker placement. Anoxic brain damage with short term memory loss. - Left breast cancer status post mastectomy with radiation therapy in ___ and ___. - AML - in CCR, ___ Cy/TBI conditioning and allogeneic T-cell depleted allogeneic bone marrow transplant from sister in ___. - BMT complicated by lymphoproliferative disorder status post tonsillectomy and Rituxan in ___, ITP ___ Rituxan in ___ without recurrence, and hypogammaglobulinemia requiring monthly IVIG. - Basal cell carcinoma with excision in ___. - Iron overload diagnosed by liver biopsy in ___ and undergoing periodic phlebotomy - cirrhosis due to hemachromatosis c/b varices, UGI bleed, hepatic encephalopathy - obstrucitve airway disease per PFTs - recurrent pleural effusions ___ pleurX catheter (___), last thoracentesis ___ (800cc drained) Social History: ___ Family History: Breast cancer in mother and sister. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS: T97.5 BP109/48 P78 RR20 100%3L Wt 55.9kg General: Chronically ill appearing, sad affect, no acute distress. HEENT: Pupils equal and reactive to light. Oropharynx clear. Neck: JVP at 8cm. CV: RRR, normal S1, S2. ___ systolic murmur loudest at LLSB. Lungs: Bibasilar crackles, L>R. Abdomen: +BS, soft, nondistended, nontender to palpation. GU: No foley. Ext: Warm and well perfused. Pulses 2+. 1+ pitting edema up to knees bilaterally. Neuro: A+Ox3. Moves all extremities grossly. Skin: No rash. PHYSICAL EXAMINATION ON DISCHARGE: VS: Weight 51.6 ___ yesterday, 55.9 on admit) BP 83-99/42-54 P ___ RR 18 94% RA General: Elderly female, in NAD HEENT: NC/AT, EOMI, sclera anicteric Neck: JVP 2-3cm above clavicle at 45 degrees CV: RRR, normal S1, S2. ___ systolic murmur loudest at LUSB. Lungs: Mild bibasilar crackles. No w/r. Abdomen: +BS, soft, nondistended, nontender to palpation. Ext: Warm and well perfused. Pulses 2+. Edema decreased from 2 days ago, currently trace-to-1+ edema to ankles. Neuro: A+Ox3. moving all extremities, speech fluent. Skin: No rash. Pertinent Results: LABS ON TRANSFER ___ 09:10AM BLOOD WBC-6.8 RBC-3.17* Hgb-8.5* Hct-28.9* MCV-91 MCH-26.9* MCHC-29.5* RDW-18.2* Plt ___ ___ 09:10AM BLOOD Neuts-79.2* Lymphs-9.0* Monos-9.6 Eos-1.8 Baso-0.5 ___ 09:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+ Ovalocy-OCCASIONAL ___ 09:10AM BLOOD Plt ___ ___ 09:10AM BLOOD Glucose-107* UreaN-22* Creat-1.0 Na-137 K-5.0 Cl-104 HCO3-23 AnGap-15 ___ 09:10AM BLOOD ALT-41* AST-56* AlkPhos-417* TotBili-0.5 ___ 09:10AM BLOOD Lipase-46 ___ 09:40AM BLOOD ___ 09:10AM BLOOD Albumin-3.6 ___ 09:20AM BLOOD Lactate-1.3 LABS ON DISCHARGE ___ 06:00AM BLOOD WBC-6.7 RBC-3.07* Hgb-8.1* Hct-27.1* MCV-88 MCH-26.4* MCHC-29.9* RDW-18.1* Plt ___ ___ 09:30PM BLOOD Glucose-170* UreaN-29* Creat-1.2* Na-136 K-4.1 Cl-97 HCO3-28 AnGap-15 ___ 09:30PM BLOOD Calcium-9.7 Phos-2.9 Mg-2.3 STUDIES EKG ___ 9:11:36 AM Atrial sensed, ventricularly paced rhythm. Underlying rhythm is sinus rhythm. Compared to the previous tracing of ___ there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 ___ 51 -95 63 CXR ___ FINDINGS: Compared with prior, there has been no significant interval change. Right chest wall port and left chest wall dual lead pacing device are again seen. Partially loculated right-sided pleural effusion persists. Probable small left effusion is partially loculated laterally. Right basilar opacities medially may be due to atelectasis, similar to prior. The cardiomediastinal silhouette is unchanged, mitral valve prosthesis again noted. Surgical clips seen in the right upper quadrant. No acute osseous abnormalities. IMPRESSION: No significant interval change. Bilateral effusions. Right medial basilar opacity potentially atelectasis noting that infection is not excluded. Brief Hospital Course: ___ with complicated medical history including recent admission for variceal bleed and endocarditis, dCHF, and cirrhosis of unknown etiology who presents due to CHF exacerbated. ACTIVE PROBLEM # Heart Failure: She was transferred on 3L O2 by NC, which was easily weaned. Symptomatically she improved over the course of one day. Her shortness of breath was believed to be due to heart failure due to diastolic dysfunction vs restrictive cardiomyopathy (history of hemachromatosis) given evidence of HF on history and exam (med noncompliance, weight gain, orthopnea, increased ___ and EF of >55% in ___. Her diuretic dose had been decreased recently from Torsemide 40mg BID to Lasix 20mg daily and she endorsed not having taken her diuretics as she already spent too much time in the bathroom with the lactulose. She has recurrent pleural effusions and is periodically drained by IP. They were consulted and felt that her pleural effusions were stable from the last time she was seen and drainage was not indicated at this time and not likely to help symptoms. She was diuresed with IV lasix with her weight decreasing from 55.9kg on admit to 51.7kg on discharge. She was discharged on lasix 40mg PO BID. She is seen by Dr. ___. # Vaginal Lesions: Small, non-palpable dark purple pinpoint lesions (?purpura) seen on inner labia, found incidentally when placing foley. Asymptomatic, unclear etiology. Denies any recent sexual activity. Follow up arranged with ___. # Deconditioning: Was admitted from rehab, where she was scheduled to be discharged home on day of/day after admission. Seen by ___, provided a walker with plan for home ___ services. CHRONIC PROBLEMS # Cirrhosis: Cirrhosis secondary to hemochromatosis, complicated by encephalopathy and variceal bleed. No history of SBP. ___ Classification A, MELD score 8. Patient currenly A+O, without signs of encephalopathy. Home doses of propranalol, midodrine, pantoprazole, lactulose, rifaxamin, and spironolactone were continued. # AML: Pt is ___ transplant (___) c/b lymphoproliferative disorder, ITP, and hypogammaglobulinemia. She receives monthly IVIG, last on ___. Patient seen by Dr. ___. Anemic, borderline thrombocytopenic-- both stable compared to last 3 months. =================================================== TRANSITIONAL ISSUES =================================================== Ms. ___ is a ___ yo woman with cirrhosis ___ hemochromatosis, CHF, recent hospitalization for endocarditis (on pulmonic valve), severe MR ___ MVR, h/o PEA arrest c/b heart block ___ PPM, AML ___ BMT who was admitted for CHF exacerbation. [ ] Diuresis: From past records, it appears she was on torsemide 40mg BID in the past, but at her previous discharge was sent home on lasix 20mg. Patient has GI upset with torsemide, therefore we will discharge on lasix 40mg BID. [ ] Chronic pleural effusion: Seen by IP for intermittent drainage. IP did not feel she would benefit from thoracentesis during hospitalization. [ ] Vaginal lesions: Seen incidentally when placing a foley. Appointment made with the ___ further evaluation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. FoLIC Acid 1 mg PO DAILY 3. Lactulose 30 mL PO HS:PRN PRN 4. Midodrine 10 mg PO TID 5. Rifaximin 550 mg PO BID 6. Sucralfate 1 gm PO QID 7. Phosphorus 500 mg PO DAILY 8. Potassium Chloride 20 mEq PO BID 9. Spironolactone 25 mg PO DAILY 10. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID 11. Propranolol 20 mg PO TID 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Gabapentin 100 mg PO HS 14. Aspirin EC 81 mg PO DAILY 15. Baclofen 5 mg PO BID 16. Furosemide 20 mg PO DAILY 17. Pantoprazole 40 mg PO Q12H 18. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob 21. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids 22. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 23. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 24. Senna 8.6 mg PO HS:PRN constipation 25. Milk of Magnesia 30 mL PO Q6H:PRN constipation 26. Fleet Enema ___AILY:PRN constipation 27. Bisacodyl ___AILY:PRN constipation 28. Lorazepam 0.25 mg PO BID:PRN anxiety 29. Acetaminophen 325-650 mg PO Q4H:PRN pain Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Aspirin EC 81 mg PO DAILY 3. Baclofen 5 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 40 mg PO BID RX *furosemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Gabapentin 100 mg PO HS 7. Lactulose 30 mL PO HS:PRN PRN 8. Lorazepam 0.25 mg PO BID:PRN anxiety 9. Midodrine 10 mg PO TID 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Propranolol 20 mg PO TID 13. Rifaximin 550 mg PO BID 14. Spironolactone 25 mg PO DAILY 15. Sucralfate 1 gm PO QID 16. Acetaminophen 325-650 mg PO Q4H:PRN pain 17. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 18. Bisacodyl ___AILY:PRN constipation 19. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 20. Fleet Enema ___AILY:PRN constipation 21. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids 22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob 23. Milk of Magnesia 30 mL PO Q6H:PRN constipation 24. Ondansetron 4 mg PO Q8H:PRN nausea 25. Phosphorus 500 mg PO DAILY 26. Potassium Chloride 20 mEq PO BID Hold for K > 27. Senna 8.6 mg PO HS:PRN constipation 28. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID 29. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Heart Failure, Diastolic Dysfunction vs Constrictive Cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were transferred due to shortness of breath, which we believe was due to fluid overload. To remove fluid, we used intravenous diuretic medication. Interventional Pulmonology also reviewed your studies and imagine and felt that removing fluid from your lungs was not indicated at this time as your pleural effusions were stable from the last time they saw you. Your dose of lasix was increased to prevent fluid build up in the future, please take 40mg of furosemide (lasix) twice a day. It will be important to follow up closely with your Cardiologist. An appointment was made for ___ at 12:30, please see below for more information. Please weigh yourself every morning and call your cardiologist if your weight changes by more than 2 pounds in 24 hours or more than 5 lbs in a week. This can be a sign of fluid build up. During this stay, we also noted some asymptomatic vaginal lesions. A follow up appointment with the woman's health center was made to further evaluate these as an outpatient. The appointment information is included below. Sincerely, Your ___ Team Followup Instructions: ___

19997367-DS-23

DS

2127-08-21 00:00:00

2127-09-01 15:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox / Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide / Minocycline / Cleocin / Percocet / vancomycin Attending: ___. Chief Complaint: Dyspnea/Confusion Major Surgical or Invasive Procedure: There were no major surgical or invasive procedures. History of Present Illness: ___ with PMHx of AML s/p allo ___, MV stenosis s/p mitral valve replacement, recent pulmonic endocarditis, dCHF, heart block s/p cardiac pacemaker, and cirrhosis c/b multiple variceal bleeds, who is admitted with an episode of dyspnea and possible confusion. Per ED report, the patient's husband notice she was 'not acting like herself' while having dinner at 6pm day prior to admission. He reported that she had some difficulty getting up from the table, had trouble following commands, and was weak. He also felt she was short of breath and confused, and decided to bring her to the ED. In the ED, initial VS were 97.7, HR 94, BP 107/49, RR 22, O2 100%RA. Patient was noted to be alert, oriented to place and self, but was having difficulty following commands. Initial labs were notable for Na 131, Cr 1.3, HCT 30.7, lactate 2.2, and AP 205. Remainder of CBC, Chem10, trops x1, and LFT's were unremarkable. UA showed 40RBC with <1 epi and negative nitrates. Head CT and CXR were negative for acute process. Patient was admitted to ___ for further management. On arrival to the floor, patient is without complaint. She reports she chronically gets DOE while walking up the stairs at her house, and did report some prolonged dyspnea today during dinner. She denies any worsened issues with confusion, although does suffer from some short term memory loss. She also notes several weeks of diarrhea, but reports this resolved three weeks ago. She since denies any signficant diarrhea or consitpation. She also denies recent fevers or chills. No ST. No cough. No frank chest pain. No nausea, vomiting, or abdominal pain. She reports her appetite is good. No dysuria. She does note chronic neuropathy of the arms and legs, for which she takes gabapentin and also some chronic very mild pleuritic chest pain. She also occaisionally has nocturnal hand and leg cramps. ROS is otherwise unremarkable. Past Medical History: PAST ONCOLOGIC HISTORY: -Left breast cancer status post mastectomy with radiation therapy in ___ and ___. -AML status post allogeneic T-cell depleted bone marrow transplant from a sibling donor in ___. -Post-transplant lymphoproliferative disorder status post tonsillectomy and Rituxan in ___. -ITP, treated with Rituxan in ___ without recurrence. -Chronic sinus infections and sinusitis receiving monthly intravenous gamma globulin to improve her B-cell activity. -Basal cell carcinoma with recent excision in ___. PAST MEDICAL/SURGICAL HISTORY: Cardiac -- PEA arrest in ___. Husband resuscitated her. Found to be in complete heart block s/p pace maker placement. Anoxic brain damage with short term memory loss. -- Severe mitral stenosis (area < 1.0cm2) s/p MVR ___/b AMS, recurrent pleural effusions, pneumonia, septic shock with bacteremia, and GI bleed due to varices -- Chronic diastolic heart failure --PV endocarditis in ___ in setting of Strep bovis bactermia (completed AbX course) Hematologic/Oncologic -- Left breast cancer status post mastectomy with radiation therapy in ___ and ___. --AML - in CCR, s/p Cy/TBI conditioning and allogeneic T-cell depleted allogeneic bone marrow transplant from sister in ___. --___ disorder post allo, now status post tonsillectomy and Rituxan in ___ --ITP s/p Rituxan in ___ without recurrence --Hypogammaglobulinemia requiring monthly IVIG. - Basal cell carcinoma with excision in ___. GI --Cirrhosis (hemachromatosis) c/b varices, variceal hemorrhage, and hepatic encephalopathy Pulm --Obstrucitve airway disease per PFTs --Recurrent pleural effusions s/p pleurX catheter (___), last thoracentesis ___ (800cc drained). Now resolved PAST SURGICAL HISTORY: --Hysterectomy ___. --Ovarian cysts and remaining ovarian tissue removed ___ and ___. --Discography and diskectomy ___. --Sinus surgery with biopsy ___. --Cataract surgery, right on ___ and left on ___. --Status post diagnostic and therapeutic pars plana vitrectomy on the left to rule out lymphoma on ___. --Status post replacement of breast implants with correction of contractures and radiation skin damage on ___. --Mitral valve replacement: ___ Social History: ___ Family History: Father with MS. ___, denies sister and mother having cancer despite prior documentation. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: 98.7 HR 75 BP 98/60 RR 18 O2 98%RA Gen: Pleasant, calm, AAOx3, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: No signficant JVD. CV: Normocardic, regular. Normal S1,S2. Loud holosytolic murmur throughout the pericardium LUNGS: Nonlabored on RA. 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. Able to ___ backwards. Follows simple commands. CN III-XII intact. Has antigravity strength in all limbs. FTN normal. Gait deferred LINES: Right POC c/d/i DISCHARGE PHYSICAL EXAM ======================= Vitals: 97.9-99.0, 93-101/39-56, 74-78, 20, 94-96% on RA. Gen: Pleasant appearing female laying in bed in NAD. HEENT: Moist mucous membranes, no oropharyngeal lesions. NECK: No signficant JVD. CV: Regular rate and rhythm, S1 and S2 present, loud holosystolic murmur throughout the precordium. LUNGS: Clear to auscultation except for crackles noted at the right lower base. No evidence of wheezing. ABD: soft, non-tender, non-distended, no rebound or guarding. No fluid wave noted of abdomen. EXT: Trace pedal edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. LINES: Right POC c/d/i Pertinent Results: ADMISSION LABS ============== ___ 10:39PM BLOOD WBC-7.1 RBC-3.87* Hgb-9.5* Hct-30.7* MCV-80* MCH-24.7* MCHC-31.1 RDW-18.1* Plt ___ ___ 10:39PM BLOOD Neuts-84.7* Lymphs-9.0* Monos-5.9 Eos-0.3 Baso-0.2 ___ 10:39PM BLOOD Plt Smr-LOW Plt ___ ___ 10:39PM BLOOD Glucose-195* UreaN-30* Creat-1.3* Na-131* K-3.4 Cl-94* HCO3-24 AnGap-16 ___ 10:39PM BLOOD ALT-24 AST-40 AlkPhos-205* TotBili-1.1 ___ 10:39PM BLOOD Lipase-44 ___ 10:39PM BLOOD cTropnT-<0.01 ___ 06:01AM BLOOD cTropnT-<0.01 ___ 10:39PM BLOOD Albumin-3.6 Calcium-9.4 Phos-2.7 Mg-2.2 ___ 10:39PM BLOOD TSH-3.6 ___ 10:46PM BLOOD Lactate-2.3* ___ 07:16AM BLOOD Lactate-1.8 DISCHARGE LABS ============== ___ 12:07AM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.1 Mg-2.1 ___ 12:07AM BLOOD ALT-21 AST-24 LD(LDH)-295* AlkPhos-165* TotBili-0.6 ___ 12:07AM BLOOD Glucose-139* UreaN-30* Creat-1.1 Na-139 K-3.4 Cl-104 HCO3-24 AnGap-14 ___ 12:07AM BLOOD ___ PTT-50.4* ___ ___ 12:07AM BLOOD WBC-6.4 RBC-3.79* Hgb-9.2* Hct-29.9* MCV-79* MCH-24.2* MCHC-30.7* RDW-18.0* Plt ___ IMAGING ======= ___: CT HEAD WITHOUT CONTRAST IMPRESSION: No significant intracranial abnormality. Volume loss out of proportion to patient age. ___: CHEST (PA and LATERAL) IMPRESSION: No definite acute cardiopulmonary process. Right basilar changes appear chronic. ___: ECHOCARDIOGRAM The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. There is abnormal septal motion/position. The aortic valve is not well seen. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is probably mild aortic valve stenosis). A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral leaflets appear normal. The transmitral gradient is normal for this prosthesis. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, no clear change. ___: LUNG SCAN IMPRESSION: Low likelihood ratio for acute pulmonary embolism. ___: ULTRASOUND ABDOMINAL IMPRESSION: No intra-abdominal ascites. MICROBIOLOGY ============ ___: BLOOD CULTURE PENDING ___: BLOOD CULTURE PENDING ___: URINE CULTURE Time Taken Not Noted Log-In Date/Time: ___ 6:35 am URINE URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Cefepime sensitivity testing confirmed by ___. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>___ R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: ___ with PMHx of AML s/p allo ___, MV stenosis s/p mitral valve replacement, recent pulmonic endocarditis, dCHF, heart block s/p cardiac pacemaker, and cirrhosis c/b multiple variceal bleeds, who is admitted with an episode of dyspnea and possible confusion which has resolved. # DYSPNEA: Patient with chronic DOE being evaluated as an outpatient. Generally thought due to HFpEF, although patient does not appear clincally overloaded at this time. Patient also with known obstructive disease but is not taking her inhalers at home. However, lung physical exam was relatively unremarkable except for right lower lobe crackles. V/Q scan obtained which indicated "Low likelihood ratio for acute pulmonary embolism." Echo also obtained which did not reveal any acute changes from ___. Based on our evaluation and clinic notes from pulmonary, it appears as though this shortness of breath is likely multifactorial that had been worked up as an outpatient. Appears resolved as her shortness of breath was stable and back at baseline at the time of discharge. She was given duonebs as needed for dyspnea. # URINARY TRACT INFECTION: Likely the cause of altered mental status. Patient's urinary tract infection grew >100,000 klebsiella pneumonia resistant to ceftriaxone but sensitive to nitrofurantoin. She was prescribed nitrofurantoin 100 milligrams every 12 hours for a total course of seven days with end date on ___. During hospitalization, as her urinary tract infection was treated, her mental status improved. She was not confused at the time of discharge. # CONFUSION/WEAKNESS: Patient with a reported acute episode of confusion and weakness the night prior to presentation. During hospitalization she remained alert and oriented x 3. Neurology was consulted during hospitalization and they did not believe there was an ischemic cause of the confusion and did not believe an MRI was necessary. CT of head did not reveal significant intracranial abnormality although did note volume loss out of proportion to patient's age. An echocardiogram was also obtained and did not reveal any worsening of her diastolic heart failure. Additionally her liver disease (secondary to hemochromatosis) appeared well compensated during hospitalization with no evidence of asterixis. As noted above, patient was diagnosed with a urinary tract infection. As this urinary tract infection was treated her confusion resolved. She was alert and oriented x 3 and was not confused at the time of discharge. # ACUTE ON CHRONIC KIDNEY DISEASE: Cr 1.1 at time of discharge. Ranged between 1.1-1.3 during hospitalization. Patient's with variable baseline. Has been up to 1.2-1.7 over the past year, although was lower recently. Creatinine remained stable during hospitalization. CHRONIC ISSUES ============== # CIRRHOSIS: Due to hemochromatosis. Has had multiple episodes of variceal hemorrhage, last in ___. Most recent GI note from ___ mentions plan for outpatient EGD with banding. During hospitalization, there was no evidence of GI bleed as H/H remained stable. Not currently concerned about active GIB. Also with history of HE, and will monitor as above. Notably, patient denies taking lactulose, rifampin, lasix, and spironolactone, despite med list. INR 1.4. She was continued on her home medications of propanolol 20 mg PO tid and midodrine 10 mg PO TID. Ultrasound of abdomen was obtained which showed no intra-abdominal ascites. # CHRONIC DIASTOLIC HEART FAILURE: Most recent echo ___ showed LVEF>55% with functional mitral valve prosthetic, but was notable for likely PV endocarditis which has already been treated. During hospitalization she remained euvolemic. Due to concern that weakness was secondary to worsening heart failure an echocardiogram was obtained on ___ which did not show acute changes from ___. LVEF was maintained at >55%. # HISTORY OF COMPLETE HEART BLOCK/ARREST: Patient is permanently paced and remained on telemetry. There were no worrisome telemetry alarms. # ACUTE MYELOID LEUKEMIA: Pt is s/p transplant (___) c/b lymphoproliferative disorder, ITP, and hypogammaglobulinemia, currently on monthly IVIG. She was continued on her home acyclovir during hospitalization. # ANEMIA: Likely multifactorial, patient currently at recent baseline. TRANSITIONAL ISSUES =================== #ANTIBIOTIC REGIMEN: Nitrofurantoin 100 milligrams PO BID for total course of 7 days with end date on ___. #MEDICATION RECONCILIATION: Please discuss home medications and which medications she is truly taking at home as denies taking lactulose, rifampin, lasix, and spironolactone, despite being on home medication list. #CODE STATUS: FULL CODE. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Aspirin EC 81 mg PO DAILY 3. Baclofen 5 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 40 mg PO BID 6. Gabapentin 100 mg PO HS 7. Lactulose 30 mL PO HS:PRN PRN 8. Lorazepam 0.25 mg PO BID:PRN anxiety 9. Midodrine 10 mg PO TID 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. Propranolol 20 mg PO TID 13. Sucralfate 1 gm PO QID 14. Acetaminophen 325-650 mg PO Q4H:PRN pain 15. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 16. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids 17. Milk of Magnesia 30 mL PO Q6H:PRN constipation 18. Potassium Chloride 20 mEq PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN pain 2. Acyclovir 400 mg PO Q8H 3. Aspirin EC 81 mg PO DAILY 4. Baclofen 5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 100 mg PO HS 7. Lorazepam 0.25 mg PO BID:PRN anxiety 8. Midodrine 10 mg PO TID 9. Pantoprazole 40 mg PO Q12H 10. Propranolol 20 mg PO TID 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob 12. Furosemide 40 mg PO BID 13. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids 14. Lactulose 30 mL PO HS:PRN PRN 15. Milk of Magnesia 30 mL PO Q6H:PRN constipation 16. Multivitamins W/minerals 1 TAB PO DAILY 17. Potassium Chloride 20 mEq PO BID 18. Sucralfate 1 gm PO QID 19. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth every 12 hours Disp #*14 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= URINARY TRACT INFECTION SHORTNESS OF BREATH SECONDARY DIAGNOSIS =================== CIRRHOSIS DIASTOLIC HEART FAILURE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted after an episode of shortness of breath and confusion. During your admission you were diagnosed with a urinary tract infection. This was sensitive to a medication called nitrofurantoin (macrobid). The urinary tract infection was likely the cause of your confusion. Please continue taking the antibiotic nitrofurantoin (macrobid) 100 milligrams EVERY 12 HOURS for a total of seven days with end date on ___. You were seen by neurology who did not believe you had a stroke as the cause of your confusion. Your shortness of breath remained at baseline during your hospitalization with no further worsening of your shortness of breath. Please continue to take your medications as prescribed. Weigh yourself every morning, call MD if weight goes up more than 3 lbs, since you are currently taking a diuretic medication (furosemide). It was a pleasure taking care of you during your hospitalization. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___

19997538-DS-21

DS

2168-11-03 00:00:00

2168-11-03 12:57:00

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, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Per admission note: ___ Hx rectal CA s/p robotic LAR, diverting loop ileostomy (reversed), repair L ureteral injury in ___ now presenting with abdominal pain and N/V. Sudden onset crampy, intermittent LLQ abdominal pain at 11 AM today that worsened during the day. Emesis x 3, bilious. +chills, no fevers. Denies nausea now. +flatus, multiple BMs last night He completed FOLFOX about 3 weeks ago. Denies history of prior bowel obstructions. In the ED, NGT was placed with 300 cc of light-colored output. Patient received 8 mg of IV morphine and 2 mg IV dilaudid. Past Medical History: PMH: rectal CA, HTN, DM PSH: ___: Reversal of ileostomy and placement of left internal jugular Port-A-Cath ___: Robotic low anterior resection, diverting loop ileostomy, repair of left ureteral injury. Social History: ___ Family History: non-contributory Physical Exam: Admission Physical Exam: VS: 98.5, 104, 134/71, 18, 95% RA Gen - NAD Heart - borderline tachycardic, regular rhythm Lungs - CTAB Abdomen - soft, mildly distended, tender to deep palpation on the left, no rebound or guarding, well-healed abdominal incisions Extrem - warm, no edema ======================== Discharge Physical Exam: 98.1, 132/86, 104, 18, 100%/RA GEN: NAD, A&Ox3 HEENT: NCAT, EOMI CV: RRR, No JVD PULM: normal excursion, no respiratory distress ABD: soft, mild distension, non tender, no rebound, no guarding EXT: WWP, no CCE, 2+ B/L radial NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: ___ 06:59AM BLOOD WBC-6.3 RBC-3.14* Hgb-9.4* Hct-29.1* MCV-93 MCH-29.9 MCHC-32.3 RDW-13.4 RDWSD-45.4 Plt ___ ___ 06:40AM BLOOD WBC-6.6 RBC-3.25* Hgb-9.8* Hct-30.5* MCV-94 MCH-30.2 MCHC-32.1 RDW-13.3 RDWSD-45.9 Plt ___ ___ 07:00AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.1* Hct-30.9* MCV-94 MCH-30.7 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt ___ ___ 05:22AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.1* Hct-30.9* MCV-93 MCH-30.4 MCHC-32.7 RDW-14.1 RDWSD-47.7* Plt ___ ___ 02:45PM BLOOD WBC-12.8* RBC-3.69* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.1 MCHC-32.8 RDW-13.7 RDWSD-45.9 Plt ___ ___ 02:45PM BLOOD Neuts-87.1* Lymphs-6.7* Monos-4.1* Eos-1.1 Baso-0.5 Im ___ AbsNeut-11.16* AbsLymp-0.86* AbsMono-0.53 AbsEos-0.14 AbsBaso-0.06 ___ 06:59AM BLOOD Glucose-165* UreaN-10 Creat-0.9 Na-143 K-4.3 Cl-102 HCO3-29 AnGap-12 ___ 06:40AM BLOOD Glucose-178* UreaN-15 Creat-1.0 Na-147 K-4.3 Cl-105 HCO3-30 AnGap-14 ___ 07:00AM BLOOD Glucose-121* UreaN-21* Creat-0.9 Na-147 K-4.3 Cl-105 HCO3-33* AnGap-9* ___ 05:22AM BLOOD Glucose-146* UreaN-32* Creat-1.2 Na-142 K-4.7 Cl-105 HCO3-24 AnGap-13 ___ 02:45PM BLOOD Glucose-195* UreaN-24* Creat-1.0 Na-140 K-5.4 Cl-109* HCO3-16* AnGap-15 ___ 02:45PM BLOOD ALT-21 AST-24 AlkPhos-138* TotBili-0.7 ___ 02:45PM BLOOD Lipase-155* ___ 06:59AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.7 ___ 06:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.6 ___ 07:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.5* ___ 05:22AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.4* ___ 02:45PM BLOOD Albumin-4.4 ___ 02:53PM BLOOD Lactate-1.7 Brief Hospital Course: Mr. ___ presented to the emergency department at ___ ___ on ___ with complaints of abdominal pain, nausea, and vomiting. The patient underwent a CT scan that showed High-grade small-bowel obstruction with abrupt transition point in the right lower quadrant and possible internal hernia, as described above. The patient was examined by and admitted to the colorectal surgery service for further management. The patient had a nasogastric tube for bowel decompression, was given bowel rest, intravenous fluids, and symptom management. His abdominal exam was monitored closely which improved daily. The output from the nasogastric tube was very high with greater than 2500cc output daily and the patient required intermittent IV fluid boluses. On ___, the patient had a bowel movement. On ___, the nasogastric tube output decreased significantly. He was given a clamping trial with residual gastric output of 100cc, the tube was sequentially removed. The patient was later advanced to and tolerated a regular diet. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 40 mg PO DAILY 2. Gabapentin 300 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. amLODIPine 5 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Gabapentin 300 mg PO DAILY 4. GlipiZIDE 10 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Tamsulosin 0.4 mg PO QHS 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 Mr. ___, You were admitted to the hospital for a small bowel obstruction. You were given bowel rest, intravenous fluids, and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You are tolerating a regular diet, passing gas and your pain is controlled with pain medications by mouth. If you have any of the following symptoms please call the office or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: ___

19997540-DS-3

DS

2154-03-03 00:00:00

2154-03-03 11:10:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: food impaction Major Surgical or Invasive Procedure: endoscopy with intubation - ___ History of Present Illness: ___ with no significant medical history presents with a piece of steak stuck in his throat. He was eating dinner at a ___ the evening of admission when, at about 10:30pm, a piece of steak lodged in his throat. He could recall no inciting event. He had no difficulty breathing, but could not clear the bolus despite drinking water. He had no difficulty breathing. Given his inability to clear the bolus and increasing difficulty swallowing fluids, he was taken to the ED. In the ED, initial vitals 5 98.8 78 129/74 16 100% RA. He developed nausea and was eventually unable to clear even his own saliva, spitting it up to an emesis basin. He vomited several times, both after drinking and due to pooling secretions. He received glucagon x 1 and nitroglycerin x 1. Neither were effective in loosening the GE junction sufficiently to allow passage of the bolus. He also received Zofran 4 mg IV and Reglan 10mg IV for nausea management. GI was consulted who recommended immediate endoscopy to clear the bolus. He was taken to the OR for removal. Given concern for airway protection after his recent meal, Anaesthesia intubated the patient. He recieved Versed 2mg IV, fentanyl 250mcg IV, propofol and succinylcholine induction. Immediately after intubation his esophageal musculature relaxed and the bolus spontaneously passed into the stomach. Endoscopy revealed a large amount of food in the stomach, including the recently passed bolus, esophagitis, and possible mild furrowing of the esophagus. There was no sign of obstruction or stricture. He received 700cc IVF during the procedure. He tolerated it well, was extubated easily. In the PACU, he recovered swiftly and was able to tolerate small sips of water without pain or nausea. He received Zofran 4mg IV x1 for prophylaxis of possible post-anaesthesia nausea/emesis. He was resting comfortably with slight neck stiffness. Past Medical History: Herpes on finger H/o appendicitis s/p appendectomy Social History: ___ Family History: +Cardiovascular diseases, no GI diseases in the family Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: ___ 97.8 130/61 62 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. No pain to palpation of posterior neck. CARDIAC: RRR, nl S1 S2, no MRG LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength and gait testing deferred SKIN: warm and well perfused, no excoriations or lesions, no rashes . DISCHARGE PE: VS: 98.4, 53, 129/61, 16, 100% RA General: well-appearing young male, in NAD HEENT: MMM with small <1cm ecchymosis to L of uvula in posterior oropharynx Neck: supple, nontender, no LAD CV: RRR, no murmurs Lungs: CTAB Abd: soft, NT, ND, +BS Ext: no ___ edema Ext: no ___ edema Pertinent Results: EGD: There was some possible mild furrowing in the esophagus. Esophagitis Food in the stomach Otherwise normal EGD to third part of the duodenum . CXR, prelim: No radiopaque foreign body identified Brief Hospital Course: ___ with no significant medical history presents with a piece of steak stuck in his throat. . # Food impaction: No evidence of obstruction or stricture. The patient's food bolus spontaneously passed following anaesthesia without apparent damage to the esophagus. He had no respiratory compromise, and his nausea resolved with passing of the bolus into the stomach. He has no history of similar events. Aside from mild esophagitis, there is no evidence of structural problem. Pt started on BID PPI. Will need repeat EGD in ___ weeks after PPI for reassessment of distal esophagus and biopsies for EoE. Pt felt well the AM after admission and tolerated PO challenge. . # HSV treatment: The patient has an HSV vesicle on his finger, for which is under treatment with acyclovir for a planned 5 day course. He completed the course of acyclovir during his admission. . >> Transitional issues: - ___ in GI in ___ for repeat scope - PCP ___ recommended - Pt adamant about rapid discharge on ___ AM as he was feeling very well. Team requested he wait for attending evaluation but he insisted on immediate discharge AMA. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H ___dmitted on day 5 Discharge Medications: 1. Omeprazole 20 mg PO BID Take until a repeat endoscopy is done in ___ weeks. RX *omeprazole 20 mg 1 capsule,delayed ___ by mouth twice a day Disp #*120 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: food bolus impaction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at ___ ___. You came to the hospital after getting a piece of steak stuck in your throat that you were unable to clear. This was removed with an endoscopy. There was no evidence of a narrowing of your esophagus that would make you more likely to have future problems with food getting stuck. There was mild irritation of the esophagus from the piece of steak. You will need a repeat endoscopy in ___ weeks; until that time, please use omeprazole (Prilosec) to treat this irritation. You can avoid future problems with food being stuck in your esophagus by eating smaller bites and chewing more thoroughly. Please follow-up at the appointments listed below. Please see the attached list for updates to your home medications. Please start takeing Omeprazole 20mg twice daily for the irritation in your esophagus. You chose to leave before seeing the attending. We suggested you wait for attending evaluation but you wanted to leave. Followup Instructions: ___

19997886-DS-16

DS

2186-12-10 00:00:00

2186-12-14 17:18:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___ Chief Complaint: abdominal distension Major Surgical or Invasive Procedure: Diagnostic and therapeutic paracentesis bedside ___ Diagnostic and therapeutic paracentesis bedside ___ ___ TIPS ___ Central venous line insertion ___ Diagnostic paracentesis ___ History of Present Illness: ___ year old man with PBC c/b esophageal varices and ascites and schizoaffective disorder who presented to clinic yesterday with worsening abdominal distention in the setting of not taking his diuretics. He has lost a tremendous amount of weight and he has not been able to eat. Per OMR on ___, his PCP spoke to him because she had received an email from his psychiatrist that he reported that he is no longer taking his Lasix due to concerns that it is an amphetamine and concerns about dizziness. At that point he agreed to restart his Lasix and spironolactone but his PCP did not feel confident in him following through with this. On ___ there is a note from his psychiatrist that he had been seen in the ___ ED 3 days prior with dizziness causing him to be unable to ambulate. He was seen by ___, labs were checked, and he was discharged home. He had self decreased his Seroquel from 300 to 200 mg qHS and his psychiatrist recommended decreasing his lamotrigine from 200 to 100 due to the concern that dizziness may have been related to this medication. A serum level of the medication was checked while he was on 200 mg which was within normal limits and thus it was felt that the lamotrigine was less likely to be causing his dizziness. On ___ he was seen by psychiatry at which point he had been doing "all right" on the reduced doses of his psychiatric medications. In the ED initial vitals: Temperature 97.4, heart rate 97, blood pressure 143/91, respiratory rate 18, 98% on room air - Exam notable for: Tense, distended abdomen, non-tender. Breathing comfortable on room air with crackles at bilateral bases - Labs notable for: CBC: Hemoglobin 12.9, otherwise unremarkable Chem7: Unremarkable LFTs: Unremarkable, except for albumin of 3.1 Coags: Not obtained Ascites: TNC of 685, 6% polys Urinalysis: 9 WBCs, 0 epis, 10 ketones, few bacteria, negative nitrite - Imaging notable for: RUQUS with Doppler: 1. Cirrhosis with large ascites. 2. Patent portal vein. CXR: Low lung volumes without focal consolidation or pulmonary edema. - Patient was given: Nothing - ED Course: Patient underwent diagnostic and therapeutic paracentesis for 2 L with improvement in symptoms. On arrival to the floor he says he feels better after therapeutic paracentesis. He says that last ___ he started to feel tired and fatigued and had some shortness of breath which has been worsening over the last 6 months or so. He can only walk about 7 blocks before feeling tired and short of breath at this time. He does state that he feels that the diuretics are making him dizzy and so he has been only taking them about twice a week. He denies dysuria, urinary frequency, hematuria, hematochezia, melena. He endorses swelling around his ankles. He endorses chills but no fevers. He says that over the last ___ weeks he only ate ___ boosts per day in addition to some juice and coffee and water. He says that he has been doing this in order to make his stool softer and is afraid to eat regular food because it will make him constipated. He says he did have a soft bowel movement over the weekend but still feels constipated. He does say that people have told him that he looks much thinner than previously. Past Medical History: BPH Depression Schizoaffective disorder Colon polyps Portal hypertensive gastropathy Primary biliary cirrhosis complicated by ascites s/p banding and ascites Chronic cough, improved Social History: ___ Family History: Father died from complications from polio. His mother died at the age of ___ and she had a tumor removed at some point (he thinks from her abdomen). Brother with stage IV rectal cancer who recently underwent surgery. He was diagnosed with colon cancer in his late ___. Physical Exam: ADMISSION EXAM: =============== VS: 98.1F, 129/84, HR 77, RR 18, on room air GENERAL: NAD, appears markedly cachectic with muscle wasting and temporal wasting 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: Breathing comfortable on room air, crackles at the bases of his lungs bilaterally ABDOMEN: distended but soft, nontender in all quadrants, no rebound/guarding, normoactive bowel sounds, right sided para site with bloody bandage in place EXTREMITIES: 2+ pitting edema to the knees bilaterally PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis DISCHARGE EXAM: =============== VS: 24 HR Data (last updated ___ @ 2340) Temp: 98.3 (Tm 100.3), BP: 127/72 (112-127/68-72), HR: 105 (82-105), RR: 20 (___), O2 sat: 91% (89-100), O2 delivery: 2 L Nc Fluid Balance (last updated ___ @ 530) Last 8 hours Total cumulative 873ml IN: Total 873ml, TF/Flush Amt 447ml, IV Amt Infused 426ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative 2001ml IN: Total 4061ml, PO Amt 120ml, TF/Flush Amt 748ml, IV Amt Infused 3193ml OUT: Total 2060ml, Urine Amt 2060ml, Flexiseal 0ml GEN: Elderly, frail man, lying in bed, appears uncomfortable HEENT: Anicteric sclerae. NG tube in place, dried blood in nares. CV: Normal rate and rhythm. Grade ___ systolic murmur. Lungs: Clear to auscultation bilaterally without wheezes, rhonchi, or rales in anterior fields. Abdomen: Hyperactive bowel sounds throughout. Soft. Significantly distended, tympanitic to percussion. Mildly tender to deep palpation diffusely, no rebound or guarding. Extremities: Warm. No pitting edema. Neuro: Alert. Oriented to self, place ___ building"). Not oriented to year. Does not answer all questions or follow commands appropriately. Dysarthric. No asterixis appreciated. Pertinent Results: ADMISSION LABS: =============== ___ 05:53PM WBC-7.4 RBC-4.41* HGB-12.9* HCT-41.4 MCV-94 MCH-29.3 MCHC-31.2* RDW-17.3* RDWSD-60.1* ___ 05:53PM PLT COUNT-183 ___ 05:53PM NEUTS-72.6* LYMPHS-15.0* MONOS-11.2 EOS-0.8* BASOS-0.3 IM ___ AbsNeut-5.36 AbsLymp-1.11* AbsMono-0.83* AbsEos-0.06 AbsBaso-0.02 ___ 05:53PM GLUCOSE-76 UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-10 ___ 05:53PM ALT(SGPT)-32 AST(SGOT)-38 ALK PHOS-109 TOT BILI-1.5 ___ 05:53PM proBNP-560* ___ 05:53PM LIPASE-15 ___ 05:53PM ALBUMIN-3.1* CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-2.2 PERTINENT LABS: =============== ___ 07:05PM BLOOD 25VitD-49 ___ 04:41AM BLOOD CRP-52.0* ___ 02:12PM ASCITES TNC-1131* RBC-120* Polys-48* Lymphs-2* Monos-10* Mesothe-5* Macroph-32* Other-3* ___ 03:40PM URINE RBC-65* WBC-83* Bacteri-FEW* Yeast-NONE Epi-<1 DISCHARGE LABS: =============== ___ 03:51AM BLOOD WBC-15.5* RBC-2.80* Hgb-8.4* Hct-27.1* MCV-97 MCH-30.0 MCHC-31.0* RDW-21.0* RDWSD-73.1* Plt ___ ___ 03:51AM BLOOD ___ PTT-46.5* ___ ___ 07:58AM BLOOD Glucose-150* UreaN-28* Creat-0.7 Na-150* K-4.1 Cl-114* HCO3-23 AnGap-13 ___ 03:51AM BLOOD ALT-27 AST-42* AlkPhos-109 TotBili-3.0* DirBili-0.9* IndBili-2.1 ___ 07:58AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1 ___ 06:18AM BLOOD ___ pO2-206* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Comment-GREEN TOP ___ 10:32AM BLOOD Lactate-2.1* PERTINENT MICROBIOLOGY: ======================= __________________________________________________________ ___ 10:52 pm STOOL CONSISTENCY: LOOSE Source: Stool. C. difficile PCR (Pending): __________________________________________________________ ___ 9:45 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 9:30 pm BLOOD CULTURE Source: Line-CVL. Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:40 pm URINE Source: Catheter. URINE CULTURE (Pending): __________________________________________________________ ___ 5:13 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 2:12 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): No growth to date. __________________________________________________________ ___ 2:12 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 11:44 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 11:03 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 9:13 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 4:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. __________________________________________________________ PERTINENT IMAGING: =================== LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ IMPRESSION: 1. Limited evaluation of the left hepatic lobe due to poor sonographic windows. 2. Cirrhosis with large volume ascites. 3. Patent portal vein. Transthoracic Echocardiogram Report ___ IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. Mild mitral regurgitation. Dilated thoracic aorta. CT CHEST W/CONTRAST Study Date of ___ IMPRESSION: Mild-to-moderate diffuse interstitial lung disease may explain chronic cough. NS IP is the most likely diagnosis alternatively severe elevation of the diaphragm due to ascites may be triggering coughing. Fusiform aneurysm noncalcified ascending thoracic aorta, 50 mm diameter. CT ABD & PELVIS WITH CONTRAST Study Date of ___ IMPRESSION: 1. Cirrhotic liver without focal liver lesions. Evaluation for HCC is limited on this portal venous phase contrast-enhanced study. Recommend further evaluation a dedicated liver CT which includes the noncontrast, arterial, and 3 minutes delayed phases. The portal venous phase does not need to be repeated. 2. Large volume ascites, splenomegaly, and portosystemic varices compatible with sequela of portal hypertension. 3. Multiple pancreatic cystic lesions better evaluated on MR, likely represent side branch IPMNs. Recommend attention on follow-up imaging. 4. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. TIPS Study Date of ___ FINDINGS: 1. Pre-TIPS right atrial pressure of 11 mm Hg and balloon-occluded portal pressure measurement of 31 mm Hg resulting in portosystemic gradient of 20 mmHg. 2. CO2 portal venogram predominantly shunted into alternative hepatic veins with minimal opacification of the portal vein. 3. Contrast enhanced portal venogram showing patent portal venous system and hepatopetal flow. 4. Post-TIPS portal venogram showing predominant flow of contrast through the TIPS. 5. Post-TIPS right atrial pressure of 14 mm Hg and portal pressure of 20 mmHg resulting in portosystemic gradient of 6 mmHg. 6. Right upper quadrant ultrasound demonstrated trace ascites, too small volume for paracentesis IMPRESSION: Successful transjugular intrahepatic portosystemic shunt placement with decrease in porto-systemic pressure gradient from 20 to 6 mmHg. DUPLEX DOPP ABD/PEL Study Date of ___ IMPRESSION: Patent TIPS in this baseline ultrasound. Velocities as reported. CT ABD & PELVIS WITH CONTRAST Study Date of ___ IMPRESSION: 1. No evidence of perforation. Air and fluid filled mildly dilated colon. 2. Patent TIPS 3. Cirrhosis and findings compatible with portal hypertension. Interval decrease in extent of abdominopelvic ascites. 4. Unchanged pancreatic hypodensities, presumably reflecting IPMNs. PORTABLE ABDOMEN Study Date of ___ IMPRESSION: Dilated colonic bowel loops measuring up to 10 cm. Evaluation for small bowel dilatation is limited. CHEST (PORTABLE AP) Study Date of ___ IMPRESSION: 1. Unchanged bibasilar opacities may represent atelectasis or pneumonia/aspiration. 2. Mild interstitial pulmonary edema. 3. Multiple dilated colonic loops. MR HEAD W & W/O CONTRAST Study Date of ___ IMPRESSION: Moderately motion limited exam. No evidence for an acute infarction or other acute intracranial abnormalities. Brief Hospital Course: BRIEF DISCHARGE SUMMARY ========================= Mr. ___ is a ___ man with PBC c/b cirrhosis (c/b esophageal varices and ascites) and schizoaffective disorder who presented from clinic with worsening abdominal distension in the setting of not taking his diuretics due to dizziness. We found that he had lost a tremendous amount of weight and was fearful of eating because of chronic constipation. Given his anorexia and significant weight loss, there was concern for malignancy. A CT torso showed no evidence of cancer. We placed a feeding tube and had it advanced post-pyloric and initiated tube feeds for nutrition. We did a TTE that showed no significant cardiac abnormalities and did two bedside paracenteses for comfort. We recommended a TIPS procedure, which was done on ___ after Mr. ___ son was able to visit from ___. His post-TIPS course was complicated by ongoing fluid overload, and septic shock secondary to spontaneous bacterial peritonitis. After discussion with his family, patient was transitioned to comfort care and was discharged to hospice. TRANSITIONAL ISSUES =================== [ ] NG tube to suction kept in place at discharge for symptom relief of colonic and intestinal distension. ACTIVE ISSUES ============= #Primary biliary cholangitis #Acute decompensated cirrhosis #Refractory ascites s/p TIPS MELD 12 and CHILDS B on admission. Presented with large volume ascites in the setting of not taking diuretics due to persistent dizziness. RUQUS showed no evidence of PVT, infectious workup was negative, and he had no signs of bleeding. He had a paracentesis in the ED to remove 2L fluid which resulted in significant improvement in symptoms. He was actively diuresed with IV furosemide, which removed significant volume clinically but caused low blood pressures (systolics ___, asymptomatic). Additional large volume paracenteses were performed for ongoing reaccumulation of ascites. Patient underwent a TIPS procedure on ___. His post-TIPS course was complicated by volume overload requiring additional diuresis, hepatic encephalopathy requiring lactulose and rifaximin, and septic shock secondary to SBP (see below). Given his poor prognosis, a discussion was held with his sister and son, and the decision was made to transition the patient to comfort care and discharge to hospice. #Septic shock #Spontaneous bacterial peritonitis #Hospital acquired pneumonia Patient developed fever, hypotension, and tachycardia, concerning for infection. Infectious workup was significant for ascites fluid with PMN>250. Patient was transferred to the ICU and maintained on pressors. Patient was started on antibiotics for SBP. Chest imaging was also concerning for a pulmonary consolidation, so he was maintained on broad spectrum Vancomycin, cefepime, and metronidazole. He was stabilized and transferred back to the general medical floor. Antibiotics were discontinued after patient was transitioned to comfort care. #Acute colonic pseudoobstruction Patient developed worsening abdominal distension and tenderness. Imaging revealed dilated colonic bowel loops measuring up to 10cm. Patient was evaluated by the surgical service, who recommended strict NPO and maintaining NG tube to suction for decompression. #Severe malnutrition #Weight loss Reported purposeful food restriction because of concern for constipation and that he was mostly drinking Ensures. His significant weight loss raised concern for malignancy and he had a CT torso, which showed no evidence of cancer. A colonoscopy was deferred given his significant improvement with treatment of his liver disease. Nutrition was consulted and a dobhoff was placed (and advanced post-pyloric) to initiate tube feeds. Tube feeds were subsequently held after development of acute colonic pseudoobstruction. #Dyspnea #Lower extremity edema Appeared significantly volume overloaded on exam with crackles in bilateral bases, subjective shortness of breath, and 2+ pitting edema to his knees bilaterally. Likely in the setting of not taking his diuretics due to persistent dizziness. His symptoms improved with diuresis and therapeutic paracentesis. BNP and TTE on admission were unremarkable so there was less concern for a cardiogenic cause of his volume overload. Given diuretic intolerance, a TIPS procedure was performed. He had ongoing peripheral edema after his TIPS that required diuresis. #Asymptomatic bacteriuria UA showed pyuria and bacteriuria but patient had no symptoms. Treatment was therefore deferred. CHRONIC ISSUES =============== #Depression #Schizoaffective disorder Continued home seroquel 100mg QHS. Psychiatry initially recommended continuing the seroquel and then follow up after discharge to consider cross downtitration with another medication as seroquel can be constipating. However, after discussion with the family, patient was transitioned to comfort care, and this plan was not undertaken. Of note, we discontinued his home lamotrigine per recommendation from his outpatient psychiatrist Dr. ___ due to conflicting reports about whether he was taking/stopping/restarting this medication. Per Dr. ___, patient is not a good candidate for lamotrigine with risk of abrupt start/stop and risk for SJS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. LamoTRIgine 100 mg PO DAILY 3. QUEtiapine Fumarate 100 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Ursodiol 500 mg PO BID 6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 7. Calcium Carbonate 500 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Polyethylene Glycol 17 g PO BID 10. Vitamin A ___ UNIT PO DAILY Discharge Medications: 1. rifAXIMin 550 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. QUEtiapine Fumarate 100 mg PO DAILY Discharge Disposition: Expired Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= ACUTE DECOMPENSATED CIRRHOSIS SECONDARY DIAGNOSES =================== PRIMARY BILIARY CHOLANGITIS LIVER CIRRHOSIS ASCITES SPONTANEOUS BACTERIAL PERITONITIS ACUTE COLONIC PSEUDOOBSTRUCTION SEPTIC SHOCK SEVERE MALNUTRITION WEIGHT LOSS ANOREXIA SHORTNESS OF BREATH LOWER EXTREMITY EDEMA ASYMPTOMATIC BACTERIURIA CONSTIPATION DEPRESSION SCHIZOAFFECTIVE DISORDER Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr ___, It was our pleasure to take care of you at ___. You came to the hospital because your abdomen was getting very big. WHAT HAPPENED IN THE HOSPITAL? - We removed extra fluid from your belly through a procedure known as a paracentesis - You had a TIPS procedure, which was done to help reduce the amount of fluid that built up in your belly - We treated you for an infection in the fluid in your belly. You were briefly in the intensive care unit because the infection made you very sick. - We placed a tube through your nose into your stomach to remove the gas and help make you feel more comfortable - We discussed with you and your family and decided to no longer perform any invasive procedures, and rather to focus on symptom management and helping you feel comfortable. - You were discharged to hospice. WHAT SHOULD YOU DO WHEN YOU LEAVE? - You should enjoy spending time with your family We wish you the best, Sincerely, Your care team at ___ Followup Instructions: ___

19998330-DS-19

DS

2178-10-15 00:00:00

2178-10-15 13:10:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ history of sleep apnea on CPAP, A. fib on Coumadin, COPD (1L O2 NC at home), diabetes on insulin, CHF presents with hypoglycemic episode after being discharged from hospital yesterday ___ after a MICU admission for hypercarbic respiratory failure. This AM, she took both her Lantus 60U and 10U of regular insulin for an AM FSG of 259, but did not eat anything b/c she was in a hurry to get to her PCP's appt. About 2 hrs after taking her insulin, she was found walking around and confused (per the daughter, however, the pt was found down in the hallway by a neighbor). EMS was called by her husband and she was found to have a fingerstick glucose of 21. She was given an amp of D50, after which her mental status improved, and her repeat blood glucose was in the 200s. She denies any recent fevers or chills; she was recently hospitalized for hypercarbic respiratory failure thought to be secondary to a COPD exacerbation, and she was intubated from ___. She was initially on ABx but they were d/c'd during hospitalization. No cough. No SOB per patient. No Abd pain/N/V/D/changes in bowel or bladder habits, no dysuria. In the ED, initial VS were: 96.2 89 134/46 20 96%. She was lethargic, but arousable, A+O x1. She had a FSBG of 71 and was given repeat D50, 290 on repeat. Repeat at 1455 was 22. She was given another amp of D50, and was started on a D5 drip. Pt was hypercarbic on ABG even when sitting up and talking. On 1L O2 NC 92-94%. On arrival to the MICU, the pt is comfortable and has no complaints. ROS negative. Pt remarked that she has never had a problem with hypoglycaemia in the past. Review of systems: Per HPI Past Medical History: - COPD on home oxygen-dependent - Obstructive sleep apnea with BiPAP at night - Type 2 diabetes mellitus, on insulin - Atrial fibrillation on coumadin - Diastolic congestive heart failure - Diverticulitis s/p colostomy, then s/p reversal - OSA, on BiPAP - Obesity - Anemia of chronic disease - Hypertension - Dyslipidemia - Chronic kidney insufficiency stage III in f/u renal ___ - GERD Social History: ___ Family History: No history of CKD, lung disease, or malignancies. Physical Exam: General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear but with macroglossia, EOMI, PERRL Neck: supple, JVP could not be assessed due to habitus CV: Regular rate and rhythm, normal S1 + S2, 2+ systolic murmur at RUS border Lungs: Clear to auscultation bilaterally but with decreased breath sounds throughout, only mild wheezes in RUL field, no crackles Abdomen: soft, non-distended; multiple surgical scars; bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. Can say days of wk backwards without difficulty. Pertinent Results: ___ 07:00AM BLOOD WBC-6.5 RBC-2.92* Hgb-7.8* Hct-26.2* MCV-90 MCH-26.8* MCHC-29.9* RDW-16.1* Plt ___ ___ 06:55AM BLOOD WBC-6.7 RBC-2.90* Hgb-7.8* Hct-26.4* MCV-91 MCH-26.8* MCHC-29.4* RDW-15.4 Plt ___ ___ 06:00AM BLOOD WBC-5.7 RBC-3.08* Hgb-8.2* Hct-28.1* MCV-91 MCH-26.5* MCHC-29.1* RDW-15.2 Plt ___ ___ 05:08AM BLOOD WBC-5.1 RBC-2.88* Hgb-7.7* Hct-26.4* MCV-92 MCH-26.9* MCHC-29.3* RDW-15.3 Plt ___ ___ 03:23AM BLOOD WBC-6.1 RBC-2.90* Hgb-7.8* Hct-26.4* MCV-91 MCH-26.7* MCHC-29.4* RDW-15.1 Plt ___ ___ 01:35PM BLOOD WBC-6.6 RBC-3.24* Hgb-8.3* Hct-29.6* MCV-91 MCH-25.6* MCHC-28.0* RDW-14.9 Plt ___ ___ 01:35PM BLOOD Neuts-72.2* ___ Monos-4.9 Eos-2.3 Baso-0.3 ___ 07:00AM BLOOD ___ PTT-49.4* ___ ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD ___ PTT-48.5* ___ ___ 07:00AM BLOOD Glucose-134* UreaN-45* Creat-1.8* Na-144 K-4.6 Cl-98 HCO3-38* AnGap-13 ___ 06:55AM BLOOD Glucose-154* UreaN-52* Creat-1.9* Na-146* K-5.0 Cl-102 HCO3-35* AnGap-14 ___ 06:00AM BLOOD Glucose-248* UreaN-61* Creat-2.0* Na-145 K-4.4 Cl-99 HCO3-36* AnGap-14 ___ 05:08AM BLOOD Glucose-120* UreaN-62* Creat-2.4* Na-143 K-4.7 Cl-100 HCO3-34* AnGap-14 ___ 03:23AM BLOOD Glucose-79 UreaN-64* Creat-1.9* Na-142 K-5.4* Cl-102 HCO3-35* AnGap-10 ___ 11:18PM BLOOD Glucose-124* UreaN-64* Creat-1.9* Na-145 K-4.8 Cl-101 HCO3-38* AnGap-11 ___ 01:35PM BLOOD Glucose-123* UreaN-68* Creat-2.1* Na-148* K-4.4 Cl-103 HCO3-35* AnGap-14 ___ 01:35PM BLOOD TSH-1.2 . ___ EKG: Atrial fibrillation with a controlled ventricular response. Left axis deviation. Left anterior fascicular block. There is a late transition with small R waves in the anterior leads consistent with possible infarction. Non-specific ST-T wave changes. Compared to the previous tracing of ___ atrial fibrillation is new. . ___ CXR: IMPRESSION: Mild pulmonary vascular congestion with small bilateral pleural effusions. Bibasilar airspace opacities may reflect atelectasis. Brief Hospital Course: ACTIVE ISSUES: ## Hypoglycemia: Most likely due to taking home dose of Lantus 60U in setting of lack of oral intake on the day of admission and mild renal failure with associated decreased insulin clearance. There was no sign of infectious etiology. TSH and AM Cortisol were normal. She was started on a D10 drip in the ICU until fingersticks stabilized. Despite excellent oral intake on the floor, her Insulin requirements initially remained relatively minimal compared to her home dose. ___ was consulted and recommended a lower dose of basal insulin at [3 uptitrated to 8 units on the day of discharge per ___ recommendations, received 5units QHS ___. They also recommended that a DDPV-4 inhibitor that does not require renal clearance and recommended linagliptin 5mg daily to start upon discharge. She should follow up with ___ upon discharge from rehab facility. Would check finger sticks QIDACHS at this time. ## Atrial fibrillation: Rate controlled and in sinus rhythm. Her INR was elevated on admission 3.2 and then increased to 4.6. Her Warfarin 6mg was held until the INR trended down and was restarted at 5mg on ___. Given that pt was supratherapeutic today ___. Her dose should be held on ___ and restarted at 3mg warfarin daily when INR is <3 (possibly on ___ with close INR monitoring. Her BB was continued at the equivalent home dose. She was discharged on her home dose. . ## Sleep apnea on CPAP: CPAP was continued at night during admission. Patient and her family spoke of the need for a new machine as the current machine is not operating correctly. CHRONIC ISSUES: ## COPD (2L O2 NC at home): Continued home nebs, maintained on supplemental O2 for goal saturation 88-90% Pt is on 1L o2 at home. ## Primary respiratory acidosis with compensatory metabolic alkalosis: Likely chronic in setting of her COPD. Respiratory status appeared stable. ## Chronic diastolic CHF: No active issues during this admission. Home cardiac meds were continued. ## Stage 3 CKD, baseline Cr 1.8: Cr upon admission was 2.1 and peaked at 2.4, which was thought to be aberrant since it rose and improved without any intervention. 1.8 on day of DC. ## Anemia: normocytic, chronic. Likely related to CKD and diabetes. Hct remained stable during admission without any transfusion requirement. Can consider further work up as an outpatient such as iron studies and colonoscopy. 26.2 on discharge. ## Glaucoma: Continued latanoprost, apraclonidin, prednisolone. TRANSITIONS OF CARE: -Per PCP, pt needs pulmonary rehab given that this is her third admission. She also needs a new CPAP machine, and per her family's report, the pt will need assistance to work through insurance and other issues in order to get the machine provided. Case mgmt and social work were consulted, and in the meantime the pt was approved for ___ skilled nursing, given concern for her ability to care for herself. She will require confirmation that she has adequate CPAP machinery at home or at ___. Pt will need close glucose monitoring while her regimen is being titrated. She will also need INR monitoring and adjustment of her warfarin dosing prn. -hydralazine increased, coumadin decreased, glargine decreased, linagliptin added to medication regimen -Pt will need PCP and ___ follow up arranged at the time of DC from rehab Medications on Admission: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Left Eye Ophthalmic DAILY (Daily). 6. Lantus 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. 7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) unit Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. 10. apraclonidine 0.5 % Drops Sig: One (1) Drop Left Eye Ophthalmic DAILY (Daily). 11. latanoprost 0.005 % Drops Sig: One (1) Drop Right Eye Ophthalmic HS (at bedtime). 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: ___ INH Inhalation every ___ hours as needed for shortness of breath or wheezing. 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) INH Inhalation twice a day. 14. warfarin 6 mg Tablet Sig: One (1) Tablet PO Q 4 pm. 15. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H 16. Home Oxygen 1 Liter/min 17. Outpatient Pulmonary Rehab 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 3. linagliptin Linagliptin 5mg daily 4. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): left eye. 8. Combivent ___ mcg/actuation Aerosol Sig: One (1) Inhalation every ___ hours as needed for shortness of breath or wheezing. 9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop Ophthalmic once a day. 10. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for HTN: increased from q8 at home. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): right eye. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. humalog sliding scale QID ACHS. Please see attached sheet 17. warfarin Please start warfarin 3mg daily when INR is <3. Please check INR ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hypoglycemia . Chronic COPD CKD HTN diastolic CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the Intensive Care Unit at ___ ___ for treatment of low blood sugar, which was likely due to taking your Insulin without eating anything the following day. The ___ saw you during this admission and recommended reducing dose of your long-acting insulin (Lantus) to 8 units daily. They also recommended that you start another medication for your blood sugar called, linagliptin 5mg daily . MEDICATION CHANGES: - Your Lantus dose was decreased from 60 units daily to 8 units daily - you were started on linagliptin - your hydralazine was increased to four times a day Followup Instructions: ___

19998330-DS-20

DS

2178-10-25 00:00:00

2178-10-25 21:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: ___ year-old woman with a history of severe COPD (1L O2 at home, baseline pCO2 = 70. Multiple recent admissions including ___ requiring intubation), OSA on CPAP, afib on coumadin, IDDM, diastolic CHF, admitted to ___ for hypercarbic respiratory failure in setting of COPD exacerbation. Of note, pt has had two recent admissions. On ___, she was admitted with hypercarbic respiratory acidosis ___ COPD exacerbation, requiring intubation. She was readmitted to ___ on ___ for hypoglycemia. This morning, pt was found at nursing home to be less arousable and with difficulty breathing. O2 sat 99% but EtCO2 low ___, started on CPAP by EMS and improved symptoms. On arrival to ED, patient confused, but reports increased SOB and difficulty breathing. Denies CP, abdominal pain, cough or recent fever. In the ED, initial VS were: BP 140s/70s, HR in ___, sating in ___ on CPAP, on arrival to ED he was switched to BiPAP at ___, 30% FiO2. Initial ABG done 10 min after started on bipap was 7.21/99/119/42. RR ___ on BiPAP, arousable, knows she's in the hospital. She was given 500mg Azithromycin and 125mg IV solumedrol. EKG shows afib with rate of 68, no STTW changes. Trop was 0.03, INR was 1.9, CBC without leukocytosis and anemia at baseline. Chem 10 pending at time of transfer. CXR showed small bilateral effusions + increase pulm vascular congestion, difficult to assess for any infiltrates. BNP was also almost 3K with baseline at 300-500. Past Medical History: - COPD on home oxygen-dependent - Obstructive sleep apnea with BiPAP at night - Type 2 diabetes mellitus, on insulin - Atrial fibrillation on coumadin - Diastolic congestive heart failure - Diverticulitis s/p colostomy, then s/p reversal - OSA, on BiPAP - Obesity - Anemia of chronic disease - Hypertension - Dyslipidemia - Chronic kidney insufficiency stage III in f/u renal ___ - GERD Social History: ___ Family History: No history of CKD, lung disease, or malignancies. Physical Exam: ADMISSION EXAM: Vitals: 98.9, 73, 180/84, rr 12, 100% 40% FiO2 General: Intubated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP difficult to assess, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: breath sounds are decreased at right base. no crackles or wheezes Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated grossly intact DISCHARGE EXAM: VS: O2 sat mid 90's on 2L, Wt 162# GEN: NAD CHEST: CTAB Pertinent Results: ___ 08:54PM TYPE-ART TIDAL VOL-380 PEEP-5 O2-30 PO2-73* PCO2-50* PH-7.46* TOTAL CO2-37* BASE XS-9 -ASSIST/CON INTUBATED-INTUBATED ___ 07:07PM TYPE-ART TEMP-36.7 ___ TIDAL VOL-350 PEEP-5 O2-40 PO2-85 PCO2-63* PH-7.37 TOTAL CO2-38* BASE XS-7 INTUBATED-INTUBATED ___ 06:49PM GLUCOSE-220* UREA N-55* CREAT-2.1* SODIUM-136 POTASSIUM-5.9* CHLORIDE-96 TOTAL CO2-26 ANION GAP-20 ___ 06:49PM CALCIUM-9.6 PHOSPHATE-4.1 MAGNESIUM-2.0 ___ 06:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 06:45PM URINE RBC-7* WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-<1 ___ 06:45PM URINE HYALINE-5* ___ 06:45PM URINE WBCCLUMP-RARE MUCOUS-RARE ___ 03:28PM LACTATE-1.0 ___ 02:43PM ___ PO2-83* PCO2-114* PH-7.17* TOTAL CO2-44* BASE XS-8 COMMENTS-GREEN TOP ___ 02:42PM TYPE-ART PO2-119* PCO2-99* PH-7.21* TOTAL CO2-42* BASE XS-7 INTUBATED-NOT INTUBA ___ 02:30PM GLUCOSE-193* UREA N-53* CREAT-2.1* SODIUM-141 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-37* ANION GAP-13 ___ 02:30PM cTropnT-0.03* ___ 02:30PM proBNP-___* ___ 02:30PM WBC-6.5 RBC-3.02* HGB-7.9* HCT-27.9* MCV-92 MCH-26.1* MCHC-28.2* RDW-15.1 ___ 02:30PM NEUTS-76.3* LYMPHS-16.7* MONOS-4.6 EOS-1.8 BASOS-0.5 ___ 02:30PM PLT COUNT-397 ___ 02:30PM ___ PTT-50.6* ___ ___ 05:32AM BLOOD ___ pO2-243* pCO2-70* pH-7.35 calTCO2-40* Base XS-10 ___: BLOOD CULTURES: NO GROWTH TO DATE ON DAY OF DISCHARGE ___: URINE CULTURE: Negative ___: MRSA SCREEN: Negative CXR ___: Pulmonary edema, small bilateral effusions. If there is oncern for pneumonia, recommend repeat chest radiograph post-diuresis. ECHO ___: IMPRESSION: Moderate LVH, normal regional LV wall motion, and hyperdynamic LV systolic function. No significant valvular disease. Moderate pulmonary hypertension. Compared with the findings of the prior study (images reviewed) of ___, there is moderate pulmonary hypertension but no evidence of resting LVOT obstruction. The rest of the findings are similar. Brief Hospital Course: ___ year-old woman with severe COPD, OSA, afib, chronic diastolic heart failure was admitted for acute hypercarbic respiratory failure in the setting of her home BIPAP machine not functioning properly. She was intubated in the ED and admitted to the ICU. She quickly improved and was extubated the next day. Antibiotics, steroids, and furosemide were stopped because her presentation was not consistent with pneumonia or COPD flare. She was stable while on BIPAP and then she was transferred to the floor. On the floor she was at her baseline. She was discharged with a new, functional BIPAP machine. # Hypercarbic respiratory failure. ABG revealed peak pCO2 114. She improved with intubation and mechanical ventilation. # Severe COPD: Peak pCO2 114. Per pulmonary sleep service, she should be on BIPAP with backup rate. Continue advair and other regular inhalers and nebulizers. Patient will be seen in ___ clinic with close follow-up. # Mild acute diastolic heart failure. CXR revealed mild pulmonary vascular congestion. She was given some IV lasix while in the ICU. On the floor she was euvolemic and continued on her PO lasix. Continue benazepril and metoprolol. # Atrial fibrillation: Rate controlled, in afib. Pt was subtherapeutic on admission with INR of 1.9. Of note, during admission of ___, her home dose was decreased from 5mg to 3mg daily. When INR dipped below 2.0, warfarin was increased back to 5mg daily # Sleep apnea on BiPAP # Stage 3 CKD, stable. # Anemia: normocytic, chronic. At baseline. # Glaucoma: Continued latanoprost, apraclonidin, prednisolone. # DM type II, on insulin, uncontrolled with complications, stable # Code status: Full code TRANSITIONAL ISSUES: - INR re-check on ___ - F/u in ___ clinic - Consider pulmonary rehab - F/u Blood cultures ___ Medications on Admission: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 3. linagliptin Linagliptin 5mg daily 4. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): left eye. 8. Combivent ___ mcg/actuation Aerosol Sig: One (1) Inhalation every ___ hours as needed for shortness of breath or wheezing. 9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop Ophthalmic once a day. 10. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for HTN: increased from q8 at home. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): right eye. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. humalog sliding scale QID ACHS. Please see attached sheet 17. warfarin Please start warfarin 3mg daily when INR is <3. Please check INR ___ Discharge Medications: 1. BiPAP Machine BiPAP ST ___ with backup rate of 8 with humidification and 3L O2 titrated, Fisher and Paykel FFM, ICD9: 518.83 (chronic respiratory failure). 2. Oxygen Continuous oxygen ___ Liters/min for portability, pulse dose system. Goal O2 sat 88-92%. ICD9: 491.21 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 5. linagliptin 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 8. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 9. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 10. Combivent ___ mcg/actuation Aerosol Sig: One (1) inhalation Inhalation every ___ hours as needed for shortness of breath or wheezing. 11. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 17. Humalog 100 unit/mL Solution Sig: sliding scale as directed Subcutaneous QAC and QHS. 18. warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 19. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 20. Outpatient Lab Work Check INR ___. Please fax the results to your PCP, ___. ___ at ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: - Acute hypercarbic respiratory failure SECONDARY DIAGNOSES: - Chronic obstructive pulmonary disease - Obstructive sleep apnea - Chronic diastolic heart failure - Atrial fibrillation - Chronic kidney disease, stage III - Anemia - Diabetes mellitus type II on insulin - Glaucoma 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 with respiratory failure and required intubation (breathing tube) with mechanical ventilation. The breathing tube was removed when you improved and you were then further treated with BiPAP for your chronic respiratory conditions. HEART FAILURE MANAGEMENT INSTRUCTIONS: Weigh yourself every morning. Call your doctor if your weight goes up more than 3 lbs above your baseline (or lowest regular) weight. COPD AND SLEEP APNEA INSTRUCTIONS: Use your BiPAP machine every night while you sleep. ANTICOAGULATION INSTRUCTIONS: You should go to the laboratory to have your INR re-checked on ___ at the ___ when you come in for your ___. Have the lab fax the results should be faxed to your PCP, ___ at ___. MEDICATION CHANGES: - STOPPED Hydralazine - No other changes were made to your medication regimen. Followup Instructions: ___

19998350-DS-4

DS

2128-02-22 00:00:00

2128-02-24 09:30:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old gentleman with DMII and hypertension presented with Substernal chest pain associated with SOB since the night prior to day of admission, on/off for few seconds, worse with movement or exertion. Reproducible pain with palpation of right chest wall whenever having the pain. No history of chest trauma. No diaphoresis, pain radiation or coughing. No presyncope or symptoms with exertion. No PND, orthopnea or lower extremity swelling. He has history of prior stress test in ___, reportedly normal per in Atrius records. No prior history of similar symptoms. . In the ED, initial vitals were 98.2 73 135/68 20 99% he reported pain ___. Labs and imaging significant for Cr 1.0, Trop < 0.01 x1, EKG showed NSR at 74 with LAE, LVH with strain, TWI in II, II, aVL, V4-V6. Compaired with prior ___, TWI in V4-V6 appear deeper. Her CXR showed moderately enlarged cardiac silhouette (likely LVH), no CHF, no PTX; Patient given ASA 325mg, Nitro 0.4mgSL x2 without improvment in pain, the then developed headache, he was given morphine 4mg IV with improvment in chest pain, now only with chest pain when moving. Cards seen the patient in the ED and recommended admission on telemetry for observation with stress test. . Vitals on transfer were 98.1,79, 122/70, 19, 98%RA . On arrival to the floor, patient had 2 episodes of ___ seconds of right lower chest pain that resolved spontaneously, otherwise no complaints. . 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, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Chronic intractable pain Colonic Adenoma Vitamin D Deficiency OBESITY - MORBID ANEMIA, UNSPEC SLEEP APNEA ASTHMA Impulse control disorder Social History: ___ Family History: Father Cancer; ___ - Unknown Type; Hypertension Mother Alive CAD/PVD Physical Exam: Admission physical exam: VS: T=98 BP=154/79 HR=80 bpm regular, RR= 14 O2 sat=100%RA GENERAL: obese ___ gentleman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 4 cm above sternal angle at 45 degrees. CARDIAC: normal RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. obese. No HSM or tenderness. + BS EXTREMITIES: No c/c/e. PULSES: Right: Carotid 2+ DP 2+ ___ 2+ Left: Carotid 2+ DP 2+ ___ 2+ . Discharge physical exam: VS: T=98.2 BP=144/81 (120's-150's/___'s-___'s), HR=67 (___) bpm regular, RR= 14 O2 sat=96%RA GENERAL: obese ___ gentleman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 4 cm above sternal angle at 45 degrees. CARDIAC: normal RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. obese. No HSM or tenderness. + BS EXTREMITIES: No c/c/e. PULSES: Right: Carotid 2+ DP 2+ ___ 2+ Left: Carotid 2+ DP 2+ ___ 2+ Pertinent Results: CBC: ___ 08:45AM BLOOD WBC-5.6 RBC-4.97 Hgb-13.1* Hct-39.8* MCV-80* MCH-26.3* MCHC-32.8 RDW-13.4 Plt ___ . Blood chemistry: ___ 08:45AM BLOOD Glucose-109* UreaN-14 Creat-1.0 Na-143 K-4.6 Cl-107 HCO3-30 AnGap-11 ___ 06:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9 . Cardiac markers: ___ 01:50PM BLOOD CK-MB-6 cTropnT-<0.01 ___ 08:45AM BLOOD cTropnT-<0.01 ___ 08:45AM BLOOD CK-MB-7 ___ 08:45AM BLOOD CK(CPK)-594* ___ 01:50PM BLOOD CK(CPK)-557* . Stress echo ___ The patient exercised for 7 minutes and 0 seconds according to a Modified ___ treadmill protocol ___ METS) reaching a peak heart rate of 130 bpm and a peak blood pressure of 160/90 mmHg. The test was stopped at the patient's request. This level of exercise represents a poor exercise tolerance for age. In response to stress, the ECG showed non-diagnostic ST changes in the setting of baseline abnormalities (see exercise report for details). There is resting mild hypertension. The blood pressure response to stress was blunted. Target heart rate was not achieved. Echo images were acquired within 53 seconds after peak stress at heart rates of 127 - 98 bpm. These demonstrated appropriate augmentation of all left ventricular segments. There was augmentation of right ventricular free wall motion. IMPRESSION: Poor functional exercise capacity. Non-diagnostic ECG changes in the setting of baseline abnormalities and the absence of 2D echocardiographic evidence of inducible ischemia to achieved workload. Resting hypertension. Abnormal hemodynamic response to physiologic stress (blunted blood pressure response). Target heart rate not achieved. Mild symmetric left ventricular hypertrophy . Stress Test report ___: INTERPRETATION: This ___ yo man with h/o HTN, NIDDM, former smoker, obesity, and family h/o premature CAD was referred to the lab for evaluation of chest discomfort. The patient exercised for 7 minutes of a Modified ___ protocol and was stopped at the patient's request for fatigue. The peak estimated MET capacity was 4.9, which represents a poor exercise tolerance for his age. There were no reports of chest, back, neck, or arm discomforts during the study. There were marked TWI in the inferolateral leads at baseline, which did not normalize with exercise. At peak exercise, there was 0.5-1 mm ST segment depression in the inferolateral leads, resolving back to baseline by 2 minutes of recovery. Rhythm was sinus with no ectopy. The heart rate response was appropriate during exercise and recovery. Mild resting hypertension with a blunted blood pressure response during exercise. IMPRESSION: In the presence of baseline STT abnormalities, non-specific EKG changes in the absence of anginal type symptoms at a moderate cardiac demand and poor functional capacity. Blunted blood pressure response to exercise in the setting of baseline hypertension. Study limited by patient's request. Echo report sent separately. Brief Hospital Course: ___ year old gentleman with DMII and hypertension presented with reproducible right lower sternal chest pain, negative troponins and normal exercise test in ___, found to have slightly deeper T wave inversions in V4-V6, was admitted to rule out ACS and to have stress test. Stress echo was pursued which was not very conclusive, however not concerning of coronary artery disease. Discharged home in stable condition. . # CORONARIES: normal exercise test per report in ___. chest pain atypical, very brief, reproducible. Tpn x2 negative. EKG changes slightly worse given the worsened TWI in v4-v6. Atenolol was held prior to ___ test. Stress echo was not very conclusive (please see results section). We continued amlodipine and hydrochlorothiazide for hypertension. Atenolol was resumed on discharge after the stress test. We did not initiate statin given his LDL in ___ was < 100. He is not no ACEi given severe nausea in the past. . # DM-II: well controlled, last HA1c is 6.6%, on metformin. We held metformin while in hospital and placed him on insulin sliding scale. Metformin was resumed on discharge. . # Hypertension: on amlodipine and atenolol and HCTZ at home. Held atenolol as above. Medications on Admission: -Cholecalciferol (Vitamin D3) 1,000 unit Cap 1 (One) Capsule(s) by mouth once a day -Hydrochlorothiazide 25 mg Tab 1 (One) Tablet(s) by mouth once a day -Amlodipine 10 mg Tab 1 (One) Tablet(s) by mouth once a day -atenolol 25 mg Tab Oral 1 Tablet(s) Once Daily -metformin 500 mg Tab Oral 1 Tablet(s) Once Daily -Sildenafil (VIAGRA) 100 mg Oral Tablet (occasional use, last use ___ month ago) -Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA Aerosol Inhaler inhale 2 puffs by mouth every 4 to 6 hours AS NEEDED Discharge Medications: 1. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 6. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for erectile dysfunction: occasional use. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation every ___ hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Chest pain - muskuloskeletal Hypertension . Secondary Diagnoses: Diabetes Anxiety Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, . It was great pleasure taking care of you as your doctor. . As you know you were admitted to ___ ___ chest pain. Your pain is believed to be muskuloskeletal and not from your heart given the description of your pain. . You had a stress echo test which was not very conclusive. However, the findings were not concerning of heart vessel disease. . We did not make changes in your medication list. Please continue to take them the way you were taking prior to admission. . Please follow with your appointment as illustrated below. Followup Instructions: ___

19998444-DS-11

DS

2155-06-10 00:00:00

2155-06-12 16:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo w/ETOH pancreatitis presents with abd pain and nausea consistent with pancreatitis flare. Pt was dx in ___ with chronic pancreatitis. Followed with GI (Dr. ___ and has had stent placement in the past. However last stents in ___ increased his pain and were removed. He has been having increasing frequency of flares for several months requiring multiple admissions to multiple hospitals, most recently admitted to ___ and discharged 3 days ago. Was tolerating PO at that time and discharged with plan to get second opinion from BID as outpatient. However on the day of admission pt developed nausea and epigastric pain which radiates to his back. Denies emesis, diarrhea, constipation, CP, SOB. Pt does endorse an 80lb unintentional weight loss over the past year which has not yet been evaluated. All other ROS negative except as above. Past Medical History: -chronic ETOH pancreatitis -h/o alcohol abuse, no use since ___ -GERD -Hirshprung's -- s/p colectomy as infant -Multiple Hernias with repair in ___ and ___ -Tremor -DJD of back -- s/p L4&L5 laminectomy -depression/axiety Social History: ___ Family History: mom w/GERD Physical Exam: Admission PE VS 97.6 72 162/98 95% on RA Pain ___ GEN: nad, lying in bed HEENT: op clear, mmm NECK: no LAD, supple CHEST: ctab SKIN: no rashes or bruises CV: rrr no m/r/g ABD: hypoactive BS, nondistended, soft, tender RUQ EXT: wwp, no e/c/c NEURO: alert, answers questions apprpropriately, moving all extremities PSYCH: appropriate, cooperative . Discharge PE VSS General: AAOX3, somewhat tired but otherwise wnl Abdomen: active BS X4, no HSM, mild point TTP in the right periumbilical area Pertinent Results: ___ 09:50PM GLUCOSE-119* UREA N-16 CREAT-0.7 SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 ___ 09:50PM ALT(SGPT)-52* AST(SGOT)-27 ALK PHOS-67 TOT BILI-0.3 ___ 09:50PM LIPASE-45 ___ 09:50PM WBC-10.5 RBC-5.24 HGB-15.6 HCT-46.2 MCV-88 MCH-29.7 MCHC-33.7 RDW-13.7 . RUQ US ___ IMPRESSION: 1. No sonographic evidence of cholelithiasis. 2. Splenomegaly. . AXR ___ IMPRESSION: Dilated loops of small and large bowel, concerning for possible cecal volvulus. Recommend followup CT scan to further characterize. These findings were communicated with Dr. ___ at 4:50 p.m. today. . ___ CXR IMPRESSION: No acute cardiopulmonary process. No evidence of free air. . CT AP ___ IMPRESSION: 1. No acute abdominal pathology, especially no evidence of bowel obstruction. 2. No CT evidence of acute or chronic pancreatitis. . Scrotal US ___ IMPRESSION: Normal scrotal ultrasound without evidence of testicular mass or torsion. . ___, RF and ANCA negative . Hepatitis A, B and C serologies negative . TTG-negative . ___ 06:10 IGG SUBCLASSES 1,2,3,4 Test Result Reference Range/Units IMMUNOGLOBULIN G SUBCLASS 1 310 L 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 208 L 241-700 mg/dL IMMUNOGLOBULIN G SUBCLASS 3 57 ___ mg/dL IMMUNOGLOBULIN G SUBCLASS 4 16.6 4.0-86.0 mg/dL IMMUNOGLOBULIN G, SERUM 639 L ___ mg/dL . Porphobilinogen Screen NEGATIVE . ___ 7:38 am SEROLOGY/BLOOD CHEM# ___ ___. **FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). . TFT's wnl . Brief Hospital Course: ___ yo w/ previous diagnosis of ETOH pancreatitis presents with nausea and abdominal pain consistent with pancreatitis flare with a normal lipase and CT showing no evidence of chronic pancreatitis. . # Abdominal pain with prior diagnosis of alcoholic related chronic pancreatitis: The patient has a history of abdominal pain and a diagnosis of pancreatitis going back to ___ which prior to this admission has been managed by outside providers. He has had an increase in his flares recently and this has caused him to go to multiple hospitals for this. As evidence by the records obtained from his outside GI physician, ___ has had several stents placed with varying degrees of success. He has also had imaging done outside that has not shown findings consistent with chronic pancreatitis. As a result, the differential diagnosis of his abdominal pain was broadened to include cecal volvulus, constipation related, acute intermittent porphyria, autoimmune vasculitis or SLE/RA related, hernia related, PUD or IBS/IBD. GI was consulted in house and advised checking a TTG for celiac disease (negative) ESR/CRP (CRP was elevated) and IGG4 for autoimmune pancreatitis (negative). Due to persistent abdominal pain, the patient got a plane film abdominal XR which showed findings suggestive of cecal volvulus. A CT of the abdomen and pelvis was obtained which was negative for an acute process. These films were reviewed with the radiologist to evaluate a narrowed and dilated segment near the patients prior colostomy but they felt this was just several slices missed in the CT scanner. The patient also had a RUQ US which was wnl. Hepatitis serologies, RF, ___ and ANCA were also done and were negative. H. pylori serology was negative. The patient endorsed persistent pain and was treated with a morphine pca for several days and made npo and given IV fluids. The patients pain marginally improved. His diet was slowly advance, which he tolerated well. He was discharged home on a bland diet and a PPI BID. He should follow closely with a pancreas specialist for further evaluation. . # History of alcoholism with persistent pain without an obvious organic cause: The patient reports not using alcohol since ___. The patients family voiced some concerns about narcotic/opioid dependence. In addition, after extensive evaluation and conservative management, the patient was still requiring high dose of IV morphine (in the 200-300 mg IV range in 24 hours) from his PCA without any obvious cause. The pain service was consulted and they advised using gabapentin, Tylenol and discontinuing the pca and using both long and short acting morphine. The day following removal of the PCA, the patient had a minimal narcotic requirement. Thus, he was sent home with just short acting morphine for breakthrough pain in addition to a lower dose of gabapentin to prevent sedation. He was also sent home with NSAID's, tramadol and a bowel regimen. . # Urinary retention The patient has had issues with this in the past without any obvious cause. His retention was exacerbated with his high narcotic use. A Foley needed to be placed. The patient was weaned off his narcotics and his Foley was then taken out. He was able to urinate on his own . # Schistocytes on automated smear and persistent abdominal pain with weight loss The hematology/oncology service was consulted for further evaluation of an occult malignancy vs. a hematologic process that was causing the patients symptoms. The patients smear was reviewed by the hematology team and it was negative for schistocytes. They recommended checking urine PBG (was negative) and a testicular US for occult malignancy (negative). Can consider checking 24 hr urine test for ALA, PBG, and total porphyrins as an outpatient. LDH was also normal and the patients smears did not show any signs of MDS or myeloproliferative disorder. . # Dysthymia The patient endorsed depressed mood without SI or HI. Psychiatry was consulted per pain recommendations and they recommended d/c of the patients hydroxyzine and starting Remeron at night. The patient should follow up with his psychiatrist as an outpatient. . # Transitional Issues: -Follow up with PCP ___ ___ weeks, Psychiatry in ___ weeks and GI in ___ weeks . Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Duloxetine 60 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Creon 12 1 CAP PO TID W/MEALS 4. HydrOXYzine 50 mg PO QHS:PRN insomnia 5. Propranolol 10 mg PO TID 6. Nicotine Patch 21 mg TD DAILY Discharge Medications: 1. Duloxetine 60 mg PO DAILY 2. Omeprazole 20 mg PO BID 3. Creon 12 1 CAP PO TID W/MEALS 4. Propranolol 10 mg PO TID 5. Nicotine Patch 21 mg TD DAILY 6. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*100 Tablet Refills:*0 7. Bisacodyl 10 mg PO DAILY:PRN Constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 9. Finasteride 5 mg PO DAILY RX *finasteride 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 11. Ibuprofen 600 mg PO Q8H:PRN moderate pain RX *ibuprofen 200 mg 3 tablet(s) by mouth every eight (8) hours Disp #*100 Tablet Refills:*0 12. Mirtazapine 7.5 mg PO HS RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 13. Morphine Sulfate ___ 15 mg PO Q6H:PRN severe pain RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a day Disp #*30 Packet Refills:*0 15. Tamsulosin 0.4 mg PO HS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*30 Tablet Refills:*0 16. TraMADOL (Ultram) 50 mg PO Q8H:PRN moderate pain RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: acute on chronic abdominal pain of unknown etiology, possibly due to fecal loading and constipation . Secondary Diagnosis: Depression Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for management of acute on chronic abdominal pain, and you improved with IVF, bowel rest, and pain control. You saw the GI physicians during your course and got a CT scan which did not show any acute changes. You were also seen by the Hematology team who recommended a scrotal ultrasounds. This was also normal. You were able to tolerate a diet, your pain was controlled on by mouth medications and were agreeable to discharge. You should follow up with your physicians as scheduled below. . Medication Changes: 1) please stop your hydroxyzine 2) remeron 7.5 QHS 3) tylenol ___ Q8H standing for pain 4) ibuprofen 600 Q6H prn mild pain 5) gabapentin 300 TID, standing for pain 6) tramadol 50 Q6H prn moderate pain 7) morphine ___ 15 mg PO Q6H prn severe pain 8) docusate 100 mg BID, standing for constipation 9) miralax 17 g QD prn, please take when no BM X2 days 10) bisacodyl 10 mg QD prn, please take when no BM X 2 days 11) finasteride 5 QD for urinary retention 12) flomax .4 QD, for urinary rention Followup Instructions: ___

19998444-DS-13

DS

2156-01-15 00:00:00

2156-01-15 23:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid Attending: ___. Chief Complaint: Abdominal pain, alcohol binge Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. ___ is a ___ man with a h/o childhood Hirshsprung's s/p resection, EtOH abuse, and GERD with multiple recent hospitalizations for recurrent abdominal pain, who p/w periumbilical abdominal pain after an alcohol binge. He said the pain began yesterday evening after he drank ___ beers and several glasses of hard liquor as a way of coping with stress. He reports a history of chronic pancreatitis s/p ERCP with stent placement that transiently improved his symptoms. He had a second ERCP with sphincterotomy and biliary/PD stent placement, but had the stents removed when his postprandial abdominal pain did not resolve. He has had numerous CTs, MRIs, and MRCPs at many different hospitals per outpatient GI docs report without evidence for acute or chronic pancreatitis on those evaluations. Last hospitalization for abdominal pain was in ___ at ___ for which he was conservatively managed with analgesia and IVFs with subsequent improvement and resolution of symptoms. Of note, he also says he underwent an inguinal hernia repair ___ one to date) on ___ at an OSH c/b immediate readmission for abdominal pain. On admission, he reports inability to tolerate POs, with some intermittent constipation, but no D/N/V/F/C. No AH/VH/SI/HI. Last bowel movement was yesterday and was nonbloody. No CP/SOB/F/C. In the ED, initial vitals: 8 96.8 101 128/77 20 96% RA. He was given IVF, pain control, and made NPO with negative RUQ u/s for any e/o CBD dilatation or gallstones. However there was splenomegaly. Transfer vitals were: Vitals prior to transfer: 7 98.1 72 142/70 18 100%. On arrival to the floor, still c/o epigastric abdominal pain ___. No N/V/F/C. No tremors or AH/VH/SI/HI. Last bowel movement was yesterday and was nonbloody. Past Medical History: -h/o alcohol abuse, no use since ___ -GERD -Hirshprung's -s/p colectomy as infant -Multiple Hernias with repair in ___ and ___ -Tremor -DJD of back -s/p L4&L5 laminectomy -depression/axiety -inguinal hernia repair in ___ Social History: ___ Family History: mother w/GERD Physical Exam: PHYSICAL EXAM: VS - Temp 97.8 F, BP 118/65, HR 86, R 16, O2-sat 94%RA GENERAL - NAD, A&Ox3 HEENT - NC/AT, EOMI, sclerae anicteric, dry MM NECK - supple, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft, TTP over supraumbilical area, R costal margin, and inguinal area. Well-healed surgical scars. No rebound/guarding, no CVAT. EXTREMITIES - WWP 2+ peripheral pulses bilaterally, no c/c/e. SKIN - no concerning rashes or lesions, all existing scars were free of any evidence of disease. NEURO - CNII-XII grossly intact, motor function grossly normal. Pertinent Results: ___ 08:15AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 07:08AM LACTATE-2.1* ___ 06:28AM GLUCOSE-119* UREA N-14 CREAT-0.7 SODIUM-146* POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-22 ANION GAP-20 ___ 06:28AM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-83 TOT BILI-0.2 ___ 06:28AM LIPASE-35 ___ 06:28AM ALBUMIN-4.4 CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.2 ___ 06:28AM ___ ___ 06:28AM WBC-8.5 RBC-5.01 HGB-14.9 HCT-45.2 MCV-90 MCH-29.7 MCHC-33.0 RDW-13.2 ___ 06:28AM NEUTS-55.1 ___ MONOS-5.6 EOS-5.9* BASOS-1.3 ___ 06:28AM PLT COUNT-205 Imaging IMPRESSION: 1. Normal gallbladder and CBD. 2. Splenomegaly. Brief Hospital Course: ___ man with a h/o childhood Hirshsprung's s/p resection, EtOH abuse, and GERD who p/w periumbilical abdominal pain after an alcohol binge. # Abdominal Pain: Patient was admitted on ___ for epigastric abdominal pain after alcohol binge, without evidence of acute pancreatitis clinically, on imaging or by laboratory studies (CBC, lipase, LFTs, LDH wnl on admission). No AH/VH/tremors. No hernias on exam. In the ED, he was started on IVF, pain control with IV morphine, and made NPO for bowel rest. RUQ u/s was performed and was negative for CBD dilatation or gallstones. His symptoms improved with pain control with oxycodone 5 mg, and we advanced his diet gradually from clears to regular diet, which he tolerated well. # Substance abuse/dependence: Recurrent lapses of alcohol binging followed by acute abdominal pain, but no h/o withdrawal seizures. Binge drinking as a way to cope with stressors at home. Patient endorses a history of EtOH abuse, with recent rebounding of multiple episodes of abuse. There is a history of opiate abuse as well. He did not exhibit any symptoms of withdrawal during his hospitalization from ___, and was scoring a CIWA of 0. He was supplemented with folate, thiamine, and MVI. # h/o urinary retention during prior hospitalizations. Patient reported that foley catheter was helpful in the past. Given his history of urinary retention, we monitored daily his I/Os with special attention to UOP. # Depression/Anxiety: No SI or HI on admission. Reports intermittently taking cymbalta at home due to insurance issues. We continued him on his cymbalta with good effect. # GERD: Patient has a history of GERD. We continued him on his home PPI during his hospitalization. Transitional Issues: 1. f/u with Gastroenterology re: recurrent abdominal pain 2. f/u with PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Creon 12 1 CAP PO TID W/MEALS 5. Duloxetine 60 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Creon 12 1 CAP PO TID W/MEALS 3. Duloxetine 60 mg PO DAILY 4. Gabapentin 300 mg PO BID 5. Omeprazole 20 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 7. Multivitamins 1 TAB PO DAILY RX *multivitamin [Chewable Multi Vitamin] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 8. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care at ___ ___. You came in with abdominal pain. While you were here, we controlled your pain, gave you fluids, and had you not eat to allow your bowel to rest. You improved with pain control, fluids, and bowel rest such that you were able to tolerate food without increased pain. There were no concerning events on your abdominal ultrasound and lab testing was all reassuring. It is important that you do not consume alcohol, as this can trigger these episodes of abdominal pain. We would like you to follow up with gastroenterology and PCP following your discharge for further management and evaluation of your recurrent abdominal pain. No changes were made to your home medications. Sincerely, Your ___ Care Team Followup Instructions: ___

19998497-DS-7

DS

2144-01-17 00:00:00

2144-01-17 15:36:00

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 hip pain Major Surgical or Invasive Procedure: ___ L hip TFN History of Present Illness: ___ with PMH significant for R THA ___ ___ at ___) complicated by perioperative MI and ___ 6 presents as OSH transfer complaining of L hip pain. Patient was attempting to use the bathroom at approximately 630PM tonight when she missed the toilet bowl and fell onto her L hip. She denies headstrike or LOC and experienced immediate onset of L hip pain. She was taken initially to ___ in ___ where ED workup included L hip films that reportedly revealed a L intertrochanteric hip fracture. She was subsequently transferred to ___ for further management. Past Medical History: Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension . Percutaneous coronary intervention, in ___, anatomy as follows: 3VD CAD s/p NSTEMI with BMSx2 to LCx and RCA (___), rota-ablation and DES to mid LAD on (___), DES to mid RCA (___), DES to diagonal-2 and OM-2 (___). . Additional Past Medical/Surgical History: - Hyperlipidemia - Hypertension - Diabetes, type II - CRI (baseline creatinine 1.3-1.4) - Peripheral arterial disease - Paget's disease - Osteoporosis - Arthritis - Mild Mitral Valve Prolapse - S/P cataract surgery - S/P right hip replacement on ___ - Hysterectomy Social History: ___ Family History: No family history of heart disease. Lung ca in father, gastric cancer in mother. Sister with angina now s/p pacemaker. Son alive and healthy. Physical Exam: admit: GEN: Well appearing, NAD AVSS Left lower extremity: Skin intact Tenderness to palpation appreciated over the anterior and lateral hip Pain with movement of the LLE ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused d/c: GEN: Well appearing, NAD AVSS Left lower extremity: incision c/d/i ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Pertinent Results: ___ 11:29AM URINE HOURS-RANDOM ___ 11:29AM URINE UHOLD-HOLD ___ 01:40AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 01:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 01:40AM URINE RBC-1 WBC-60* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 12:40AM GLUCOSE-197* UREA N-46* CREAT-1.4* SODIUM-141 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17 ___ 12:40AM estGFR-Using this ___ 12:40AM CK(CPK)-133 ___ 12:40AM CK-MB-6 cTropnT-<0.01 ___ 12:40AM WBC-12.4*# RBC-2.92* HGB-9.0* HCT-27.6* MCV-95# MCH-30.7 MCHC-32.4 RDW-13.3 ___ 12:40AM NEUTS-88.2* LYMPHS-7.9* MONOS-2.8 EOS-0.7 BASOS-0.3 ___ 12:40AM PLT COUNT-171 ___ 12:40AM ___ TO PTT-UNABLE TO ___ TO 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 hip fx and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L hip TFN, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. Pt w some word finding difficulty AM of POD1 - head CT at that time was negative, likely delayed anesthetic effect. Pt also w anemia at baseline, exacerbated by surgery - was transfused 1u PRBC intraoperatively as well as 2u PRBC post-operatively with appropriate bump in Hct which then remained stable. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is WBAT in the LLE, and will be discharged on lovenox 40mg x2wks for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO DAILY 4. Aspirin 81 mg PO BID 5. Vitamin D 1000 UNIT PO DAILY 6. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO BID 2. Atenolol 50 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Rosuvastatin Calcium 40 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Acetaminophen 1000 mg PO Q8H 8. Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Days 9. Enoxaparin Sodium 40 mg SC Q24H Duration: 2 Weeks Start: Today - ___, First Dose: Next Routine Administration Time 10. Senna 1 TAB PO BID 11. Milk of Magnesia 30 ml PO BID:PRN Constipation 12. Polyethylene Glycol 17 g PO DAILY 13. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: L intertrochanteric hip fracture Discharge Condition: stable Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - WBAT LLE Physical Therapy: Activity: Activity: Out of bed w/ assist Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: Site: L HIP Description: s/p l HIP TFN, CDI Care: Daily dressing changes Followup Instructions: ___

19999068-DS-14

DS

2161-09-02 00:00:00

2161-09-02 14:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: alcohol withdrawal, delirium tremens Major Surgical or Invasive Procedure: endotracheal intubation ___ History of Present Illness: Pt is a ___ yo male with a h/o etoh abuse transferred from ___ ___ for etoh withdrawal and question of intraventricular hemorrhage. Pt was found down with a right forehead abrasion and reported at the OSH that he tripped and fell on pavement. He denies any loss of consciousness. Head and C-spine at the OSH were concerning for possible intraventricular hemmorhage. He was hypertensive, tachycardic and hyperpertensive and there was concern for alcohol withdrawal and he was given 1 mg of ativan at the OSH before transfer. His potassium was also found to be 2.9 and he was given 40 mEq K in his IVF. . On arrival to ___, his initial VS were 150, RR: 22, BP: 152/93, O2Sat: 97 on 2 L NC. He was tremulous and agitated requiring 5 people to place him in restraints. In the ED he was given 28 mg of IV lorazepam within the first 30 minutes. He received a total of 36 mg iv lorazepam. His OSH head showed focal rounded area of hyperdenisity within temporal horn of L lateral ventricle, may represent acute IV hemorrhage.Neurosurgery evaluated the pt and recommended loading with dilantin 750 mg iv x1. He also received IVF with thiamine and folic acid. Repeat K here was 3.6. Prior to transfer his, BP dropped to 50/57 and his dilantin infusion was slowed. His VS prior to transfer were: 98 °F, P: 67, RR: 15, BP: 89/58, O2 Sat 100% on 2 L NC. . On arrival to the ICU, patient was tremulous, unable to assess for pain. Past Medical History: EtOH dependence, h/o withdrawal Hypertension GERD HCV Social History: ___ Family History: noncontributory Physical Exam: On admission: Vitals: T: 96.9 BP: 133/82 P: 95 R: 10 O2: 98% 2L NC General: tremulous on arrival and mumbled speech then obtunded HEENT: large contusion over right forehead, Sclera anicteric, dry MM, oropharynx clear Neck: c- collar in place Lungs: Clear to auscultation over anterior chest 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 Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Pupils 3 mm ->1 mm bilaterally, equally reactive, initially moving all extremites with tremor, then with rest, withdraws to pain equally in all extremities . Pertinent Results: ADMISSION LABS: ___ 03:45AM BLOOD WBC-6.1 RBC-3.67* Hgb-12.3* Hct-36.8* MCV-100* MCH-33.6* MCHC-33.4 RDW-12.2 Plt ___ ___ 03:45AM BLOOD Neuts-78.9* Lymphs-11.9* Monos-8.3 Eos-0.2 Baso-0.7 ___ 03:45AM BLOOD ___ PTT-27.3 ___ ___ 03:45AM BLOOD Glucose-139* UreaN-7 Creat-0.8 Na-136 K-3.6 Cl-100 HCO3-22 AnGap-18 ___ 03:45AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.4* TOXICOLOGY: ___ 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LABS: MICROBIOLOGY: MRSA SCREEN: NEGATIVE IMAGING: ___ CXR: Compared to the previous radiograph, there is a subtle right medial and basal opacity, consistent with aspiration in the appropriate clinical setting. Otherwise, unchanged normal chest radiograph with normal size of the cardiac silhouette. The observation was made at 10:08 a.m. on ___ and the findings were communicated at the same time to the referring physician, ___ the findings were discussed over the telephone. ___ CXR: AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next previous similar study of ___. On previous examination identified right lower parenchymal density partially overshadowed by the heart contours and apparently located in the right lower lobe posterior segment has cleared up. No new pulmonary abnormalities are identified and no pulmonary vascular congestion is found. Similar as on the preceding examination of ___, there is a rounded mass overlying the contour of the ascending arch. This abnormality has not changed significantly since yesterday. Comparison with a supine chest examination transferred from ___, this mass is new. Unfortunately, the transferred image is not identified by date. ___ CXR: Patient with alcohol withdrawal and concern for aortic dissection, intubated for sedation for CT. Comparison is made with prior study performed five hours earlier. ET tube tip is in standard position, 4.2 cm above the carina. There are lower lung volumes with increasing bibasilar opacities. There is no evident pneumothorax. Cardiomediastinal silhouette is unchanged. ___ CTA CHEST: 1. No acute aortic pathology. No CT abnormality to account for the radiographic abnormality described on chest radiographs ___. 2. Bibasilar atelectasis with volume loss in the lower lobes bilaterally. Supervening aspiration cannot be excluded. No pneumonia. Secretions in the left main stem bronchus. 3. 4-mm right middle lobe nodule. If the patient has no risk factors for malignancy, no followup is needed. If the patient has risk factors for malignancy, followup with dedicated chest CT in one year is recommended if there is no prior imaging documenting stability. 4. Fatty liver. ___ CT HEAD: IMPRESSION: Study is somewhat limited by motion; within this limitation, no acute abnormality is seen. ATTENDING NOTE: Study limited. Outside CT shows blood near left temporal horn which is not apparent on current study. The scalp hematoma is decreased. . ___ CT HEAD: IMPRESSION: No acute intracranial hemorrhage or mass effect. Previously seen left temporal horn blood products are no longer present. Brief Hospital Course: HOSPITAL COURSE: Patient is a ___ yo male with history of alcohol abuse who was brought to OSH after fall and found to be in ETOH withdrawal at OSH with question of intraventricular hemorrhage and transferred to ___ for further eval who required 36 mg iv lorazepam in the ED for signs of ETOH withdrawal, intubated for CTA given concern for question of aortic dissection and for increasing agitation. Patient was kept on propofol and IV ativan prn while intubated. He was started on standing ativan for agitation and extubated successfully on ___. . # Alcohol withdrawal/Delirium Tremens: Patient had evidence of delirium tremens and severe alcohol withdrawal in the ED with tachycardia to 150s, BP to 153/93, agitation and question of hallucinations. He received 36 mg iv lorazepam in ED. Patient was first maintained on IV ativan prn on CIWA, however, he required increasing doses of IV ativan, up to 16 mg at a time. He was intubated and placed on propofol gtt with prn ativan for increasing agitation, and for the need for CTA of chest (as below) given question of aortic dissection. His agitation and ativan requirement decreased over time and he was started on standing PO ativan and extubated successfully. He was started and continued on thiamine, folate and MVI daily. His Mg and K were repleted aggressively throughout the hospital stay. He required intermittent doses of IV haldol for acute agitation. Pt remained stable and was transferred to the floor ___. . # Intraventricular hemorrhage vs contusion s/p fall: Patient presenting to outside ED with evidence of trauma given his large R forehead hematoma and lacerations on extremities. CT head was done at OSH and showed possibility of intraventricular hemorrhage and transferred to ___ for neurosurgery eval. Patient seen in ED by neurosurgery who reviewed the imaging, which showed a hypodensity in R temporal horn. C-spine was cleared by CT and by exam. It was thought to be due to artifact and no hemorrhage seen. He had no edema on head CT from OSH. Neurosurgery recommended Dilantin 100 mg q8hrs x7 days for prophylaxis. Patient had an episode of oversedation and unresponsive, and given change on neuro exam on ___, repeat head CT was obtained without acute abnormality. Had f/u head CT on ___, which continues to show no evidence of acute abnormaility or bleed. . # Question of aortic dissection: Patient has a new finding on CXR of potential aortic dissection. Given discordant blood pressure of 150/90 right arm and 130/85 left arm, and as patient was unable to relate clear history given his agitation, he was intubated and CTA of chest was obtained. The imaging did not show aortic dissection. . # History of GERD: Pt has hx of GERD per OSH, on pantoprazole daily per OSH record. He was continued on pantoprazole in house. . # Social: patient reports living in a house with a girlfriend, and also reports a daughter. Unable to contact any of these people, social work was consulted to assist with locating family members and to assist with his alcohol dependence. Daughter was able to be located, is amenable to becoming health care proxy. #Conjunctivitis: erythema, injection, and exudate on R eye present on ___. Rx for erythromycin drops started Medications on Admission: none known Discharge Medications: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day). Disp:*1 tube* Refills:*0* 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Alcohol withdrawal Acute delirium HCV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted with a fall while intoxicated. You were sent here as there was concern that you had bleeding in your brain. Your follow-up head imaging showed resolution of bleeding in your brain. You were briefly on precautionary (prophylactic) anti-seizure medication. You were seen by the S/W regarding your alcohol abuse history, and you were provided with information regarding resources for alcohol abuse treatment. You Should not be driving. Medication changes: STARTED Thiamine and Folate Started Erythromycin eye ointment Followup Instructions: ___

19999287-DS-7

DS

2197-07-31 00:00:00

2197-08-01 17:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___ 1. Flexible and rigid bronchoscopy 2. Cryodebridement and cryobiopsies of LMSB tumor 3. APC 4. EBUS TBNA 10L 5. Deployment and revision of 14 x 30 covered Ultraflex LMSB stent History of Present Illness: Ms. ___ is a ___ with a history of COPD, T1 N0 poorly differentiated squamous cell carcinoma s/p RUL lobectomy and mediastinal LN dissection in ___ recent recurrence s/p Cyberknife and now with mediastinal and hilar LAD concerning for progression of disease who was scheduled for an IP procedure ___ who presents with worsening shortness of breath over the past few days. In review of her records, a PET-CT from ___ showed a lesion in the left lower lobe which may represent residual squamous cell carcinoma and FDG avid left hilar adenopathy which almost certainly represents nodal metastases from this lesion. There is also definite narrowing of the left upper lobe bronchus and possibly some narrowing of the left lower lobe bronchus. Dr. ___ IP was following with a plan for bronchoscopy with biopsy and possible dilatation and stent placement if the bronchoscopy confirms significant bronchial narrowing. She has had a three-segment resection on the right and now has significant bronchial narrowing on the left radiographically. She was seen recently at ___ at ___ and treated with azithromycin and prednisone which finished ___. ___ she saw Rad-Onc here (had recently been treated with Cyberknife) and they are planning further chemo/xrt pending her bx results. Per her nephew who was with her in the ED, he had been encouraging her to seek care of the past few days for hemoptysis, and convinced her to call EMS today. When they arrived she was satting in the 70's which improved to low 80's after a neb. On arrival in our ED initial vitals were 98.9, 108, 125/54, 20, 87% Non-Rebreather. On exam she was using accessory muscles, but clear on exam. CXR was concerning for hilar mass. IP was contacted since she was scheduled for stent placement today; they will keep her on the schedule, suggested Heliox if necessary. She was tried on non-invasive but was dyssynchronous and sats decreased to 70's and was put back on a non-rebreather where she is satting low 90's, still using accessory muscles. Received cefepime and vancomycin for post-obstructive pneumonia, vancomycin ordered. Has 2 18g IV's. Per ED she is confirmed full code, okay to intubate. Labs in our ED significant for WBC 20.2, hgb 14.5, plt 308, 86%N. VBG ___ then 7.49/31, INR 1.2, blood and urine cx obtained. Lactate 1.8. On arrival to the MICU she complains of continued shortness of breath and some chest/back pain worsened with cough and deep breaths. Review of systems: (+) Per HPI, in addition some weight loss (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: COPD, Pulmonary function tests on ___ showed an FEV1 of 1.13 L or 49% of predicted and compatible with severe obstructive ventilatory defect. HLD DM arthritis h/o spine surgery SCC / lung cancer s/p VATS and mediastinal LN dissection ___, with recurrence s/p Cyberknife ___ Social History: ___ Family History: Non-contribitory Physical Exam: Admission Physical Exam: ========================= Vitals- T: 98.4 HR 100 bp 106/86 rr 21 sat 88% on NRB GENERAL: Alert, oriented, speaking in short sentences HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: no wheezes or crackles, slightly diminished on the L side CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: aox3, mae Discharge Physical Exam: ========================= Vitals: 98.4, afebrile overnight, 126/71; ___ 86; ___ 16 96% 3L GENERAL: Alert, oriented, speaking in short sentences HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: rhonchi bilaterally, no wheezing, decreased breath sounds on the R CV: Regular rate and rhythm, normal S1 S2, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: aox3, no focal deficits Pertinent Results: Admission labs: ================ ___ 03:10AM BLOOD WBC-20.2*# RBC-4.50 Hgb-14.5 Hct-41.8 MCV-93# MCH-32.2* MCHC-34.6 RDW-13.4 Plt ___ ___ 03:18AM BLOOD Lactate-1.8 ___ 03:18AM BLOOD ___ pO2-32* pCO2-31* pH-7.49* calTCO2-24 Base XS-0 ___ 03:10AM BLOOD Glucose-136* UreaN-18 Creat-0.9 Na-135 K-4.6 Cl-98 HCO3-22 AnGap-20 ___ 03:20AM BLOOD ___ PTT-27.5 ___ Discharge labs: ================ ___ 08:00AM BLOOD WBC-9.6 RBC-3.47* Hgb-11.0* Hct-32.8* MCV-95 MCH-31.8 MCHC-33.6 RDW-14.0 Plt ___ ___ 08:00AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-138 K-4.1 Cl-104 HCO3-27 AnGap-11 ___ 08:00AM BLOOD Calcium-9.7 Phos-3.1 Mg-1.9 RELEVANT LABS: =============== ___ WBC-20.2 ___ WBC-9.6 ___ ___ pO2-32* pCO2-31* pH-7.49* calTCO2-24 Base XS-0 Images: A chest x-ray on ___ showed a 2.2 x 1.4 cm opacity over the left cardiac apex and possible other small nodules in the left lower lobe. PET CT on ___ showed a stable FDG-avid nodule in the right lobe of the thyroid with an SUV of 8.4; there was a 2.4 x 1.9 cm spiculated nodule with a contiguous satellite nodule in the left lower lobe with SUV of 15.4; there were no other FDG-avid nodules and there was no mediastinal or hilar adenopathy; there were no abdominal, pelvic, or bone metastases. ___: CT scan of the chest on ___, showed no pulmonary embolism; there was a 3.7 x 2.5 cm left lower lobe lung mass; there was 4 x 2 cm left hilar adenopathy. CXR ___: IMPRESSION: 1. New upper lobe collapse and some lower lobe atelectasis around a large obstructing left hilar mass. 2. Probable small bilateral pleural effusions. PATH: ___: lung, left mainstem tumor, biopsy: squamous cell carcinoma, invasive, moderately to poorly differentiated Procedures ___ Bronchoscopy Recommendations:The patient was brought to the OR and placed supine. After adequate anesthesia was obtained the trachea was intubated with ___ 12 ventilating rigid bronchoscope. Jet ventilation was established. The airways were inspected. There was obstructing clot in the LMSB which was removed with cryodebridement. There was an underlying obstructing LMSB tumor with 80% occluding which was bleeding. Topical epinephrine was applied and hemostasis was achieved with APC. EBUS TBNA sampled were obtained at 10L. The airway was balloon dilated to 15. The tumor was then cyrodebrided and cryobiopsied. A 14x30mm covered Ultraflex was deployed, repositioned and balloon dilated. There was a fracture of a subsegmental carina at in the LLL. Hemostasis was confirmed, secretions were cleared and the bronchoscope was removed. The patient was extubated in the OR and transported back to the MICU in stable condition: Procedures: 1. Flexible and rigid bronchoscopy 2. Cryodebridement and cryobiopsies of LMSB tumor 3. APC 4. EBUS TBNA 10L 5. Deployment and revision of 14 x 30 covered Ultraflex LMSB stent Brief Hospital Course: Ms. ___ is a ___ with a history of poorly differentiated squamous cancer of the lung s/p VATS in ___ with recurrence s/p Cyberknife ___ who presented with shortness of breath and was found to have post-obstructive pneumonia in the setting of reccurent poorly differentiated squamous cell lung cancer. # Hypoxia: Initially admitted to MICU requiring NRB; discharged to home on 3L O2. Likely due to both poor reserve (s/p VATS on R) and new partial obstruction of airways from recurrent SCC on Left with some resulting post-obstructive collapse and post-obstructive pneumonia. Discharged on home O2 and home COPD meds. Will ___ with rad-onc, med-onc, and IP as an outpt as outlined below. # Recurrent poorly differentiated squamous cell Ca of lung: s/p yCberknife ___. Bronch ___ with SCC. Has outpt ___ in place to discuss salvage chemo/radiation as well as further metastic work-up (brain MRI). Discharged on home O2. # Pneumonia: Initially treated with vancomycin/cefepime in ED for post-obstructive pneumonia, and IP report with purulence seen on bronch. Afebrile, VSS, WBC trended down. Discharged PO levaquin through ___ #COPD: Continued on home meds + duonebs #HTN. Normotensive since transfer to medicine; continued on home dose amlodipine Health Care Proxy: patient completed HCP paperwork on this admission, designating her sister as her HCP and her nephew as her alternate HCP. GOC: pt is full code at this time. A MOLST form was provided to the patient. She will further consider her wishes and will discuss with her outpatient providers at ___ TRANSITIONAL ISSUES: ====================== # Levofloxacin 750 mg PO/NG DAILY through ___ for a total of 8 days antibiotics # Hx of several months of intermittent mild vaginal bleeding. Per pt, normal pap ___ year ago. Consider further work-up as outpt # Follow up in place with IP and Onc to coordinate outpatient chemo/radiation # discharged with home O2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Amlodipine 5 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Dexamethasone 4 mg PO ONLY ON DAYS OF CYBERKNIFE TREATMENT 5. Lorazepam 0.5 mg PO 30 MINUTES PRIOR TO CYBERKNIFE 6. Ascorbic Acid Dose is Unknown PO DAILY 7. Bisacodyl 5 mg PO DAILY:PRN constipation 8. Vitamin D Dose is Unknown PO DAILY 9. Lactobacillus acidoph-L. bifid unknown oral daily 10. Polyethylene Glycol 17 g PO Frequency is Unknown Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Bisacodyl 5 mg PO DAILY:PRN constipation 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Tiotropium Bromide 1 CAP IH DAILY 5. Levofloxacin 750 mg PO DAILY Duration: 3 Days RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB RX *albuterol sulfate 90 mcg 1 puff IH Q6H:PRN Disp #*1 Inhaler Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Post-obstructive pneumonia Recurrent poorly differentiated squamous cell carcinoma of lung Secondary: COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your recent hospitalization. You were admitted because you had pneumonia in the setting of recurrent lung cancer. The pulmonary team placed a stent in one of the branches of your lung to help keep it open with the hope of preventing future obstructive pneumonias and preventing the cancer from collapsing your lung again. We're treating your pneumonia with antibiotics; please continue to take the Levaquin for 2 more days through ___. We have arranged ___ at the multi-disciplinary thoracic ___ clinic to plan outpatient treatment for your recurrent lung cancer. We have also arranged for you to have supplemental oxygen at home to help with your breathing. Please take your medications as directed and ___ with your doctors as ___ below. Sincerely, Your ___ Care Team Followup Instructions: ___

19999784-DS-7

DS

2119-07-02 00:00:00

2119-07-03 16:21:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: LLE weakness, dysphagia Major Surgical or Invasive Procedure: Lumbar puncture Bone marrow biopsy History of Present Illness: ___ is a ___ year-old right-handed male without ___ medical history who presents to the ED for evaluation of LLE weakness. He was seen in ___ outpatient clinic this morning for evaluation of new dysphasia and dysphonia (began ___. He reports that he had gone to bed the previous day feeling normal but woke up with new difficulty swallowing as well as a change in his voice (more raspy, hoarse). With regards to his dysphagia, he describes feeling that solids "won't go down...the food gets stuck" but he has not had any difficulties with liquids. He was seen by a community physician who told him that he likely had sinus disease and recommended a few days of Sudafed. When the symptoms persisted and he had lost 15 pounds due to difficulty eating, he had a video swallow test performed ___, see below) which revealed "significant oropharyngeal and esophageal dysphagia most notable for diffuse right-sided weakness." This prompted referral to ___ clinic, where he was seen today and diagnosed with right vocal fold paralysis. He was noted to have LLE weakness, so was prompted to come to the ED for further evaluation. He reports that the LLE weakness began gradually, probably over the ___. This did not impair him in any way until the last week of ___ when he was unable to stand up from a squatting position without the use of his hands. Overall, his weakness has been progessively worsening since that time. In particular, he notices difficulty with lifting his left leg up in order to cross it over the right leg, difficulty going upstairs > downstairs -- and needs to hold onto the railing for both. He is able to stand up out of a chair without difficulty but cannot stand from the floor. He has not had any foot drop or toe stubbing. He has not had any difficulty with the right leg or either arm. On neuro ROS, Mr. ___ denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness or parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, this is notable for + unintentional weight loss over the past 2 weeks (15 pounds), which he attributes to his dysphagia. He has also noticed saliva pooling in his mouth which he sometimes has difficulty swallowing. He has been coughing more, but he attributes this to the irritation in his throat, as he has not had any nasal congestion or "deep cough." He denies recent fever or chills. No night sweats. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Tobacco use disorder Social History: ___ Family History: - Great nephew ___ years) with recently diagnosed epilepsy - Father (now deceased) had prostate cancer. Physical Exam: ADMISSION Physical Exam: ============================ Vitals ___, time: 14:23): T: 98.6 HR: 80 RR: 18 BP: 161/100 SaO2: 100% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, full ROM Pulmonary: breathing comfortably on RA Cardiac: warm and well-perfused with brisk capillary refill Abdomen: ND Extremities: + signficant atrophy of the left thigh. No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam revealed no disc blurring, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric at rest and upon activation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. + gag on the left, equivocal on the right XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline; + fasciculations. -Motor: Normal tone throughout. Significantly decreased bulk in the L thigh. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. ___ strength throughout with the following exceptions: - Bilateral abductor pollicis brevis: 4+/5 - Left IP: 2+/5 - Left Quad: 2+/5 - Left Hamstring: 4+/5 - Left ___: 4+/5 Reflexes: Bi ___ Pat Ach L 3 3 tr* 1 R 3 3 2* 1 *: with reinforcement Of note: + spread (finger flexion) in the bilateral UE reflexes Plantar response was upgoing in the left, mute on the right. ___: negative -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. DISCHARGE Physical Exam: ======================== Vitals: T: 98.6 BP: 113/79 HR: 98 RR: 18 SpO2: 99% RA General: awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: breathing comfortably, no tachypnea or increased WOB Cardiac: skin warm, well-perfused Abdomen: soft, ND Extremities: symmetric, no edema Neurologic: -Mental Status: Alert, cooperative. Language is fluent with intact comprehension. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL (3 to 2 mm ___. EOMI without nystagmus. Face symmetric at rest and with activation. Hearing intact to conversation. Palatal elevation symmetric. Tongue protrudes in midline. -Motor: No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FE IP Quad Ham TA Gastroc L 5 ___ 5 4+ 3 5 5 5 R 5 ___ ___ 5 5 5 -Sensory: Intact to LT throughout. No extinction to DSS. -DTRs: Bi ___ Pat Ach L 2 2 1 1 R 2 2 1 1 -Coordination: No intention tremor or dysmetria on FNF bilaterally. Pertinent Results: ADMISSION LABS: =============== ___ 04:30PM URINE HOURS-RANDOM ___ 04:30PM URINE HOURS-RANDOM ___ 04:30PM URINE HOURS-RANDOM ___ 04:30PM URINE UHOLD-HOLD ___ 04:30PM URINE GR HOLD-HOLD ___ 04:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 04:10PM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-143 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 ___ 04:10PM estGFR-Using this ___ 04:10PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.2 ___ 04:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:10PM WBC-3.3* RBC-5.41 HGB-14.8 HCT-44.9 MCV-83 MCH-27.4 MCHC-33.0 RDW-13.4 RDWSD-40.1 ___ 04:10PM NEUTS-53.8 ___ MONOS-6.9 EOS-0.6* BASOS-0.6 IM ___ AbsNeut-1.78 AbsLymp-1.25 AbsMono-0.23 AbsEos-0.02* AbsBaso-0.02 ___ 04:10PM PLT COUNT-241 INTERVAL LABS: ============== ___ 05:40AM BLOOD calTIBC-251* VitB12-722 Ferritn-172 TRF-193* ___ 01:14PM BLOOD ANCA-NEGATIVE ___ 10:34AM BLOOD CEA-3.4 ___ 01:14PM BLOOD RheuFac-<10 ___ ___ 02:40PM BLOOD CRP-1.5 ___ 05:25AM BLOOD ___ Fr K/L-1.1 ___ 10:34AM BLOOD PEP-ABNORMAL B IgG-2326* IgA-204 IgM-44 IFE-MONOCLONAL ___ 01:14PM BLOOD C3-114 C4-20 ___ 02:40PM BLOOD HIV Ab-NEG ___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:34AM BLOOD QUANTIFERON-TB GOLD-Test ___ 10:34AM BLOOD TOXOCARA (T. CANIS & T. CATI) ANTIBODY-Test ___ 10:34AM BLOOD CA ___ -Test ___ 01:14PM BLOOD RO & ___ ___ 01:14PM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN BLOT-Test ___ 01:14PM BLOOD ANGIOTENSIN 1 - CONVERTING ___ ___ 02:40PM BLOOD SED RATE-Test ___ 02:40PM BLOOD PARANEOPLASTIC AUTOANTIBODY EVALUATION-CANCELLED ___ 02:40PM BLOOD ENCEPHALOPATHY, AUTOIMMUNE EVALUATION, SERUM-PND ___ 10:00AM URINE U-PEP-NO PROTEIN IFE-NEGATIVE F ___ 10:00AM URINE Hours-RANDOM Creat-153 TotProt-12 Prot/Cr-0.1 ___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-2 ___ Monos-9 Promyel-0 Plasma-3 Other-0 ___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-18* RBC-4 Polys-4 ___ Monos-6 Eos-1 Plasma-2 Other-0 ___ 04:55PM CEREBROSPINAL FLUID (CSF) TotProt-114* Glucose-63 ___ Misc-BODY FLUID ___ 04:55PM CEREBROSPINAL FLUID (CSF) BETA 2 MICROGLOBULIN-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) CA ___ ___ 04:55PM CEREBROSPINAL FLUID (CSF) VDRL-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY PCR-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name ___ 04:55PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION-CANCELLED IMAGING: ======== + MRI of L-spine notable for mild expansion in T2/STIR hyperintensity of the distal lumbar spinal cord with differential including infectious, inflammatory etiologies, or intramedullary neoplasm. On the contrast-enhanced study, this is described as 1.5 x 0.6 x 0.5 cm with associated cord expansion and extensive leptomeningeal involvement extending superiorly and inferiorly beyond the margins of the intramedullary lesion with possible involvement of the adjacent nerve roots. Abnormal bone marrow signal diffusely is also noted. Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. ___ was admitted to the Neurology service for evaluation of subacute progressive LLE weakness as well as dysphagia and dysphonia, found on ENT evaluation to be due to right-sided vocal cord paralysis. Despite initial concern for motor neuron disease, his EMG instead revealed a moderate to severe, chronic and ongoing left L4-L5 radiculopathy, without electrophysiologic evidence for a more generalized disorder of motor neurons or their axons. Follow-up MR imaging of the neuraxis was notable for: 1. Multilevel patchy cervical vertebral body T1 hypointensities with possible minimal postcontrast enhancement concerning for a potential marrow infiltrative process; 2. A 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing focus with surrounding STIR/T2 signal abnormality and associated cord expansion, along with extensive leptomeningeal involvement and possible involvement of the adjacent nerve roots. These findings were concerning for infectious, inflammatory, or neoplastic processes. Inflammatory evaluation revealed unremarkable CSF ACE, ESR, CRP, and SS-A and SS-B Ab. Infectious evaluation revealed negative Lyme serologies, CSF culture, RPR/VDRL, Toxoplasma serologies and CSF PCR, HSV/CMV PCR, QuantiFERON Gold, and HTLV I/II Ab. Neoplastic evaluation revealed negative ___ and CSF cytology and flow cytometry. CT chest/abdomen/pelvis was also negative for additional malignancy. SPEP, however, revealed a monoclonal gammopathy, though with negative skeletal survey and absence of renal findings to suggest multiple myeloma; in consultation with the Hematology/Oncology service, a bone marrow-biopsy was obtained that preliminarily revealed plasma cells as well as abnormal proliferation of lymphocytes concerning for lymphoma. As it remained unclear whether the bone marrow findings could also be implicated in the intramedullary spinal cord lesion and leptomeningeal/radicular enhancement seen on imaging, the Hematology/Oncology and Neuro-oncology teams deferred inpatient treatment in lieu of close outpatient follow-up for repeat imaging, repeat lumbar puncture, and follow up of molecular testing. With respect to Mr. ___ leg and vocal cord symptoms, these may be related to the leptomeningeal/nerve root infiltrative process noted on imaging. During admission he also developed mild hyperreflexia and spasticity in the RLE (without weakness), indicating myelopathy, in line with cord signal abnormalities seen on imaging. Accordingly, Mr. ___ was evaluated by ___ and SLP as an inpatient, with plans for outpatient follow-up. Mr. ___ was cleared for a regular diet and advised to turn his head to the right to facilitate swallowing. TRANSITIONAL ISSUES: =================== [] Follow-up outpatient MRI. [] Follow up with Neuro-oncology and Hematology/Oncology as noted above. [] Follow up final report from bone marrow biopsy as well as serum autoimmune encephalopathy panel. [] Outpatient ___ and SLP follow up as noted above. Medications on Admission: None Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2.Outpatient Physical Therapy Diagnosis: Left leg weakness, L4/L5 radiculopathy 3.Outpatient Speech/Swallowing Therapy Diagnosis: right vocal cord paralysis, dysphonia Please continue to evaluate and treat dysphagia and dysphonia Discharge Disposition: Home Discharge Diagnosis: Lumbar Radiculopathy Lumbar myelopathy Intramedullary intradural spinal cord lesion Vocal cord paralysis Monoclonal gammopathy Suspected lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ for evaluation of difficulty swallowing and speaking, as well as left leg weakness. Imaging of your spine showed an area of swelling and inflammation affecting your spinal cord and surrounding coverings; blood and cerebrospinal fluid tests did not show signs of an infection or inflammation, so there is concern that the spine findings may be due to cancer. Although imaging of your chest, abdomen, and pelvis did not show signs of additional cancer, your bone marrow did have abnormal blood cells (lymphocytes) that could reflect lymphoma. In order to further direct treatment of your spinal cord lesion, a follow-up appointment has been scheduled for you with Dr. ___ in Neruo-oncology; you are also scheduled for a repeat MRI the day prior. A follow-up appointment was also requested with Hematology/Oncology regarding your bone marrow biopsy findings; you may call ___ to follow up on this appointment with Drs. ___. Please also follow-up with a speech and swallow specialist for your voice as well as swallowing function and for speech therapy. We have written a prescription for outpatient speech therapy. Your follow-up is being coordinated by ___. Please call the number below (under recommended follow-up section) to follow-up regarding your appointment. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___

19999828-DS-6

DS

2147-08-04 00:00:00

2147-08-12 15:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lamictal / hydrochlorothiazide Attending: ___. Chief Complaint: Enterocutaneous/enteroatmospheric fistula Major Surgical or Invasive Procedure: ___: 1. Split-thickness skin graft, left and right thigh to abdominal bowel site and closure of intestinal fistula. 2. VAC sponge 20 x 15 cm. History of Present Illness: Ms. ___ is a ___ F w/hx of Afib on diltizaem, Factor V not on anticoagulation, diverticulosis, HTN, COPD and DMII who presents with abdominal pain and an abdominal wound site with exposed mesh. She reports a complex surgical history including laparoscopic cholecystectomy in ___ followed by ___ Procedure for diverticulitis ___ with colostomy take down ___. After this procedure she states she developed a large ventral hernia and underwent open VHR with cadaveric underlay mesh and prolene overlay mesh ___ c/b skin dehiscence beginning in ___ and progressing until today, despite multiple debridements at ___ and the use of a wound vac, which was last used 2 mo ago. She presents to the ED for follow up of her ventral hernia since the wound continues to expand and has become more painful. 3 weeks ago, Ms. ___ developed pain at the RUQ of the wound that has since progressed and intermittent nausea without vomiting. This morning at 7 am she changed her dressings and noticed brown, foul-smelling staining in the middle of the mesh and a "nipple-like" protrusion that resolved. At 8pm in the ED, her 12x17 cm open wound with visible mesh currently had more brown staining than this morning. When she pressed on the edges of her wound, which is tender and erythematous circumferentially, pus drained out at the 10 o'clock position. She was given dilute barium contrast PO for a CT +IV +oral contrast; CTAP was not read as showing enterocutaneous fistula. However, after drinking the contrast the patient began to leak feculent material that appeared to be succus mixed with contrast. . She smokes recreational marijuana which help curb the nausea, which allows her to eat. She is passing flatus and has regular BM, though she notes her stools are hard and she has felt constipated since her last hernia repair (___). She is afraid to strain while going to the bathroom because of the pressure it puts on her hernia. She has not had any fevers, chills, diarrhea, constipation different from baseline, SOB, chest pain, or urinary symptoms. . Past Medical History: PMH a fib on diltiazem Factor V Leiden deficiency diverticulosis (with diverticulitis episodes) SBO (___) gallstones HTN COPD anxiety sciatica scoliosis varicose veins DMII PSH cholecystectomy ___, ___ umbilical hernia repair ___, ___ Left ventral hernia c/b SBO s/p colostomy (___) colostomy reversal ___, ___ ventral hernia repair w/ mesh ___, ___ ventral hernia repair, debridement ___, ___) Social History: ___ Family History: - both parents and multiple siblings have DVTs ___ Factor V Leiden deficiency Physical Exam: Discharge Physical Exam: VS: T: 98.1 PO BP: 110/74 R Sitting HR: 81 RR: 18 O2: 96% Ra GEN: A+Ox3, NAD HEENT: normocephalic, atraumatic CV: RRR PULM: CTA b/l ABD: soft, non-distended. Area of wound with skin graft about 14x16 cm, skin graft approximately 90% taken, left and right edges still not taken up skin graft, but edges beginning to scar down. EXT: wwp, no edema b/l. B/l thigh donor sites OTA, healing w/ no s/s infection Pertinent Results: ADMISSION LABS: ___ 06:04PM BLOOD WBC-9.5 RBC-4.08 Hgb-9.9* Hct-32.3* MCV-79* MCH-24.3* MCHC-30.7* RDW-15.8* RDWSD-45.4 Plt ___ ___ 06:04PM BLOOD Neuts-46.9 ___ Monos-14.4* Eos-2.5 Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-3.35 AbsMono-1.37* AbsEos-0.24 AbsBaso-0.06 ___ 06:04PM BLOOD ___ PTT-28.4 ___ ___ 06:04PM BLOOD Glucose-152* UreaN-11 Creat-0.7 Na-136 K-4.7 Cl-98 HCO3-24 AnGap-14 IMAGING: ___: CT Abdomen/Pelvis: 1. No enterocutaneous fistula or small-bowel obstruction identified. 2. Open anterior abdominal wall wound measuring up to 14.5 x 16.1 cm with moderate soft tissue thickening along the lateral borders. Small focus of subcutaneous air tracking along the right superior border suggests increasing wound extension. ___: Abdominal x-ray: No enterocutaneous fistula demonstrated radiographically. Consider a fistulogram for this purpose. ___: Dx Portable PICC: Right PICC in the mid SVC. No acute cardiopulmonary process. ___: Abdominal x-ray: No acute abnormality with nonobstructive bowel gas pattern. Interval placement of wound VAC which projects over the mid abdomen. ___: CXR: No acute cardiopulmonary process. ___ 10:16 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Ms. ___ is a ___ year old female with a history of multiple prior abdominal surgeries most recently a ventral hernia repair at ___ (___) who presented to ___ ___ on ___ with an open abdominal wound, exposed mesh, and a low output entero-atmospheric fistula. She was admitted to the Acute Care Surgery Service for further management. The patient was kept NPO and initiated on TPN. She was started on octreotide for a short time period to help reduce fistula output. Plastic surgery was consulted to evaluate the patient in preparation for eventual abdominal wall reconstruction and offered to be available to assist with surgery when needed. Wound care nursing was also asked to assist with optimizing the patient's abdominal dressing, and a large wound manager was applied and placed to wall suction with good result. On ___, the patient was taken to the operating room and underwent an abdominal skin graft with anterior bilateral thigh donor sites. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complication and was taken to the post anesthesia care unit in stable condition. The patient was placed on bedrest precautions and then activity restrictions were liberalized and the patient ambulated. ___ was d/c'd and she voided appropriately. She was started on a regular diet which she tolerated and TPN was d/c'd. WBC was elevated on POD #3 and so PICC was d/c'd a fever work-up was sent and urine culture was positive for e.coli (sensitive to cipro). She was started on a 7 day course of cipro and WBC normalized. The patient's skin graft took approximately 90%. Non-adherent dressing were placed over the wound while ambulating and left open to the air for periods of time while in bed to let the graft dry. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: acetaminophen PRN albuterol (proair) aspirin 81 atorvastatin 20 suboxone Clonidine 0.2 TID Diltiazem 120mg 24 hour capsule Colace Flonase Glipizide Ibuprofen Metformin 500mg daily omeprazole 20mg daily trazodone 50mg daily umeclidinium 62.6 mcg/actuation Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 250 mg PO Q12H Closely monitor your blood sugars to assess for low blood sugar while taking this medication RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*9 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID Hold for loose stool 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: d/c oxycodone Take lowest effective dose. Patient may request partial fill. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 5. Atorvastatin 20 mg PO QPM 6. CloNIDine 0.2 mg PO TID 7. Diltiazem Extended-Release 120 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY PRN 9. GlipiZIDE 5 mg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Topiramate (Topamax) 50 mg PO BID 13. TraZODone 50 mg PO QHS:PRN PRN Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Giant abdominal hernia with exposed bowel and intestinal fistula. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with a large abdominal hernia after multiple prior surgeries. You had a fistula (an abnormal connection between the bowel and the skin) from the wound. You were initially placed on TPN to receive nutrition. You were later taken to the operating room and you underwent skin grafting from your thighs to your abdominal wound to protect the exposed bowel to prevent another fistula and also to close the current fistula. You tolerated this procedure well and your graft has mostly taken. You are now tolerating a regular diet, low residue diet. You were found to have a urinary tract infection and were started on a 1 (one) week course of an antibiotic, called ciprofloxacin. You will have a nurse visit you at home to check up on you to evaluate your wound and also help with your dressing changes. 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. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___

19999987-DS-2

DS

2145-11-11 00:00:00

2145-11-11 13:13:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: ICH Transfer from OSH Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ woman with a history of lymphoma who presents as a transfer from ___ with a L occipital hemorrhage. Per EMS report, she was last seen normal by her husband at 11:30 this am. She said she was going to bed for a little while, and then when her husband went to check on her around 2pm he found her lying on the bed, non-verbal, and drooling from the mouth with a small tongue laceration. He called EMS, and upon their arrival she was noted to have some left arm weakness and a leftward gaze preference. BP was 162/104 with pulse 140. FSBS was 217. She was somewhat combative and there was also some unclear concern for a ?dystonic reaction, for which she was given 50mg benadryl IV. Upon arrival to ___ she was reportedly awake and groaning and initially seemed to be protecting her airway. T was 100.6, BP 99/83, and O2 sats were in the 70's on RA which improved to 95% on 4L NC. She subsequently was noted to have left eye twitching for which she was given ativan 1mg x 2. CT head showed a L occipital hemorrhage measuring 5 x 3.9 x 2.1cm with mild surrounding edema and focal mass effect. She was subsequently intubated and transferred to ___ for further management. Currently pt is intubated and sedated and no family is present to corroborate history. Attempted to reach husband ___ at both numbers provided but with no response. ROS currently unable to be obtained from pt. Past Medical History: Lymphoma, s/p remission since ___ Esophageal ulcer Anxiety/depression Hypothyroidism R ankle fusion Anemia Social History: ___ Family History: Unknown Physical Exam: Physical Exam: Vitals: T: not recorded P ___ BP 118/83 RR 18 O2 100% on ventilator General: Intubated and sedated. HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Intubated and sedated on fentanyl/midazolam, no response to voice or sternal rub -Cranial Nerves: I: Olfaction not tested. II: PERRL 1.5 to 1mm and brisk. III, IV, VI: Gaze midline and conjugate, negative Doll's V: Corneals absent VII: Face appears symmetric with ETT. VIII: Unable to assess IX, X: +Strong gag XI: Unable to assess XII: Unable to assess -Motor: Normal bulk, flaccid tone throughout. No withdrawal to noxious stimulation. When suctioned has a strong gag response and briefly lifts both arms. -Sensory: Slight grimace to noxious stimulation -DTRs: ___ throughout -___: Unable to assess -Gait: Unable to assess Pertinent Results: ___ 08:27PM TYPE-ART RATES-18/ TIDAL VOL-400 PEEP-5 O2-100 PO2-439* PCO2-51* PH-7.31* TOTAL CO2-27 BASE XS--1 AADO2-227 REQ O2-46 -ASSIST/CON INTUBATED-INTUBATED ___ 07:49PM ___ PH-7.21* COMMENTS-GREEN-TOP ___ 07:49PM GLUCOSE-134* LACTATE-1.7 NA+-148* K+-5.2* CL--102 TCO2-30 ___ 07:49PM HGB-14.3 calcHCT-43 O2 SAT-72 CARBOXYHB-2 MET HGB-0 ___ 07:49PM freeCa-1.12 ___ 07:45PM UREA N-18 CREAT-1.4* ___ 07:45PM estGFR-Using this ___ 07:45PM LIPASE-26 ___ 07:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:45PM URINE HOURS-RANDOM ___ 07:45PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 07:45PM WBC-13.5* RBC-4.07* HGB-14.1 HCT-42.2 MCV-104* MCH-34.7* MCHC-33.5 RDW-15.7* ___ 07:45PM PLT COUNT-136* ___ 07:45PM ___ PTT-31.2 ___ ___ 07:45PM ___ ___ 07:45PM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-NEG ___ 07:45PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ECHO ___ The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal inferior wall and apex (LVEF 55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. No intracardiac source of embolus identified. Preserved global left ventricular systolic function with hypokinesis of the distal inferior wall and true apex. No clinically significant valvular disease. Mildly dilated descending thoracic aorta. CTA ___ IMPRESSION: 1. Unchanged 3.9 x 2.2 cm left occipital intraparenchymal hemorrhage. No midline shift. No intraventricular hemorrhagic extension. 2. Normal CTA head and neck, without aneurysm, dissection, vascular malformation or significant atherosclerotic disease. MRI ___. Large left occipital intraparenchymal hemorrhage, unchanged and with persistent mass effect on to the adjacent parenchyma. No midline shift or intraventricular hemorrhagic extension. No acute infarcts or definite postcontrast enhancement. 2. A small DVA traversing in the vicinity of the left occipital intraparenchymal hemorrhage. The presence of a nearby DVA favors the differential of cavernous malformation (hemangioma cavernoma) which hemorrhaged. 3. A punctate susceptibility artifact in the left temporal lobe, could represent either a second cavernoma or an old microhemorrhage. Angiogram ___ ___ underwent cerebral angiography which failed to reveal a source of hemorrhage in the left occipital lobe. There was a vein which appeared slightly early in the left vertebral artery injection draining into the left superior sagittal sinus; however, this was not consistent with an AVM and angiogram should be repeated in a month's time after the mass effect from the hematoma has resolved. ___ 07:45PM URINE GRANULAR-60* Brief Hospital Course: This is a ___ year old woman with a history of Lymphoma who presents with confusion and unresponsiveness and found to have a left occipital hemorrhage. The patient was in bed on the morning of ___ when her husband heard the dog barking in that room. When he went in he saw she was sitting on the side of the bed and when he asked her what was wrong she said she didn't know. He went to get a facecloth for her and when he returned she was on the floor and one side of her face was twitching. She did not respond at that time. EMS brought her to OSH where she has left eyelid twitching, left gaze preference and got ativan x1. CT showed a left occipital bleed. NEURO: Patient was transfered to ___ Neuro ICU. She had an MRI which showed, in addition to bleed, a small DVA adjacent to bleed which increases probability of cause of bleed bring cavernous malformation. Her CTA showed otherwise normal vessels. Stroke work up revealed A1c 5.1, LDL 100. Due to concern for vascular malformation of reversible cerebral vasoconstriction, angiogram was performed and was negative. She should have a repeat MRI 1 month after hematoma has resolved, and possibly another angiogram based on those results. Due to concern for seizure the patient was started on Keppra. This was transitioned to trileptal after discoverning that the patient had recently been depressed. The patient became dizzy and diaphoretic after initiation of Trileptal to she remained on only Keppra and warned to talk to her doctor if he psychiatric symptoms worsened. She had an EEG which preliminarily showed generalized slowing. Formal read to follow. While patient initially had done well with ___ and OT, on ___ she became vertiginous, diaphoretic and anxious. We initially thought this was due to Trileptal but even after stopping this she continued to have this reaction upon sitting up in bed on ___. Her orthostatics were negative and she did not have nystagmus during the vertigo. For several minutes she appeared very anxious, said her husband's name was ___ and that she lived at "___". She also developed some varying tremors. This may still have been due to trileptal as well as a psychiatric element to her symptoms. We have therefore restarted her Cymbalta and Effexor (had been held in ICU then patient declined to restart because she was feeling well). ID: The patient had leukocytosis on presentation and blood cultures were positive from ___ with gram pos cocci so she was started on vancomycin. Subsequent blood cultures were negative so vancomycin was stopped after 3 days. Urinalysis was also positive and culture grew Klebsiella so she was started on ceftriaxone. This was switched to bactrim on discharge. CARDS: The patient had a troponin elevation to 1.39 on presentation. EKG showed no acute ST or T changes. Echo showed hypokinesis of the inferior wall and apex. She was started on metoprolol for presumed CAD on the recommendation of cardiology. Troponin trended down to 1.13. RESP: The patient arrived intubated. She was extubated on the evening of ___. While in the ICU the patient had stridor and was placed on BiPAP then face mask overnight. TOX/METAB: The patient had mildly elevated LFTs and Utox positive for methadone, barbiturates, cannabinoids at ___. Repeat here was positive for benzos and barbiturates. Patient denied substance abuse. TRANSITION OF CARE: FULL code End bactrim in the evening ___ Titrate up psych meds as needed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 150 mg PO DAILY 2. Duloxetine 60 mg PO BID 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache 5. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Duloxetine 60 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Venlafaxine XR 150 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN headache 6. Heparin 5000 UNIT SC TID DVT prophylaxis 7. LeVETiracetam 1000 mg PO BID 8. Metoprolol Tartrate 12.5 mg PO BID 9. Sulfameth/Trimethoprim DS 1 TAB PO BID 10. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left Occipital bleed UTI- Klebsiella Troponin elevation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. awake, alert oriented to ___ and date. R lower homonymous hemianopsia, end gaze nystagmus, full strength. Discharge Instructions: You came to the hospital because of a bleed in your brain. You had an MRI, a CTA and an angiogram to try to determine the cause of this bleed but unfortunately we cannot say what the cause is. It is possibly an abnormal formation of blood vessels. You will need to have a repeat MRI in 1 month in order to investigate this further (once the blood in your brain has disapated) and possibly another angiogram. We think that you may have had a seizure caused by the blood in your brain and will remain at risk for seizures in the coming months. Because of this we have started you on an antiepileptic drug called Keppra (Levetiracetam). Please be aware that this medication can worsening depression/irritability. Let your doctor know if you notice this and you could be switched to another medication such as Lamictal. While you were here we also treated you for a urinary tract infection. You will complete Bactrim for this on ___. You were also treated for bacteria in the blood but this is more likely to have been a contaminate at the time of collection and not a true infection. Finally, your cardiac enzymes were elevated on admission. This may have been due to the bleed but may also have been from a mild heart attack. You should follow up with cardiology once you are discharged and continue metoprolol as directed. Followup Instructions: ___